Systems Thinking and the Planner's Mindset: Moving from Linear to Complex Adaptive Systems

The traditional view of program planning assumes a predictable world: design a program, implement it, and watch outcomes unfold as expected. This "Waterfall" approach served public health for decades.

But modern public health crises—pandemics, chronic disease epidemics, mental health emergencies—expose the fundamental flaw in this thinking. These challenges are inherently non-linear, operating within complex adaptive systems where simple cause-and-effect relationships don't hold.

This week establishes the foundation for adaptive program planning in the digital age.

The Evolution from Waterfall to Agile

Why Linear Planning Fails

Waterfall planning assumes:

• Problems can be fully understood before intervention
• Solutions can be completely designed upfront
• Implementation follows a predictable path
• Outcomes match predictions

Reality demonstrates:

• Problems evolve during planning
• Context changes during implementation
• Unexpected barriers emerge
• Outcomes rarely match predictions exactly

Public Health 3.0

The Public Health 3.0 framework emphasizes what traditional planning misses:

• Cross-sector collaboration
• Real-time data adaptation
• Community engagement as ongoing process
• Systems-level thinking

Key insight: A plan is a hypothesis, not a script. It must be tested, validated, and adjusted based on evidence.

The PRECEDE-PROCEED Framework

Despite the need for agility, structure prevents chaos. The PRECEDE-PROCEED model provides systematic diagnosis while allowing adaptive implementation.

The Eight Phases

PRECEDE (Planning):

1. Social Diagnosis - Quality of life concerns
2. Epidemiological Diagnosis - Health problems and determinants
3. Educational/Ecological Diagnosis - Predisposing, enabling, reinforcing factors
4. Administrative/Policy Diagnosis - Resources and organizational capacity

PROCEED (Implementation & Evaluation): 5. Implementation 6. Process Evaluation 7. Impact Evaluation 8. Outcome Evaluation

Beyond "What People Want"

Social diagnosis extends beyond surface-level community input. It explores:

Quality of Life Concerns:

• What do people value in their daily lives?
• What would improve their sense of wellbeing?
• What threatens what they care about?

The Behavioral-Environmental Link:

• How do behaviors contribute to health problems?
• How does environment shape behavioral choices?
• Where do genetics, behavior, and environment intersect?

Identifying Change Factors

The educational/ecological diagnosis identifies three categories:

Predisposing Factors: Knowledge, attitudes, beliefs, values, and confidence that precede behavior

• Does the population know about the health risk?
• Do they believe they're susceptible?
• Do they believe they can change?

Enabling Factors: Skills, resources, and accessibility that make behavior possible

• Are services available and accessible?
• Can people afford the healthy choice?
• Do they have the skills needed?

Reinforcing Factors: Rewards, feedback, and social support that sustain behavior

• Does the behavior produce positive outcomes?
• Do important others support the change?
• Is the new behavior socially acceptable?

Social Determinants and Equity Analysis

The Five Domains

Social determinants of health span five key domains:

1. Economic Stability: Employment, income, expenses, debt, medical bills, support
2. Education Access and Quality: Early childhood education, high school graduation, higher education, language and literacy
3. Healthcare Access and Quality: Health coverage, provider availability, provider linguistic and cultural competency, quality of care
4. Neighborhood and Built Environment: Housing quality, transportation, safety, parks, playgrounds, walkability
5. Social and Community Context: Social integration, support systems, community engagement, discrimination, stress

Moving Beyond Individual Interventions

Program planners often default to individual-level interventions because they're easier to implement and measure. But this neglects the "causes of the causes."

Individual-level thinking: "People should eat healthier" Structural-level thinking: "Why is unhealthy food the only affordable and accessible option?"

Structural Competency

Beyond cultural competency, structural competency requires:

• Understanding how social structures shape health
• Recognizing how policies create health disparities
• Designing interventions that address structural barriers
• Advocating for policy-level change

Intervention Mapping: Logic Models of the Problem

The Problem vs. The Program

Most planners jump to logic models of their program (what we'll do). Intervention Mapping starts with a logic model of the problem (what's happening).

Logic Model of the Problem asks:

• Who must do what differently for the health problem to change?
• What are the behavioral determinants of the problem?
• What are the environmental determinants?
• How do these factors interact?

Performance Objectives

Before designing interventions, specify performance objectives:

• What specific behaviors must change?
• What specific environmental conditions must change?
• Who are the actors responsible for each change?
• What would success look like?

This explicit articulation prevents vague interventions that "raise awareness" without defining actionable change.

Agile Team Chartering

Public Health as Team Sport

Complex problems require diverse perspectives. Agile team formation emphasizes:

Complementary Skills:

• Technical expertise (epidemiology, statistics)
• Domain knowledge (clinical, community)
• Communication skills (writing, presentation)
• Project management (organization, tracking)

Shared Accountability:

• Collective ownership of outcomes
• Mutual support during challenges
• Honest feedback and continuous improvement

The Team Charter

Teams create living documents that govern collaboration:

Working Agreements:

• How will we communicate?
• How will we make decisions?
• How will we handle conflict?
• How will we divide work?

Definition of Done:

• What constitutes completed work?
• What quality standards apply?
• Who reviews and approves deliverables?

This foundation enables effective collaboration throughout complex planning processes.

From Theory to Practice

The Mindset Shift

This week establishes several critical shifts:

| Traditional Thinking | Adaptive Thinking | |---------------------|-------------------| | Plans are scripts | Plans are hypotheses | | Linear causality | Complex systems | | Individual focus | Structural focus | | Expert-driven | Collaborative | | Static implementation | Iterative learning |

Practical Application

As you approach program planning:

1. Question assumptions: What are you assuming about cause and effect?
2. Map the system: Who are all the actors? How do they interact?
3. Find the leverage points: Where can small changes create large effects?
4. Build in feedback: How will you know if the plan is working?
5. Prepare to adapt: What will you do when assumptions prove wrong?

Looking Ahead

With this foundation established, the coming weeks build specific capabilities:

• Week 2: AI-augmented needs assessment for faster, deeper understanding
• Week 3: Human-centered design for user-focused interventions
• Week 4: Logic models and strategic alignment
• Week 5: Intervention design and prototyping
• Week 6: Agile implementation management
• Week 7: Resource mobilization and sustainability
• Week 8: Evaluation and storytelling

Each week builds on the systems thinking foundation established here, preparing you for the complex, data-driven, human challenges of modern public health practice.

Course Navigation

• Week 1: Systems Thinking (You are here)
• Week 2: AI-Augmented Needs Assessment
• Week 3: Human-Centered Design
• Week 4: Logic Models
• Week 5: Intervention Design
• Week 6: Agile Implementation
• Week 7: Resource Mobilization
• Week 8: Evaluation & Storytelling