PONE-D-24-05161Changes in systems thinking and health equity considerations across four communities participating in Catalyzing CommunitiesPLOS ONE

Dear Dr. Moore,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript is on a research topic of high interest and within the scope of PLOS One.

The reviewers have made very thorough and constructive analyses and suggestions with which I fully agree, and which will be key to improving the manuscript quality.

In my view:

- some concepts should be clarified (e.g. systems thinking), the background should provide more information on system dynamics and on measuring effectiveness, the description  of methods should be clear, the quantitative and qualitative results should be clearly portrayed, the discussion of results should take into account the approaches in use (e.g. interviews), and the timelines of all components of the study should be shown in a clearer format.

- the authors should make sure that all the relevant information is made available so that the study can be replicated.

Accordingly, if the address all referee comments, the manuscript has the potential to make a relevant contribution to PLOS One.

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Monica Duarte Correia de Oliveira

Academic Editor

PLOS ONE

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 [C.E. received funding that supported this study from the JPB Foundation (PR0580). The JPB Foundation did not play a role in the study design, data collection and analysis, decision to publish, or the preparation of the manuscript. https://www.jpbfoundation.org ].  

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors an important and persistent problem in public health. The paper needs to be improved by addressing the following issues:

General comment: Clarify the meaning of Systems Thinking and this is used in the research. Clarify what do you mean by the Systems Thinking skills of the stakeholders and project participants. Are these related to the adoption of a formal Systems approaches to tackle child obesity such as the Whole Systems Approach to Diet and Health Weight and/or the general "Thinking in Systems" in healthcare even if a non formal systems approach is being implemented (all health contexts and problems can be conceptualised from a Systems thinking perspective even if no formal Systems based intervention or approach is implemented).

General comment: Clarify how System Dynamics (SD) is being used in this research. There is a great deal of confusion on how Systems Dynamics is deployed in this research and to what purpose. Which SD tools and methods were used in the research and how these informed the data collection and data analysis methods in this research. There is a great amalgam of concepts included in the research (systems thinking, system dynamics, health equity, child obesity, catalizing communities interventions) and these need careful structuring and unpicking so that it is clear how each concept is used and how they are linked in a coherent way to inform the research.

1. Place the paper clearly in the literature on Child Obesity and System Dynamics as there has been a wealth of literature on these topics. Indicate how your research differs from and complements past research in this topic highlighting the novelty and contribution of your paper.

2.Page lines 61 to 70. Indicate how did you select the 4 evaluation questions. Clarify the role of "health equity" in the research as this was not developed prior to the evaluation questions.

3. Provide background information about the project you are gathering the data from.

4.Page 5. Background. Systems Thinking. Clarify the definitions of Systems Thinking and System Dynamics as these are different, albeit linked concepts. Provide a brief literature overview of the applications of System Dynamics in obesity control.

5.Page 6. Background. Provide an overview of the System Dynamics literature on Health Equity and how these relate and inform the Health Equity framework used in this study.

6. Page 12. Interview protocol. Provide references for the work done by the scholars, which informed your protocol.

7. Data Analysis. Provide more details om how the GMB activities described in Table 1 were used to help the community teams in the 4 locations develop their Systems Thinking skills. Were there any differences observed between the 4 locations.

8.Provide details about the health outcomes of the CC interventions in the 4 sites. Were there any improvements in terms of child obesity and health equity outcomes. If so, how this is linked to the development of the Systems Thinking skills by the stakeholders in the 4 sites.

9. Discussion: Discuss the findings of the research with respect to past academic literature especially with regard to the influence of GMB activities on group learning and improvements in shared problem understanding and policy making.

10. Discussion: Discuss the findings with regard to the measurement of stakeholders Systems Thinking skills and how this influences decision making quality. How these relate to the success of the interventions and health and equity outcomes.

Reviewer #2: With respect to the PLOS ONE criteria:

1. This study presents the results of primary scientific research.

2. To the best of my knowledge the results have not been published elsewhere.

3. I have some concerns/suggestions regarding the technical standard and sufficiency of the description of the analyses, which I detail below.

4. Whilst in the most part the conclusions are presented in an appropriate fashion and are supported by the data, there are a couple of areas where I do not feel that this is the case (see below).

5. The article is presented in an intelligible fashion and is written in standard English, although I do have some specific comments on how this could be improved (see below).

6. To the best of my knowledge, this research appears to meet all applicable standards for the ethics of experimentation and research integrity. However, I would ask the authors to consider whether the two student coders meet the conditions for authorship, and if so then they should be authors not just mentioned in the acknowledgements.

7. This article does not adhere to appropriate reporting guidelines and community standards for data availability. Specifically, I would suggest that the authors consider using the COREQ checklist for reporting qualitative research (or SRQR). If possible, it would be nice for the anonymised interview data to be made available, but I recognise that this may not be possible under the consent / research ethics agreement.

Summary

The authors present an interview based analysis of changes in the systems thinking, health equity thinking and health equity actions of participants involved in a community intervention for addressing childhood obesity (‘Catalyzing Communities’). They examine the intersections between systems insights and health equity thinking and action, and how these change pre/post engagement in Catalyzing Communities.

Major comments

- The quantitative approach is rather limited in the sense that: (a) the occurrence of a code does not convey the depth/quality about which someone discussed a concept, e.g. a brief surface-level mention would ‘count’ as much a lengthy in-depth and thoughtful discussion about a concept (b) code cooccurrences reflect that two different concepts were mentioned in an interview, but tells us nothing about whether/how they were discussed in relation to each other (c) the use of systems thinking language within an interview does not necessarily translate to a person understanding the concepts of systems thinking or acting in a way consistent with an understanding of systems thinking (d) an absence of a code does not mean that the participant doesn’t think/act in a particular way, it simply means that they didn’t say as much in an interview. I would expect to see these limitations noted in the manuscript at a minimum. Better still would be to include richer data in the form of quotes (see below).

- The authors state that they have conducted a mixed methods analysis, but the results are solely related to the quantitative analysis (frequencies of codes pre/post). These show some trends but are somewhat limited (see above) and complementary, richer insights could come from the qualitative aspect of the analysis, i.e. by drawing out themes and illustrating these with quotes. There are large sections of text in the results that list the cooccurrences of code categories that are shown already in the heatmap – instead, the authors could share more insightful findings through quotes that illustrate how systems insights were influencing health equity thinking/action. The authors could consider an additional table of quotes alongside the heatmaps that illustrate how different systems insights overlap with health equity thinking/action. Also - what did the participants say directly about how systems thinking had influenced their thinking and action about health equity? It seems odd not to include an analysis of that in addition to the code cooccurrence frequencies.

- The authors should include the topic guide (including any differences between the pre/post intervention interviews), either in the main manuscript or as supplementary material. When presenting frequencies of codes, i.e. the number of mentions, it is important for the reader to understand what was asked since this will naturally influence whether or not a participant will talk about something and how they talk about it. It would also be instructive for the authors to reflect on their positionality as interviewers and how this may have affected the interview responses and the findings.

- The study compares interviews conducted pre and post the first year of the CC. Over this time period many things will have influenced how the participants think and talk about healthy equity, and how they think and talk about systems (including the first interview itself, the possibility of which should be noted). Therefore increases in code frequencies alone cannot shed much light on whether the two are linked (and certainly cannot be used to attribute increases in health equity thinking to an increase in systems insights). However, through deeper qualitative analysis and illustrative quotes it might be possible for the authors to build up a richer understanding of how these things are related and influenced each other.

- The heat map encapsulates two things at the same time: the cooccurrence of systems insights with health equity thinking/action AND the change in this pre/post intervention. It would be clearer to de-couple these two things by providing an additional 2 tables that show the numbers of cooccurrences pre and post intervention separately. The authors could then describe the correlations in both cases before highlighting key changes. The key changes would also then be placed within the context of the absolute numbers, e.g. is a change in occurrence of +3 pre/post intervention due to a rise from 0 to 3, or from 12 to 15 for example?

- Some of the discussion on page 21 (lines 431-447) does not seem firmly rooted in the results. In particular, it needs to be clearer how the following statements are backed up by the results:

--- ‘The approach used in our study not only revealed participants' perceptions on key determinants influencing child obesity in local communities but also emphasized the importance of increasing system insights.’

--- ‘Firstly, our approach facilitated the identification of participants' perceptions regarding key determinants influencing child obesity prevalence in their local communities.’

--- ‘Secondly, our results reinforce the broader literature indicating that increasing system insights helps participants anticipate potential unintended consequences of prioritized actions.’

--- ‘Thirdly, the enhancement of system insights aids in designing interventions that are more adaptable to change.’

Additionally, please make it clearer how the following statement in the Abstract is backed up by the results: ‘Our findings reveal significant shifts in systems thinking… leading to improved systems insights and strategic intervention recognition’.

Minor comments

- It is not clear whether ‘health equity action’ means participants talked about possible health equity actions, or actual actions taken. The reader would benefit from a clearer definition of this term and how it is used in the paper.

- Page 7-8: ‘The whole-of-community intervention’ section would fit better in the background, not the methods, as it is about an intervention described elsewhere not the methods used within this study.

- Table 1 would be better as supplementary material rather than feature in the main body of the text since it is about an intervention reported elsewhere. There is also no reference to Table 1 in the main body of the text.

- I find the use of the term ‘systems thinking’ in this manuscript confusing. Usually, and indeed in several places in the paper, ‘systems thinking’ refers to an approach/method. Yet the authors also refer to ‘shifts in participants’ systems thinking’, by which I think they mean changes in their use of systems thinking concepts when talking about childhood obesity in the interviews (not a change in their use of systems thinking methods in practice or a change in the methodology itself). It would be helpful to find a different term to ‘systems thinking’ when referring to participants’ use of systems thinking concepts within interviews.

- More detail is required in the methods, for example were the interviews audio recorded, transcribed, anonymised? Was consent taken? What was the sampling strategy (was every committee member asked?) Did you reach saturation? Using the COREQ/SRQR will help to guide the sorts of information required in the methods section.

- In the text it says that Table 2 shows the 43 pre/post match participants, but it actually shows the coalition-committee members. Please revise Table 2 to include the details of the subset of committee members that were interviewed. Additionally, in Table 2 please clarify that it is ‘Community Race and ethnicity (%)’ and also include race and ethnicity as one of the committee characteristics. Please spell out the ‘NH’ abbreviation.

- I would suggest that the Table in the supplementary material goes instead in the main manuscript (moving the current Table 2 to the supplementary material would make room for it). I would also find it helpful to have 2-3 illustrative quotes for each code within this Table.

- I note that two students coded the transcripts - did a more senior researcher code a sample of the transcripts?

- In the Results, the ‘Systems thinking concepts’ section needs illustrative quotes (or a table or figure) so that the reader is able to get closer to the data not just a high level summary.

- Page 19 ‘the first process evaluation to …’ - is this study a ‘process evaluation’? This is not how the authors describe it elsewhere in the paper.

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Reviewer #1: No

Reviewer #2: No

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Changes in systems thinking and health equity considerations across four communities participating in Catalyzing Communities

PONE-D-24-05161R1

Dear Dr. Moore,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Monica Duarte Correia de Oliveira

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

In my view the authors made a serious revision, addressing mine and the referees' comments, and the manuscript is now worth publication by PLOS One. Congratulations to the authors.

I ask the authors to verify that all data involved in the study is made available to readers.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The study is interesting and relevant in the current public health context of child obesity. The replies to the comments are satisfactory and the required corrections have been made to the paper.

Reviewer #2: (No Response)

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Reviewer #1: No

Reviewer #2: No

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