Sense-Making, Mutual Learning and Cognitive Shifts When Applying Systems Thinking in Public Health – Examples From Sweden; Comment on “What Can Policy-Makers Get Out of Systems Thinking? Policy Partners’ Experiences of a Systems-Focused Research Collaboration in Preventive Health”

Document Type : Commentary


1 Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre, SOLIID, Karolinska Institutet, Stockholm, Sweden

2 Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden

3 Stockholm Gerontology Research Centre, Stockholm, Sweden


It is widely acknowledged that systems thinking (ST) should be implemented in the area of public health, but how this should be done is less clear. In this commentary we focus on sense-making and double-loop learning processes when using ST and soft systems methodology in research collaborations with policy-makers. In their study of policy-makers’ experiences of ST, Haynes et al emphasize the importance of knowledge processes and mutual learning between researchers and policy-makers, processes which can change how policy-makers think and thus have impact on real-world policy concerns. We provide some additional examples from Sweden on how ST has been applied to create learning and shared mental models among stakeholders and researchers in national and regional healthcare development initiatives. We conclude that investigating and describing such processes on micro-level can aid the knowledge on how to implement ST in public health.


  1. Swanson RC, Cattaneo A, Bradley E, et al. Rethinking health systems strengthening: key systems thinking tools and strategies for transformational change. Health Policy Plan. 2012;27(suppl 4):iv54‐iv61. doi:1093/heapol/czs090
  2. Russell E, Swanson RC, Atun R, Nishtar S, Chunharas S. Systems thinking for the post‐2015 agenda. 2014;383(9935):2124‐2125. doi:10.1016/S0140-6736(14)61028-X
  3. Cabrera D, Colosi L, Lobdell C. Systems thinking. Eval Program Plann. 2008;31(3):299-310. doi:1016/j.evalprogplan.2007.12.001
  4. De Savigny D, Adam, T. Systems thinking for health system strengthening. Alliance for Health Policy and Systems Research, World Health Organization; 2009.
  5. Best A, Clark PI, Leischow SJ, Trochim WM. Greater than the sum: systems thinking in tobacco control. Bethesda, MD: National Cancer Institute, US Department of Health and Human Services, National Institute of Health; 2007.
  6. Chungtai S, Blanchet K. Systems thinking in public health: a bibliographic contribution to a meta-narrative review. Health Policy Plan. 2017;32(4):585-594. doi:1093/heapol/czw159
  7. Carey G, Malbon E, Carey N, Joyce A, Crammond B, Carey A. Systems science and systems thinking for public health: a systematic review of the field. BMJ Open. 2015;5(12):e009002. doi:1136/bmjopen-2015-009002
  8. Rusoja E, Haynie D, Sievers J, et al. Thinking about complexity in health: A systematic review of the key systems thinking and complexity ideas in health. J Eval Clin Pract. 2018;24(3):600-606. doi:1111/jep.12856
  9. Augustsson H, Churruca K, Braithwaite J. Re-energising the way we manage change in healthcare: the case for soft systems methodology and its application to evidence-based practice. BMC Health Serv Res. 2019;19(1):666. doi:1186/s12913-019-4508-0
  10. Nyström ME, Westerlund A, Höög, E, Millde-Luthander C, Högberg U, Grunewald C. Healthcare System Intervention for Prevention of Birth injuries – Process Evaluation of Self-Assessment, Peer Review, Feedback and Agreement for Change. BMC Health Serv Res. 2012;12:274. doi:1186/1472-6963-12-274
  11. Jeffery AB, Maes JD, Bratton-Jeffery M-F. Improving team decision-making performance with collaborative modeling. Team Performance Management. 2005;11(1/2):40-50. doi:1108/13527590510584311
  12. Haynes A, Garvey K, Davidson S, Milat A. What can policy-makers get out of systems thinking? Policy partners’ experiences of a systems-focused research collaboration in preventive health. Int J Health Policy Manag. 2020;9(2):65-76. doi:15171/IJHPM.2019.86
  13. Zuber-Skerritt O. Action learning and action research: paradigm, praxis and programs. In: Sankara S, Dick B, Passfield R, eds. Effective Change Management Through Action Research and Action Learning: Concepts, Perspectives, Processes and Applications. Lismore: Southern Cross University Press; 2001:1-20.
  14. Booth A, Sutton A, Falzon L. Working together: supporting projects through action learning. Health Info Libr J. 2003;20(4):225-231. doi:1111/j.1471-1842.2003.00461.x
  15. Brook C. Action learning in health care. In: Dilworth RL, Bosyk Y, eds. Action Learning and its Applications. London: Palgrave Macmillan; 2010:3-14.
  16. Argyris C, Schön DA. Organizational learning II: Theory, method and practice. Reading: Addison Wesley; 1996:305.2.
  17. Nyström ME, Strehlenert H. Advancing health services collaborative and partnership research: Comment on “Experience of health leadership in partnering with university-based researchers in Canada – a call to ‘re-imagine’ research.” Int J Health Policy Manag. 2020; In Press. doi:15171/ijhpm.2020.16
  18. Nyström ME, Höög E, Garvare R, Weinehall L, Ivarsson A. Change and learning strategies in large scale change programs: Describing the variation of strategies used in a health promotion program. J Organ Chang Manag. 2013;26(6):1020-1044. doi:1108/JOCM-08-2012-0132
  19. Höög E, Garvare R, Ivarsson A, Weinehall L, Nyström ME. Challenges of managing a multi-sectoral health promotion program. Leadersh Health Serv (Bradf Engl). 2013;26(4):368-386. doi:1108/LHS-12-2011-0048
  20. Edvardsson K, Garvare R, Ivarsson A, Eurenius E, Mogren I, Nyström ME. Sustainable practice change: Professionals’ experiences with a multi-sectorial child health promotion programme in Sweden. BMC Health Serv Res. 2011;11(1):61. doi:1186/1472-6963-11-61
  21. Nyström ME, Höög E, Garvare R, Andersson Bäck M, Terris DD, Hansson J. Exploring the potential of a multi-level approach to improve capability for continuous organizational improvement and learning in a Swedish healthcare region. BMC Health Serv Res. 2018;18(1):376. doi:1186/s12913-018-3129-3
  22. Hansson J, Höög E, Nyström ME. Action research for multi-level facilitation of improvement in health and social care: Development of a change facilitation approach for a local R&D unit. Action Research. 2017;15(4):339-356. doi:1177/1476750316650928
  23. Nyström ME, Hansson J, Garvare R, Andersson Bäck M. Locally based Research and Development units as knowledge brokers and change facilitators in health and social care of older people in Sweden. Policy. 2015;11(1):57-80. doi:10.1332/174426514X14098428292539
  24. Strehlenert H, Hansson J, Nyström ME, Hasson H. Implementation of a national policy for improving health and social care: a comparative case study using the Consolidated Framework for Implementation Research. BMC Health Serv Res. 2019;19(1):730. doi:1186/s12913-019-4591-2
  25. Strehlenert H, Richter-Sundberg L, Nyström ME, Hasson H. Evidence-informed policy formulation and implementation: Comparative case study of two national policies for improving health and social care in Sweden. Implement Sci. 2015;10:169. doi:1186/s13012-015-0359-1
  26. Nyström ME, Strehlenert H, Hansson J, Hasson H. Strategies to facilitate implementation and sustainability of large system transformations: A case study of a national program for improving the quality of care for the elderly people. BMC Health Serv Res. 2014;14(1):401. doi:1186/1472-6963-14-401
  27. Foster-Fishman PG, Nowell B, Yang H. Putting the system back into systems change: A framework for understanding and changing organizational and community systems. Am J Community Psychol. 2007;39(3-4):197-215. doi:1007/s10464-007-9109-0
  28. Gilson L, Elloker S, Olckers P, Lehmann U. Advancing the application of systems thinking in health: South African examples of a leadership of sensemaking for primary health care. Health Res Policy Syst. 2014;12(1):30. doi:1186/s12961-020-00559-z.
  29. Benn J, Burnett S, Parand A, Pinto A, Iskander S, Vincent C. Studying large-scale programmes to improve patient safety in whole care systems: challenges for research. Soc Sci Med. 2009;69(12):1767-1776. doi:1016/j.socscimed.2009.09.051
  30. Tolf S, Nyström ME, Tishelman C, Brommels M, Hansson J. Agile, a guiding principle for health care improvement? Int J Health Care Qual Assur. 2015;28(5):468-493. doi:1108/IJHCQA-04-2014-0044
  31. Byskov J, Maluka S, Marchal B, et al. A systems perspective on the importance of global health strategy developments for accomplishing today’s Sustainable Development Goals. Health Policy Plan. 2019;34(9):635-645. doi:1093/heapol/czz042