We implemented a centralized colorectal cancer (CRC) screening program with navigation to follow-up colonoscopy for community health center (CHC) patients with positive stool-based test screening results. Navigation increased six-month colonoscopy completion by 24 percentage points compared with usual care. Here, we describe how we applied a functions and forms framework alongside causal loop diagramming (CLD) to understand the effectiveness of our navigation program and explore its potential for implementation in other settings. We first identified barriers to colonoscopy completion in our primarily rural sample and detailed the navigation services provided. Next, we classified our program into core functions (key components contributing to success) and corresponding forms (elements detailing how the functions were carried out and adapted to the local context). To inform classification, we reviewed program documentation (e.g., implementer notes, call logs, and protocol). We refined findings collaboratively in workshops with the navigation team and leadership. We also conducted CLD sessions to document and visualize how the functions addressed the problems affecting colonoscopy completion, refining our list of functions and forms based on these findings. We identified nine key functions of our navigation program - bridging across patients, providers, and systems; reaching and engaging patients; building rapport and trust; identifying and alleviating concerns; developing readiness and self-efficacy; linking to resources; monitoring progress; enhancing communication; and providing consistent, high-quality navigation services. We documented 29 distinct forms operationalizing these functions within our local context (e.g., motivational interviewing to address barriers and support self-efficacy). We developed a causal loop diagram to explore interactions among the multi-level factors affecting colonoscopy completion and how the navigation program addressed those factors. Organizing functions and forms clarified core elements of success and aspects adaptable for scale-up or replication across different contexts. CLD provided insights into how the functions contributed to the program's success and helped identify additional forms. Findings will guide efforts to translate this navigation model to varied contexts. ClinicalTrials.gov Identifier: NCT04406714.

Abstract Fertiliser is important in enhancing rice yields and strengthening farmers' economic stability in Indonesia. To achieve this, the Indonesian government has implemented a fertiliser subsidy policy. However, despite its intended benefits, the program's effectiveness has been undermined by persistent challenges. This study explores the complexity of Indonesia's subsidised fertiliser allocation and distribution system and identifies underlying issue patterns. Using a qualitative systems thinking approach, this research integrates data from stakeholder interviews with a causal loop diagram (CLD) developed through group model building (GMB) sessions, and validated at the national level through focus group discussion (FGD). The findings illustrate intricate interdependencies of variables within the system. An overlooked pattern also emerges: how well-intentioned government responses inadvertently exacerbate problems through mechanisms described by the ‘fixes that fail’ archetype. This study offers practical insights for policymakers to strengthen governance mechanisms, prevent recurring fertiliser shortages, and improve national food security through more sustainable, long-term strategies.

Researchers in the field of sexual and reproductive health and rights (SRHR) increasingly recognize the value of engaging young people (YP) as active partners in research. However, there are also challenges associated with youth participation in research and more evidence is needed on how participatory methods work across settings, for different groups of YP. Starting from realist principles, this paper develops an initial program theory that explains the mechanisms through which youth participatory research can create meaningful outcomes. A realist review was conducted and complemented with realist expert interviews. The review included 87 original and 30 reflective articles published between January 2019 and June 2024. It examines how participatory methods with YP (aged 10-24) contributed to SRHR research. Analysis focused on identifying relevant factors and causal relationships that were synthesized in a Causal Loop Diagram (CLD). Realist interviews with eight researchers experienced in implementing youth participatory methods were conducted to refine the CLD. Participatory methods have the potential to enhance YP's ability to talk about SRHR, have sustainable positive impact on YP, and enhance data quality, through the mechanisms of improved control, comfort, rapport, playfulness, and adapted communication tools. Several contextual variables influence these mechanisms, i.e. YP's interests and capacities to participate, rigidity of research institutions requirements, taboo, power dynamics and opportunities to learn about and evaluate participatory methods. This study proposes a theory that explains how participatory methods can achieve outcomes and offers a foundation for further application of youth participatory methods in SRHR research.

ABSTRACT The growing urgency of climate change demands educational programs capable of triggering rapid and stable transformative actions, as well as impact accounting protocols capable of assessing their long‐term effects. This study, thus, introduces a novel social impact accounting methodological framework for sustainability education for climate action (SECA)— accounting for the loops —based on system dynamics. This research applies the novel framework to a participatory case study of a university‐led community garden to identify leverage points that may affect a SECA educational activity. It integrates semi‐structured interviews with participants and stakeholders, qualitative inductive coding to identify relevant variables, and a causal loop diagram based on the identified variables to point out main leverage points that can amplify the positive impacts. Findings from the case study reveal that a sense of belonging and personal recognition activate reinforcing loops, while, counterintuitively, project size and community autonomy trigger balancing loops, increasing bureaucratic obstacles and required institutional support, which negatively affect participant motivation. The proposed approach offers both conceptual and methodological advancements for evaluating and designing sustainable community programs.

Understanding the systems dynamics of neighborhood socioeconomic inequities in health in European cities: a causal loop diagram.

System Dynamics of Preadolescent Mental Wellbeing: A Causal Loop Diagram of the Scientific Evidence.

Reimagining urban air-quality governance: A systems-thinking framework.

The Maryland Department of Education participated in the USDA's Direct Certification with Medicaid (DC-M) pilot during the 2022-2023 school year. This program lets Medicaid-enrolled students automatically qualify for Free or Reduced-Price Meals (FARM) and incorporates Medicaid data into eligibility calculations for the Community Eligibility Provision (CEP), which allows high-poverty schools to offer free meals to all students. This study assesses how DC-M impacts CEP participation from a systems perspective, using a causal loop diagramming approach across 12 Maryland public school districts. Semi-structured, in-depth interviews were conducted among stakeholders from school district offices of food and nutrition services. Inductive qualitative coding was applied to interview transcripts, identifying causal relationships among codes using Kumu software. Interview findings (n = 12 interviews) identified 36 interconnected factors organized into five reinforcing feedback loops and one balancing loop, revealing three themes: school district landscape influence on student enrollment, federal and state policies' effects on school meal funding, and school-level meal operations impacted by school meal policies. Schools can increase meal participation through DC-M. This study uses a systems approach to pinpoint barriers and facilitators that can inform strategies for improving FARM eligibility and supporting CEP programs.

Sustainable supply chain management (SSCM) involves complex and dynamic interactions among economic, environmental, and social processes. Leadership plays a critical role in shaping these interactions through strategic decisions that influence collaboration, resilience, and sustainability performance. However, existing studies often examine leadership impacts in a linear manner, overlooking the systemic feedback mechanisms inherent in supply chains. This study adopts a system dynamics perspective to explore how leadership decisions generate reinforcing and balancing feedback effects within sustainable supply chains. Drawing on system dynamics theory, the study synthesizes insights from secondary data and published case studies to develop causal loop diagrams and conceptual stock–flow structures that capture the dynamic relationships between leadership behavior, sustainability practices, and supply chain performance. The results are expected to reveal key feedback loops and leverage points through which leadership can amplify or constrain sustainability outcomes over time. By conceptualizing leadership influence as a dynamic system rather than a static input, this study contributes to SSCM literature and provides practitioners with a systems-level lens for designing resilient and sustainable supply chains.

Common Feedback Structures and the Conditions for the Emergence of Virtuous and Vicious Modes in Urban Cultural S paces: A Causal Loop Diagram Analysis from a Systems Thinking Perspective

ABSTRACT This paper introduces the Qualitative Systems Exploration Model (QSEM), a new semi‐quantitative framework for systematically interpreting and analyzing Causal Loop Diagrams within participatory system dynamics. QSEM is applied at late‐stage model conceptualization and offers researchers and modeling practitioners a set of tools and techniques to improve transparency and reproducibility in model assessment, ensuring that component and feedback structure selections are traceable and well justified. Throughout its three core phases: (i) System Factor Classification; (ii) Loops of Interest; and (iii) Archetype Identification and Analysis, QSEM integrates with established Group Model Building scripts to facilitate structured participant engagement and collaborative sensemaking. Real‐world application is demonstrated in a commissioned government project aimed at understanding factors influencing dietary choices and food systems, where the framework helped identify potential policy‐relevant system drivers. Future directions involve applying QSEM in other projects, evaluating its robustness, consistency, and scalability, refining archetype detection, enhancing data visualization, and exploring dedicated software solutions to expand its utility in qualitative SD.

ABSTRACT The World Population Prospects (2022) report by the United Nations highlights a decline in global population growth, underscoring the critical role of healthcare systems in reducing maternal and infant mortality rates. While birth rates vary across high-income and low- and middle-income countries, ensuring safe childbirth remains a fundamental healthcare objective. Despite the known risks associated with unnecessary caesarean sections, their prevalence continues to rise in developing countries. This study examines the underlying factors contributing to this trend, using Iran as a case study. A systems approach is employed, incorporating Causal Loop Diagrams (CLDs) and the Decision Making Trial and Evaluation Laboratory (DEMATEL) to identify and prioritise key influencing factors. The findings suggest that societal and cultural dynamics play a more significant role in the increasing rates of unnecessary caesarean sections than technical medical considerations and individual preferences. Notably, the influence of word-of-mouth and support from reference groups underscores the importance of a community-focused approach in addressing this challenge.

Governance systems globally face mounting pressure from simultaneous climate, technology, and policy disruptions. The United Arab Emirates (UAE), with its rapid development trajectory, high innovation intensity, and environmental vulnerability, exemplifies the need for agile governance models. This study develops a systems-based adaptive governance framework specifically tailored to UAE's climate-health interface through expert interviews, policy document analysis, and systems modelling. Using causal loop diagrams (CLDs) and agent-based modelling (ABM), the study analyses institutional agility, stakeholder engagement, and policy coordination mechanisms. Three emblematic cases Masdar City, UAE AI Strategy 2031, and Dubai Clean Energy Strategy 2050 validate the framework empirically. The methodology integrates expert interviews and identifies documents concerning sustainability policies from the UAE, applying grounded thematic analysis within the scope of qualitative systems theory and adaptive governance literature. Results reveal five critical adaptive governance components: polycentric governance systems, reflexive regulation, policy experimentation, social learning, and inclusive participatory processes. Key findings highlight systemic fragmentation in climate-health governance, underutilization of AI-enabled surveillance, and infrastructure vulnerability to compound risks. The framework provides actionable pathways for data-driven, polycentric decision-making aligned with UAE Vision 2031 and Net Zero 2050 objectives. This research contributes to adaptive governance theory in high-growth economies and offers scalable insights for regions facing similar climate-policy-innovation challenges. By creating a conceptual model based on CAS that operationalizes the Adaptive Governance Framework (AGF) through empirical insights and systemic linkages across the UAE's climate-health-policy interface, this study unites adaptive governance theory and complexity science.

Purpose Despite their environmental and economic importance, recycling rates remain low in collective housing. Public policies grounded in decontextualized psychological mechanisms show limited effectiveness in this setting. By contrast, practice-based research shifts attention to contextualized everyday routines but offers few operational pathways for intervention. This study aims to advance a more integrated perspective by examining how psychological mechanisms are activated, inhibited or reshaped by collective housing through residential elements of materiality, meanings and competences. Design/methodology/approach Twenty-two semi-structured interviews were conducted with residents living in collective housing in Paris and the surrounding departments. Psychological mechanisms were explored in depth through the practice elements of materiality, meanings and competences. Findings The results show that the residential context deeply shapes how individuals engage with waste sorting. Affordances and emotions elicited by shared spaces profoundly shape sorting practices. Residents actively reconstruct residential sorting norms and cooperation expectations, and experience shame, guilt and pride tied to recycling. Competences extend beyond the household, shaping how residents navigate shared spaces, communicate with neighbors and restore order within the residence. Research limitations/implications Future research should further examine how residential context shapes consumption practices within a systemic perspective. Observational methods, such as sensor data or resident-generated video, could help identify key change points in daily routines. Experimental designs could test residential mechanisms, such as how residential altruistic acts shape waste-sorting behavior. Finally, specialized tools like causal loop diagrams may support a systemic approach to the dynamics of social and consumption change. Practical implications This study offers a framework for field diagnostics and context-based interventions that target the residential environment rather than individuals, focusing on residential psychological mechanisms. Originality/value From a critical realist perspective, collective housing is not simply a constraint on change but a generative structure that shapes waste-sorting routines by activating and shaping residential psychological mechanisms.

BackgroundClimate change and rapid urbanisation have intensified flood risk in Global South cities, exacerbating health inequities, especially through non-communicable diseases (NCDs). However, little is known about how community resilience strategies to key climate change consequences like flooding affect NCD risk in rapidly growing cities of the Global South.MethodsWe used a Community-Based System Dynamics (CBSD) approach to examine flood resilience strategies, the determinants, and health implications of these strategies in Yaoundé, Cameroon. The study included semi-structured interviews and a participatory modelling workshop with 12 purposively sampled community stakeholders (including from the municipality, urban planning, civil society organisation, local leadership, and people affected by flooding), accompanied by an iterative development and analysis of a causal loop diagram (CLD) to capture key variables, relationships, and feedback loops.FindingsThe finalised CLD incorporated 14 key variables and featured five major feedback loops (four reinforcing, one balancing) that shape flood resilience. Community-led strategies—such as waste management, tree planting, drainage maintenance, and the construction of flood-resistant infrastructure—were driven by municipal support, enforcement of planning rules, and adaptation within informal settlements. Participants described how these strategies improved hygiene, enhanced access to food and physical activity spaces, and reduced immediate health risks. However, political interests and inadequate enforcement constrained long-term resilience. Importantly, the study identified plausible pathways through which community actors perceived flood resilience strategies influenced diet and physical activity, the main NCD risk factors, thus highlighting the climate change-NCD syndemic in an urban African context.ConclusionParticipatory CBSD provided novel, systems-level insights into community resilience, revealing dynamic feedback between local action, governance, and health. Integrating community-led approaches into formal disaster risk management and urban health policy is essential for sustainable, equitable resilience.

Emerging infectious diseases such as Ebola and Mpox pose significant public health challenges in the Democratic Republic of the Congo (DRC). Effective prevention policies require a clear understanding of the socio-ecological systems (SES) in which these diseases emerge. This study examined the SES influencing emerging infectious disease prevention in the DRC through five participatory modelling workshops conducted at national, provincial, and community levels using causal loop diagrams (CLDs). Participants were selected through stakeholder analysis to ensure cross-sectoral representation. A structured process guided the co-creation of integrated system maps, beginning with disease-specific models and culminating in validated shared maps. A total of 162 stakeholders participated across the workshops, most of whom were affiliated with government institutions (83%), with smaller proportions from civil society, academia, and technical assistance organizations. The Agriculture and Animal Health sector represented 36% of participants, followed by Human Health (31%) and Environmental Health (13%). Most participants had over 10 years of experience. Analysis of the CLDs revealed that while the number of infected individuals remained the central driver triggering feedback responses, the mechanisms of influence differed by governance level. National and provincial systems were shaped by public investment in One Health systems, political commitment, and governance capacity, whereas community-level dynamics were dominated by socio-economic conditions, hunting practices, and local sensitization. Overall, the findings highlight that current governance remains largely reactive, emphasizing response over prevention. Strengthening One Health governance will require a shift toward proactive health promotion supported by institutionalized coordination, sustained investment, and inclusive community engagement.

ABSTRACT Urban green and blue spaces contribute many non-material benefits to human wellbeing. However, there are many gaps at this interface including (a) unclear conceptualisation of the mechanisms mediating the linkages between the non-material benefits of Nature and human wellbeing, (b) disproportionate focus of studies on individual wellbeing than collective wellbeing, (c) lack of understanding of possible synergies and trade-offs between individual and collective wellbeing. Here, we aim to unravel the linkages between the non-material benefits of Nature with individual and collective wellbeing. We focus on recreational cultural ecosystem services (CES) from urban blue spaces in a rapidly transforming tourism-dependent coastal city in Vietnam. We elicit these linkages through in-depth interviews and deliberative focus group discussions (FGDs) with the local community, and systematise the linkages through causal loop diagrams. We find that recreational CES from blue spaces contribute to eight constituents of individual wellbeing, namely physical health, mental health, subjective well-being, spirituality, personal identity and autonomy, learning and capability, connectedness and belonging, and economic wellbeing. Recreational CES also contribute to five constituents of collective wellbeing, namely open communication, collective actions, communion, tolerance and distributive justice. We identify 12 mechanisms mediating these linkages, with the most important ones being regenerative, cognitive, cohesive, collaborative and destructive mechanisms. We also observe that recreational CES create synergies and trade-offs between different constituents of wellbeing. We particularly note trade-offs and synergies among constituents of individual and collective wellbeing such as trade-offs between economic wellbeing (constituent of individual wellbeing) and distributive justice (constituent of collective wellbeing), among others.

ABSTRACT The Dutch inland shipping sector aims to nearly eliminate emissions by 2050 by transitioning away from fossil fuels. While alternative fuels are being developed, scaling them up remains challenging due to complex system dynamics, often leading to innovation failure. Existing studies identify scale-up factors but often overlook interactions between factors. This study examines the scale-up dynamics of biofuels, hydrogen and LNG. Scientific literature, news articles and interviews are analysed to construct causal loop diagrams depicting the main relationships between economic, technological, political and social factors. Six mechanisms showcasing scale-up dynamics are identified, highlighting the widespread impact of uncertainty – influenced by technical challenges, resource availability and fuel alternatives – and industry interest – influenced by cost–benefit assessment, technical challenges and resource availability. While biofuels, hydrogen and LNG show common mechanisms, resource availability creates key differences. A holistic approach addressing uncertainty and industry interest is needed to shift a system currently reinforcing fossil fuels.

The sawmilling industry in South Africa has faced many obstacles that have severely impacted its competitiveness and sustainability. The complexity of the industry presents challenges for decision-making due to its dynamic nature. It has become more crucial than ever for decision-makers to incorporate expert facts and research into their choices. This study aimed to understand the operating environment of the sawmilling industry and model its complexity. A mixed-methods research approach was employed, involving the gathering of primary data through interviews with personnel in the sawmilling industry, as well as root-cause analysis and system dynamics modelling. Fishbone and causal loop diagrams were used to present and analyse the data. The study generated insights critical for modelling the sector's complexity, enabling an understanding of how the factors influence each other and impact decision-making in the sawmills. The industry has the potential to gain and sustain its competitiveness by focusing on the key factors affecting the complexity of operating a mill and those faced by the industry. Sawmillers can use the findings to examine their processes, identify areas for improvement, and assess potential implications. Other industry stakeholders can also utilise the results to identify ways to enhance the industry's competitiveness and inform the government's industrial policy on sawmilling in South Africa. A limitation of the study was the lack of input from representatives of informal sawmills. Future research will focus on understanding the issues affecting small-scale and informal sawmills to determine how they can be supported in contributing to the industry's sustainability.

Background: Clean water is an essential basic need for the community, so its management must be carried out sustainably. Purpose: This study aimed to quantify the multiplier effect on economic, social, and environmental aspects of the existence of Perumda Tirta Pakuan Kota Bogor for the period 2025-2029 and project the availability of managed drinking water. Design/methodology/approach: The data used in this study are secondary data from both internal sources at Perumda Tirta Pakuan (annual reports and the company website) and macroeconomic data for the city of Bogor obtained from various sources relevant to the purpose of the study. Data analysis in this study used a systems approach, namely a hard system methodology, namely dynamic systems. The dynamic systems approach was used through the stages of input-output diagrams, causal loop diagrams (CLD), and stock flow diagrams (SFD) using Vensim PLE Version 10.3.2 software. Then the model's prediction results were verified and validated through face validity in two FGDs involving experts and practitioners from drinking water management, resulting in a model that is scientifically accountable and well-tested.Finding/Result: The results of the study show that clean water production capacity remains stable at 2.59 m³ per second, whereas usage increases from 1.86 m³ per second in 2025 to 2.26 m³ per second in 2029. Thus, there is a surplus of 0.33 m³ per second or around 10.4 million m³ per year in 2029, which opens up opportunities to expand customer service coverage. This surplus not only guarantees the availability of clean water for the community, but also strengthens the multiplier effect that drives economic productivity and increases the purchasing power of the people of Bogor City. Conclusion: These findings confirm that dynamic system-based planning is important not only to maintain the continuity of clean water supply, but also to maximize its contribution to comprehensive regional development. Originality/value (State of the art): This study provides an up-to-date review by integrating sustainability analysis (triple bottom line) into a dynamic system model for water utilities. Its originality lies in its ability to measure the indirect impacts (multiplier effects) of clean water services on economic productivity and public purchasing power, which are often overlooked in company performance assessments. The findings regarding surpluses that create opportunities for service expansion are practical contributions that policymakers can directly act upon, specifically in Bogor City and more generally in Indonesia. Keywords: drinking water, dynamic system, perumda tirta pakuan, vensim, water resources