‘It's About Collaboration’: A Whole-Systems Approach to Understanding and Promoting Movement in Suffolk

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J., Cusimano, K. M., Freeman, P., Southall-Edwards, R., and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4711882/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Jan, 2025 Read the published version in International Journal of Behavioral Nutrition and Physical Activity → Version 1 posted You are reading this latest preprint version Abstract Background: Population-levels of physical activity have remained stagnant for years. Previous approaches to modify behaviour have broadly neglected the importance of whole-systems approaches. Our research aimed to (i) understand, (ii) map, (iii) identify the leverage points, and (iv) develop solutions surrounding participation in physical activity across an English rural county. Methods: A systems-consortium of partners from regional and local government, charities, providers, deliverers, advocacy groups, and health and social care, and public health engaged in our research, which consisted of two-phases. Within Phase 1, we used secondary data, insight-work, a scoping review, participatory workshops, and interviews in a pluralistic style to map the system-representing physical activity. Phase 2 began with an initial analysis using markers from social network analysis and the Action Scales Model. This analysis informed a participatory workshop, to identify leverage points, and develop solutions for change within the county. Findings: The systems-map is constructed from biological, financial, and psychological individual factors, interpersonal factors, systems partners, built, natural and social environmental factors, and policy and structural determinants. Our initial analysis found 13 leverage points to review within our participatory workshop. When appraised by the group, (i) local governing policies, (ii) shared policies, strategies, vision, and working relationships, (iii) shared facilities (school, sport, community, recreation), and (iv) funding were deemed most important to change. Within group discussions, participants stressed the importance and challenges associated with shared working relationships, a collective vision, and strategy, the role of funding, and management of resources. Actions to leverage change included raising awareness with partners beyond the system, sharing policies, resources, insight, evidence, and capacity, and collaborating to co-produce a collective vision and strategy. Conclusions: Our findings highlight the importance and provide insight into the early phase of a whole-systems approach to promoting physical activity. Our whole-systems approach within Suffolk needs to consider methods to (i) grow and maintain the systems-consortium, (ii) create a sustainable means to map the system and identify leverage points within it, and (iii) monitor and evaluate change. Health Policy Health Economics & Outcomes Research Exercise health intervention leverage points physical activity sport wellbeing Figures Figure 1 Figure 2 Figure 3 Background Consistent with long-term trends, across the UK, and the globe(1), 36.9% of adults(2) residing in England are physically inactivity (i.e., do not meet physical activity (PA) guidelines; >150 minutes of moderate intensity PA per-week)(3, 4). PA is a modifiable risk-factor for a multitude of non-communicable diseases(5), poor mental health and wellbeing(6, 7), reduced quality of life(6, 7), and all-cause mortality(5, 8, 9). From an economic perspective, it is estimated £7.4 billion is spent per-annum on the consequences of inactivity within the UK alone(10). For these reasons, addressing the complex behavioural challenges surrounding inactivity has remained a concern for regional and national stakeholders and policymakers for upwards of 60 years(11-14). Historically, population-level interventions, programmes, and schemes aiming to improve PA participation have reduced implementation to parsimoniously modifying single or multiple determinants on the individual (e.g., motivation), interpersonal (e.g., social support), or environmental (e.g., access to facilities) level in an effort to elicit change in the ‘intention’ of behaviour(15-17). Albeit promising over the short- to medium-term and when defined within a ‘place’ , ‘setting’ or ‘population’ or underpinned by strong participatory research and behavioural theory, these efforts often require high agency, exacerbate inequalities, and report poor long-term acceptability, feasibility and effectiveness at a population-level(16, 18). In addressing this challenge, more recently, public health policy approaches (e.g., Uniting the Movement, Local Delivery Pilots) have moved towards ‘whole systems-based’ thinking, methods, and place-based working practices to try to change and sustain population PA behaviours(19-21). Systems-thinking represents a broad set of approaches which rather than limit the intricacy underpinning a behaviour, seek to understand, embrace, and challenge its complexity(19-21). More specifically, these approaches consider PA as a product of a dynamic, adaptive, non-linear, evolving, and time-variant system, which is represented by a series of interdependent behavioural determinants (e.g., individual, interpersonal, social actors, political, structural, environmental) across multiple levels of influence(19-21). Central to systems-thinking, above non-linear ‘cause and effect’ behavioural theories which focus on the ‘intention to change’ , is that a whole-system is adaptive, in that it is influenced by feedback, interventions and actions within it, the social power of actors, and structural changes within and external to its boundaries(20, 21). Systems-maps are a commonly adopted tool to illustrate this nuanced complexity(20, 22, 23). More specifically, these maps provide visual insight into how factors across the systems influence each other(20, 22, 23), assist in the identification of points of leverage(24-26), and complement evaluation and monitoring(27, 28). Good evidence(23, 26, 29, 30) indicates maps can be produced from a variety of primary and secondary forms of qualitative (e.g., workshops, interviews, focus groups, co-production, reviews) and quantitative (e.g., surveys, analysis) sources of data. Notwithstanding, evidence suggests adopting methods which are participatory, may produce additional benefits such as building a shared agreement on the nature of the problem, identifying roles within the system, and co-producing policy and strategy responses(20, 29). Within any system, leverage points are present(24, 25). These are factors which are vital for meaningful change, and which if modified can impact upon the function of the system(24, 25). To assist stakeholders, policymakers, and researchers to understand and identify different types of leverage points, various models, theories, and frameworks exist, which are not limited to the Meadows 12(31), Public Health 12(25) and Action Scales Model(24), and various markers from social network analysis(32) (e.g., degree, betweenness, eigenvector). Broadly, leverage points are identified, formulated, and evaluated to the extent in which they influence the system(24, 25). Across multiple models, leverage points can be clustered into a hierarchy of paradigms and beliefs (e.g., deeply held philosophy at the foundation of the system – value of movement), goals (e.g., purpose, targets, and ambition of the system – aim to increase movement), systems structures (e.g., environmental, social, economic change – low traffic neighbourhoods), feedback loops, and events (e.g., behavioural interventions – daily mile, cycle to work schemes)(20, 24, 25, 31). Across this hierarchy, leverage points which modify attitudes, norms, and rules (i.e., beliefs, goals) offer a culture change and therefore greater leverage (24). In contrast, leverage points such as interventions (e.g., events) often operate in isolation and present short-term solutions to problems within the system(24). Global (i.e., WHO Action Plan, Eight Investments Which Work)(13, 33), UK (i.e., Uniting the Movement)(34), regional and local (e.g., Suffolk Core20PLUS5(35) policy emphasises the importance of place-based systems change when attempting to improve population PA participation. Suffolk, UK is one example of a place-based system, whereby defined regional geographical and policy boundaries exist(35). The county is a disparate mix of rural (i.e., village) settings, amongst coastal and high-density urban dwelling population hubs (e.g., Ipswich, Bury St Edmunds)(35). Amongst differences in geography, there are meaningful health inequalities such as variation in age, multiple deprivation, life expectancy, access to health services, housing, and education across the county(35). Moreover, Suffolk has disproportionately greater mortality related to cardiorespiratory events, poor mental health, COPD, and cancer(35), an increasingly aging population, and reduced healthcare provision, infrastructure, and investment(35). This interlinking complexity places greater emphasis on the importance of the prevention of conditions via lifestyle-based health behaviours (e.g., PA)(19-21). Indeed, current regional government strategy stresses the need for direct and indirect support for population change in lifestyle behaviours(35). This need and complexity underscores the importance of systems-thinking and whole-systems working across the county(19-21). For this reason, our research team began working with Active Suffolk (www.activesuffolk.org), the Active Partnership (see www.activepartnerships.org), to develop a systems-map that represents PA participation in Suffolk and identify leverage points for change. This was a process which stakeholders or policymakers across the county were yet to explore. Objectives The objective of this research was to explore PA participation across Suffolk through a systems-thinking approach by: (i) understanding what determines participation in PA in Suffolk (ii) mapping the system and (iii) identifying leverage points within it and (iv) inviting partners to develop solutions and actions points for change. Methods Design and Overview To determine the factors influencing participation in PA, formulate the system and identify leverage points within it, we worked alongside Active Suffolk to develop a broad consortium of partners. These actors represented (i) regional government and public bodies, (ii) local government and public bodies, (iii) regional PA stakeholders and charities, (iv) deliverers and provisions, (v) advocacy groups, (vi) participant representatives, (vii) primary, secondary and public health bodies, and (viii) education and young people. The consortium engaged in two phases of the research to varying degrees (Figure 1). Phase 1 sought to understand the determinants and map the system that underpins PA participation within the county. Phase 2 identified leverage points and actions via a mixed-methods analysis and a group workshop. Ethical approval was provided by the University of Essex (ETH2223-2022). Participants provided written informed consent to participate in the research. Systems Map Development (Phase 1) Overview and Systems-Map Development To understand the complexity underpinning PA participation (i.e., walking and cycling for transport, sport, exercise, play and leisure) we utilised a pluralistic(36) sequential process, using a ‘methods approach’ to triangulate data into our (37, 38) systems-map (constructed via KUMU™). Multiple-methods were used to explore determinants within the map from varying perspectives(37, 38), complementing philosophies that systems are non-linear, adaptive, and a changeable phenomenon. An initial map was generated on KUMU™ informed by; existing literature(20, 22, 39), an analysis of Active Lives data(2), and insight work (e.g., GAPPA mapping(13, 33)) and ripple effects mapping conducted within the system. This map formed a foundation for participatory mapping workshops, a scoping review of evaluation reports, policy and strategy, and interviews. Further, given systems are non-linear, adaptive, and changeable(19-21), we additionally trained one insight officer (Active Suffolk) in understanding the system and how to update the systems-map via KUMU™. This approach enabled over multi-iterations to layer, compare, and contrast data, which provided insight into divergence, inconsistency, or deficiency in the map(38, 40).(19-21) This provided understanding into where additional data would provide greater clarity on a given determinant or link. Where such a complication arose, additional data was collected to remove this paucity. To build our map we utilised inductive reasoning to identify, specify, and critically appraise determinants (e.g., circles on map; nodes) and the links between these. Participatory Systems Mapping Workshops and Sense Making To evolve the systems-map to a local context, we conducted two systems-mapping workshops. A half-day face-to-face participatory systems mapping(23) workshop was conducted with a heterogeneity of actors across the Suffolk PA system to explore the initial determinants influencing PA participation (workshop 1). Participants ( n =26) were sampled to represent the heterogeneity of organisations involved in the consortium and invited via email. Participants represented regional government and public bodies (23%), local government and public bodies (7.5%), regional PA stakeholders and charities (4%), deliverers and provisions (12%), advocacy groups (15.5%), participant representatives (7.5%), primary, secondary and public health bodies (23%), and education and young people's organisations (7.5%). During the first workshop, the map was modified by actors through sequential stages which considered each determinant, link, and theme (i.e., group of determinants). Following a final discussion of the map, actors suggested additional data and mapping were required to; (i) understand the enablers and challenges unique to Suffolk; (ii) perspective of residents across the county. To deepen local understanding, we conducted an independent systems-workshops with residents of Suffolk. We adopted a modified version of our initial systems-workshop to deliver a half-day face-to-face participatory systems mapping(23) workshop to understand the determinants of participation from the perspective of individuals residing within the county (workshop 2). The workshop was coordinated by a local charity, comprising working-age and older-adults ( n= 33; Age: 65.7±9.8, 45% females), and represented a range of localities, and social-demographic factors (e.g., deprivation, living arrangements). Unlike the workshop one, we adopted a simplified sequential process to development. Working in small groups ( n =5-6) and on a large sheet of paper, participants defined PA. This definition formed the centre of map. Following the process, participants listed PA enablers and challenges around their definition. Organically, and following direction from a facilitator, participants linked these enablers and challenges (e.g., crime linked to feelings of low self-confidence exercising in green space). This exercise of linkage created further conversations, and the development and adaption of additional nodes. Finally, participants were invited to visit other maps and discuss the challenges and enablers they faced. This process led to further revision of the maps. Maps were collated and layered onto the broader systems-map for Suffolk following workshop two. Systems-workshops are limited by the extent of the actors and organisations present(23). For this reason, the research team conducted interviews ( n =4) and small-group discussions ( n =6) with partners across the consortium to make sense of the system, identify additional determinants of participation, and gain feedback on the systems-map. These sessions lasted about one-hour, were conducted via online video communication software (Zoom™) or face-to-face and involved between three and eight partners in the case of group discussions. Within each session, the researcher provided an overview of the map, an insight into the functionality of KUMU™, and themes within the map (e.g., built environmental factors). Following this overview, participants were asked to reflect on how the map represented; (i) their organisation and its function/operations; (ii) Suffolk broadly. Critical feedback provided insight into the creation of new nodes, and revision of existing nodes within the map. Data were transcribed verbatim, deductively coded, and layered onto our evolving systems-map(37, 38). Document, Policy, and Strategy Review To expand on our understanding of the system we conducted a scoping review of existing documents (e.g., evaluation reports, insight reports), strategy, and policy across each of the systems sectors outlined above. To identify grey evidence, we used Google Scholar, Overton, and independent searches of each systems-partners' website. Due to relevancy, searches were limited to 2010 to date, and included search terms formulated from the initial systems map, in combination with regional locations and PA (see additional file 1). To expand our review, indexing (i.e., searches for documents within included evidence) and sibling-searches (i.e., related evidence conducted by the same author/organisation) were conducted. For inclusion, evidence had to be; (i) presented within written, audio, or visual format; (ii) be related to PA; (iii) be related to Suffolk. In total, 187 documents were included within the review. This evidence was deductively coded against the existing system-map(37, 38) Leverage Point Identification and Actions (Phase 2) Initial Analysis and Framing Workshop Three There remains no gold-standard to identify and specify leverage points within a system aiming to understand a public health phenomenon(41). Therefore, to identify leverage points with our system, we utilised a quantitative and qualitative approach, which served as a precursor to a workshop with consortium members (workshop 3). Similar to previous approaches(26, 42) we adopted quantifiable leverage measures(32) to unpick the complexity of our map. Using KUMU™ in-built metrics tool, we analysed the map across its ‘eigenvector’ (i.e., how well connected a factor is with other well-connected elements), ‘degree’ (i.e., the number of connections), and ‘betweenness’ (i.e., bottle-necking between factors)(32). Following the identification of up-stream determinants with a high eigenvector, betweenness, and closeness values, we applied the Action Scales Model(24). This was selected due to its parsimony, accessibility, and our need to translate findings to systems-partners in a clear and understandable style(24). This conceptual tool integrates the complexity of the Meadows 12(31) (and as such the Public Health 12(25)), alongside the Iceberg Model(43) and Intervention Level Framework(44). The model indicates leverage can be conceptualised into four progressively influential points of change (see Nobles et al(24) for a more detailed overview), specified as; ‘events’ (i.e., the outcomes, behaviours, symptoms of the system); ‘structures’ (i.e., the environmental and social factors which shape events within the system); ‘goals’ (i.e., the rules, policies, strategies, and ambitions within the system); ‘ beliefs ’ (i.e., deeply held values, norms, and attitudes within the system). The analysis process was sequential and conducted independently by three members of the research team (AB, KC, RSE). Researchers met to critically discuss each of the leverage points within the system. These discussions were expanded with the broader research team, whereby an internal verification process was carried out and a long-list of 54 leverage points was developed. Following these steps, this long-list was discussed by three members of the research team (AB, RSE, PF) and two members of Active Suffolk staff with local insight. Leverage points within the long list were debated on the extent in which they held the capacity to cause larger systems change. For the purposes of the leverage point workshop (workshop 3), we outlined 13 points within the system where change may be effectively leveraged. Leverage Point Workshop (Workshop 3) Workshop three built upon the initial analysis and invited actors to rank leverage points and develop strategies, methods, and approaches to leverage change. Participants involved in the workshop were sampled to represent the range of organisations across the Suffolk PA system and were invited to a half-day leverage points workshop via email (n=21). These actors were sampled from regional government and public bodies (15%), local government and public bodies (35%), regional PA stakeholders and charities (15%), deliverers and provisions (20%), and primary, secondary and public health bodies (20%). Delivered in sequential steps, the research team provided an overview of the system representing PA within Suffolk, key features of the systems maps (e.g., themes), leverage points, the Action Scale Model(24), and the analysis of leverage points conducted prior to the workshop. Following this overview, in three groups of seven, using cards, participants were asked to rank leverage points considering their; (i) feasibility; (ii) potential impact; (iii) importance within Suffolk. The research team collated this output and outlined the top four leverage points to modify within the county (i.e., based on total sum of importance). Following this, participants self-assigned themselves a leverage point to discuss, develop solutions for, and modify (four groups of n =4-6). Supported by a facilitator from the research team and inspired by the process outlined within the Action Scale Model(24), participants considered how, where, when, what, and why changes should occur. Finally, participants presented their solutions to the broader group, and the context and considerations this operates within. This was followed by questions and debate by the broader group. These presentations and conversations formed the basis of action points for on-going systems change (noted on post-it-notes). Conversations and observations by the research team were recorded via voice recorder or notes. These were transcribed verbatim, and analysed through a deductive thematic analysis(45). Finally, following the workshop, we analysed the correlation between combined feasibility and impact scores, impact and importance, and feasibility and importance scores using Spearman rank correlations. Findings Phase 1: Overview of the Systems-Map An overview of the systems-map is provided in Figure 2, with an interactive version accessible on KUMU™ (www.tinyurl.com/SuffolkPA) including definitions for each node. The map is constructed from 90 nodes that are segregated into nine themes (biological, financial, and psychological individual factors, interpersonal factors, systems partners, built, natural and social environmental factors, and policy and structural determinants). These factors influence four individual modes of PA (cycling, walking, active leisure/play, sport), which contribute to overall PA. Phase 2: Overview of Leverage Points and Initial Analysis A complete presentation of each node, and its respective eigenvector, degree, and betweenness is available via KUMU™, within the ‘table’ function. Table 1 outlines the twenty most influential nodes ranked on eigenvector (excluding modes of activity). In addition, critical discussions based on the Action Scales Model additionally highlighted ‘urban design and density’, ‘speed volume of traffic, driver behaviour and culture’, ‘shared facilities (e.g., sport, community, recreation)’, ‘multiple deprivation and socioeconomic status’, ‘cycling culture’, ‘organisational values and beliefs’, ‘funding (e.g., health, fitness professionals’ schemes, interventions, programmes), and ‘social media’ as important nodes for leverage within the system. Table 1. Leverage Point Analysis Node (Factor) Eigenvector Degree Betweenness ASM Level Sport Facilities, Clubs and Opportunity 0.043 18 0.026 Structures Inclusive/Diverse Facilities/Opportunities 0.037 23 0.088 Structures Self-Confidence, Capability and Competence 0.037 18 0.037 Events Air Quality 0.033 13 0.014 Events Walking Infrastructure 0.027 15 0.007 Structures Climate 0.026 7 0.007 Events Recreation Infrastructure, Spaces and Places 0.022 11 0.021 Structures Walking Culture 0.021 6 0.005 Beliefs Motivation 0.020 12 0.054 Events Local Governing Policies 0.019 29 0.053 Goals Physical Activity History 0.019 4 0.009 Events Promotion/Marketing 0.017 13 0.044 Structures Perceived Available Time 0.017 13 0.025 Events Crime and Anti-social Behaviour 0.016 9 0.026 Events Local Social and Cultural Norms 0.016 14 0.026 Beliefs Community Resources, Training and Support 0.016 12 0.006 Structures Physical Health Status and Function 0.016 12 0.007 Events Community Centres/Spaces 0.015 11 0.002 Structures Shared Policy/Strategy/Vision/Working 0.015 16 0.018 Goals Proximity to Destinations 0.014 10 0.008 Structures Notes: ASM (Action Scales Model). Critical discussions between the research team and Active Suffolk against each leverage points feasibility, impact, and importance within Suffolk led to the following nodes being brought forward to the leverage point workshop designed to combine scientific research with local systems-knowledge and insight. Phase 2: Findings of Leverage Point Workshop (Workshop 3) Ranking Leverage Points within the System Following critical discussion within groups, participants ranked leverage points within the system on their feasibility, impact, and importance (Table 2; see Attachment 2 for a more detailed overview). Group rankings across each leverage point and the total sum of importance were used to underpin the top-4 solutions below. Leverage points of seemingly greater impact (Median: 19, IQR: 12) were ranked poorly in terms of feasibility to change (Median: 20, IQR: 12), but not significantly (rho=-.20, p=.49). Further, leverage points with high importance (Median: 17, IQR: 12) typically represented a greater degree of leverage within the Action Scales Model(24), but were not correlated with feasibility (rho=.42, p=.14) or impact (rho=.39, p=.17). Observations from the research team indicate participants representing strategic organisations or involved in policymaking tended to preference ‘beliefs’ and ‘goals’, whilst organisations with a meaningful delivery capacity placed emphasis on ‘events’ within the system. Developing Solutions to Leverage Change, Actions, and Next Steps Solutions related to (i) local governing policies, (ii) shared policies, strategies, vision, and working relationships, (iii) shared facilities (school, sport, community, recreation), and (iv) funding were developed by four sub-groups. An example of a group’s solutions, challenges, context, and considerations when leverage change is outlined within Figure 3. Table 2. Leverage Points from Workshop Ranked on Impact, Feasibility and Overall Importance Leverage Point (Ranked by Total Importance) ASM Level Total Impact Feasibility Overall Importance 1. Local Governing Policies Goals 11 14 20 2. Shared Policies, Strategies, Vision, and Working Relationships Goals 13 17 12 3. Shared Facilities (School, Sport, Community, Recreation) Structures 14 21 19 4. Funding Structures 15 19 25 5. Inclusive/Diverse Facilities/Opportunities Structures 16 32 13 6. Self-Confidence, Capability and Competence Events 16 11 26 7. Recreation Infrastructure, Spaces and Places Structures 17 11 20 8. Local Social and Cultural Norms Beliefs 21 15 33 9. Community Resources, Training and Support Structures 22 22 14 10. Promotion/Marketing Events 27 36 3 11. Walking Culture Beliefs 30 15 24 12. Cycling Culture Beliefs 33 21 29 13. Crime And Anti-Social Behaviour Goals 38 39 35 Note: ASM (Action Scales Model). The Importance of Collective Working, Relationships, Vision, and Strategy Within the broader group discussion in workshop 3, participants acknowledged the importance of shared working relationships, a collective vision, and strategy. Whilst not complex to establish such relationships or a core ‘vision’ (i.e., to get people active) within the consortium, it was deemed challenging to get organisations to functionally work together in the long-term (e.g., creating a shared strategy on PA). Central to this challenge was that organisations often held divergent models of delivery, organisation, or policymaking that frequently conflicted or challenged each other. In proposing a solution to this challenge, one stakeholder discussed the importance of ‘collective buy-in’ where all deliverers, organisers, unexpected actors, and public health partners are provided a space and voice to co-produce strategic goals and collaborate on a shared strategy: ‘It's about collaboration. It's about understanding how we can all contribute. It's about understanding that shared vision, shared goals and recognizing that everybody has something different to add’ Senior Policymaker (Stakeholder) A Co-Produced Strategy and Vision Any co-produced strategy should be applicable at a local, district/ward and regional level, and a product of shared evidence. One solution presented by a group was a 20-year prediction of health and wellbeing in the county. In such evidence, a scenario would be presented whereby the current predicted state of health would be compared against a 20-year plan with collective change and direction surrounding PA (i.e., mapping PA within the priorities of the integrated care system). The use of shared evidence and proposed collective working was deemed essential in the ownership and function of a whole-systems approach. This ‘golden thread’ of evidence was deemed important given: (i) it raises the priority of PA within public health conversations; (ii) current health and wellbeing policymakers such as the integrated care system/board operate in a 20-year timeline currently. Central to engaging such policymakers such as regional health and wellbeing boards with any vision or strategy was switching the delivery and organisation model from being reactionary to preventative (i.e., not reacting to events in the system, but adapting structures, goals, or beliefs): ‘It’s about switching the emphasis to prevention. I'm preaching to the converted, but prevention rather than reacting to the problems that we've got. We felt perhaps in the physical activity strategy there could be a shared vision that is underpinned by some principles and evidence that everyone could buy into. That would be good’ Senior Operations Director (Local Council) Sharing Facilities and Resources A challenge related to evidence, knowledge, and insight was highlighted by the group focusing on shared facilities. Due to its rural and expansive nature, Suffolk is a region with a large quantity of facilities, spaces, and places to participate in PA. Often owned or managed by schools, education providers, councils, and unexpected providers (e.g., religious groups), there remains no collective audit or database of such facilities. An area, the group acknowledged was important in terms of a collective strategy surrounding the shared use and management of facilities. With such a strategy, participants discussed the importance of supporting unexpected providers with funding and resources to open outside of normal-working hours: ‘There are facilities that are there that are probably underused. So we're talking about school halls, not necessarily sports centres as such, but school halls, church halls, community facilities, things like that, that need to be used, but they probably have a little bit of an issues. They don't know how to open up, or they don't have the resources to open up. We talked about what do we want to get from those facilities? So is it traditional sport? Is it physical activity? Is it really, really soft approaches? We then focus a lot of our time onto the strategy stuff. So can we produce? Suffolk wide strategies that help for those facilities to open. So is there something to not necessarily force facilities into opening?............But actually, if we can force that happen with a collective approach, but this is actually going to be mutually beneficial. Regional Sports Provider (Regional Governing Body) This underscores the importance of inviting the owners, managers, or administrators of such facilities to any level of strategic development and consortium. Funding Funding was deemed as a key leverage point within the system. For example, participants acknowledged for any meaningful change to occur in PA behaviour, the way in which funding is allocated and spent across systems partners needed to be modified. Indeed, funding for PA, was deemed to focus on short-term projects (e.g., events in the system), be reactionary, rather than preventative, and rarely collaborative. To many extents, partners commented that this approach to funding within the system, promoted competition among organisations, rather than encouraging whole-systems working. Consistent with other leverage points, a collective vision and collaborative model was proposed. This centred on long-term pooling resources, shared capacity, and collective investments. Key was funding ‘what works’ and acknowledging ‘what doesn’t ’ through shared insight, evaluation, and monitoring: ‘Sharing what we do and then agreeing to replicate our work with each other, to in a sense, expand the projects we're working on, across and between the district boundaries. If we decide to work like that, we could do it. It could be really exciting’ Operations Manager (Stakeholder) Solutions and Actions Points to Promote Change Actions signalled steps for individual, organisational, and shared commitments to leverage change (see Table 2). Broadly, these ‘actions’ reflected a need to leverage change within ‘goals’ in the system, such as sharing policies, resources, insight, evidence, and capacity, working together on projects and funding applications, and collaborating to co-produce a collective vision and strategy. Actions also reflected a need to raise awareness, build an evidence base, create a step change in the priorities of public health (i.e., moving PA up the agenda) for strategic policymakers (e.g., heads of local government, integrated care system and/or board). There was a theme of influencing ‘good will’ or ‘hearts and minds’ of these policymakers via promoting the success of collaborated projects (e.g., fit villages), and a shared voice, vision, and strategy for the future. In addressing this, the consortium underpinning the current project was proposed as a solution to create advocacy. However, while this group has the positives of a flat hierarchical structure (i.e., equal partners), it was acknowledged that there remains no leader managing and coordinating the system. Table 3. Actions for Change Action (Type of Organisation) Type of Organisation Leverage Point ASM Level Include physical activity, exercise and/or sport within strategy or priorities Deliverer/organiser Local governing policies Goals Collaborate with other districts, organisations, and wider partners– share information about projects and grant funding Organiser Shared policies, strategies, vision, and working relationships Goals Shared vision, direction, relationships, and ethos within and across organisations Stakeholder Shared policies, strategies, vision, and working relationships Goals Understand, advocate, and support the use of shared spaces, places, and facilities Stakeholder/deliverer Shared facilities Structures Promote ‘work’ and good stories across county Stakeholder Shared policies, strategies, vision, and working relationships Goals Champion insight and impact Stakeholder Shared policies, strategies, vision, and working relationships Goals Advocate for physical activity across the county Stakeholder Shared policies, strategies, vision, and working relationships Goals Develop an advocacy/support group for policymakers Stakeholder Shared policies, strategies, vision, and working relationships Goals Develop a volunteer and resident voice group for physical activity across the county Organiser Shared policies, strategies, vision, and working relationships Structures Share knowledge and skills with other organisations to improve access Organiser Shared policies, strategies, vision, and working relationships Structures Engage, challenge and work with the integrated care system (NHS) to build advocacy for physical activity Stakeholder Shared policies, strategies, vision, and working relationships Goals Provide collaborative leadership on funding Stakeholder Funding Structures Coordinate a countywide physical activity strategy Stakeholder Shared policies, strategies, vision, and working relationships Goals Develop ‘future’ evidence/position – Suffolk in 20 years report Organiser/stakeholder Local governing policies Goals Note: ASM (Action Scales Model). Actions are grouped into common themes. NHS (National Health Service). Discussion The objective of this research was to explore PA participation across Suffolk through a systems-thinking approach by: (i) understanding what determines participation in PA in Suffolk (ii) mapping the system and (iii) identifying leverage points within it and (iv) inviting partners to develop solutions and actions points for change. A complex systems-map of the determinants of PA in Suffolk was developed comprising of 90 nodes that converge around nine factors. Through a participatory approach the four most important leverage points identified were; (i) local governing policies; (ii) shared policies, strategies, vision, and working relationships; (iii) shared facilities (school, sport, community, recreation); (iv) funding were deemed most important to change. Actions to leverage change included raising awareness with partners beyond the system, sharing policies, resources, insight, evidence, and capacity, and collaborating to co-produce a collective vision and strategy. These findings complement and extend the growing body of evidence, which has utilised a pluralism of methodologies to understand the dynamic system underpinning participation in PA(19-21) and chart leverage points for change within this complexity(22, 39, 42, 46-48). This research provides important insight into the steps underpinning a shift towards a whole-systems and place-based approach to working. Our analysis shares many of the same intrapersonal- (e.g., motivation), interpersonal- (e.g., social support), environmental- (e.g., facilities) and policy-determinants (e.g., funding) identified at a global, national, and regional-level within systems- and ecological approaches aiming to understand PA behaviour(20, 22, 39, 42, 46-49). Moreover, many of the same organisations present within the policy space surrounding PA (e.g., regional government, healthcare organisations, providers)(42) were present in our analysis, as were the connections between these organisations(47), and the themes in which policy is shaped around(39) (e.g., environment, society, systems, people). However, a system is a dynamic, adaptive, time-variant and emergent web(19-21), which responds to feedback, and is shaped by factors internal and external (e.g., national governmental policy) to its boundaries(20). Therefore, while systems-maps within a context (e.g., PA promotion) share many similarities(20, 22, 39, 42, 46-49), how factors (nodes) interact(19-21), how change is intentionally and unintentionally brought about, and how the social power of actors influences change is unique(20, 21). This is particularly prominent in the case of leverage points(20, 24, 25, 31), where we found the extent in which change can be influenced is underscored by its feasibility, perceived importance, and potential impact by actors within the system. Interestingly, in all cases, participants ranked leverage points which reflect goals or structures (e.g., policy, resources) in the Action Scales Model(24) as the most important to change. Modifying goals or structures within the system, is thought to influence larger whole-systems change (e.g., changing a policy has an impact on many, rather than a few)(24, 25). However, leverage points related to beliefs within the system such as cultural change, paradigms, or norms, were more often ranked poorly in terms of their feasibility to change. In agreement with Power and colleagues(47), changes upstream within the system such as a shift in paradigms, norms and culture may take sustained efforts, time and engagement(24, 25). For these reasons, leverage points reflecting beliefs may appear to be unfeasible and low in impact to actors within the system. Therefore, it remains important for future research to unpick the long-term complexities of leveraging change within the PA space(50). This is particularly important, given a shared belief in the system may support the likelihood of policies to be collectively shaped and implemented(24, 25) in the long-term. Previous research seeking to encourage movement through a systems-approach found similar leverage points(42, 51). For example, systems representing recreational participation have likewise found the importance of goals (e.g., serving the needs of young people) and varying forms of structural change (e.g., urban design, safety, policy change to support movement, laws, regulation)(42, 51-53). These studies also underscore the importance of feedback loops and delays (e.g., appeal of facilities growing as more people use them)(42, 51-53), points in which the systems-consortium also recognised and discussed in regard to implementing a shared strategy. More specifically, consistent with research, it was recognised that it would take time to build consensus and an develop an effective whole-systems approach(17, 25, 54, 55), but a shared vision would bring in new partners, grow the system, and therefore the extent to which change could be brought about. The current research identified several specific and important leverage points across the system which could enhance PA in Suffolk. Modifications to local governing policies, a shared strategy and vision, and collaborative working which transcend across the region, and into localities and districts of the county may have the capacity to cause downstream change to models of funding and the sharing of resources and facilities, points of leverage also identified within our research. However, the emphasis placed on these leverage points is consistent with the growing body of national and global strategies(19-21) and research(17, 25, 54, 55) which underscores the importance of whole-systems approaches in addressing complex societal complications and the importance of organisations working functionally in the long-term. The identification of these leverage points is also consistent with a recent evaluation of a whole-systems approach to promoting PA within an English county(46). In addressing this challenge, research broadly indicates the importance of a central organisation to bring system actors together, drive change, and manage organisational differences, understanding the needs of each actor, their motivation and similarities in approach and strategy, and highlighting the co-benefits of systems-working (e.g., shared priorities)(46, 54, 56, 57). In the case of our approach and sharing similarities with previous projects implemented within UK policy (e.g., local delivery pilots), this responsibility fell to the Active Partnership (i.e., Active Suffolk)(46, 58). In agreement with Nobles and colleagues evaluation of ‘We Move Together’ (46), in the case of the present system, bringing actors together was acceptable and pragmatic, given there was already a broad emphasis placed on the importance of the needs for systems-based approaches surrounding public health and PA promotion within regional governmental policy (e.g., Core20PLUS5)(35). Notwithstanding of this, participants within our research highlighted the absence of voices from within related areas of public health, and the broader integrated care system. The representation of voices, including the right people within a whole-systems approach, and exploring how these individuals interact (e.g., the strength of their relationships) has been previously acknowledged as a challenge to effective working and implementation(46). Future research therefore may consider the application of modes of social-network analysis(23, 59) in exploring the interaction between actors across the system, and the identification of organisations not present within whole-systems approaches to promotion. This research is likewise consistent with research unpicking whole-systems approaches, in that our participants emphasised rather than seeing divergence in strategy and policy, focus should be directed towards similarities and co-benefits(17, 25, 54, 55). With our research, the concept of a shared vision, collective evidence base and strategy may also create a ripple-effect in that it reduces the clash of mindsets and ways of working observed in previous research(17, 25, 54, 55), and draws actors towards a central way of working, collective buy in, and ownership. This is particularly important in terms of funding and sharing resources and facilities across the county, where approaches were reported to be transactional, reactionary, non-collaborative, short-term, and focused on events within the system, rather than resourcing broader upstream changes(24-26). These factors can promote competition and create divergence, rather than encouraging collective working(17, 39, 46, 56). Consistent with previous research(17, 39, 46, 56), our research underscored the importance of funding and resource sharing through effective systems-leadership and collaboration on research and insight, advocacy, and knowledge and information sharing (e.g., resource availability, funding opportunities). Reflections and Recommendations This novel research adds to the growing body of evidence into using whole-system approaches to identify and leverage change to promote increases in PA. The following recommendations and actions are made based on the findings of this research: Recommendations & Actions A whole-system, participatory approach is required to ensure the correct people and local knowledge and insight are brought together to drive and advocate for change. A shared vision is required to bring in new partners, grow the system and work towards long-term whole-system change. This will require time to identify and utilise the similarities between organisations and promote the co-benefits of working together. Resources, such as system maps that help to identify leverage points require regularly updating to reflect the dynamic and evolving nature of the system. Individuals and organisations should be bold and open to not always doing the same and should not only consider leveraging change where it is most feasible but also where it may lead to the most impact. It is important that policy to increase PA behaviour incorporates, encourages, and enables a system thinking approach. In order for a systems approach to be embedded and sustained, it is important to train and upskill partners across the system in relevant approaches and tools (e.g., systems-mapping, identifying and modifying leverage points). Limitations and Steps for Future Research While our research adds to the limited base of academic research seeking to explore whole-systems approaches within the promotion of PA, several methodological, pragmatic, and contextual reflections and considerations should be noted. Foremost, within our research and involvement in the broader system workshops, we adopted the Action Scale Model(24) over the Public Health 12(25). Whilst we found the Public Health 12(25) to be an effective and nuanced tool in the identification and appraisal of leverage points, the parsimony of the Action Scales Model(24) proved to be useful in supporting actors across the system, often without a grounding in behaviour science, to identify and understand leverage points across the system. We therefore recommend researchers consider the Action Scale Model(24) in their practice, whilst also utilising the Public Health 12(25) as and when actors are confident in systems-based approaches and the identification of leverage points. To some extent, this may be achieved by following our approach of training a key actor(s) (e.g., research and insight officers) within the system. Whilst the acceptability and feasibility of this process is on-going, and not reported in this paper in detail, we have found this process to be useful in sequentially developing our understanding of the system and improving the knowledge of key organisations within it (e.g., Active Partnership, Local Government). Further, whilst a range of data sources contributed to the development (and maintenance) of our systems-map, consistent with a body of research(22, 23, 39, 47) we found participatory mapping to be the most useful and rich tool in both developing our understanding and our actors’ understanding of the system and its the nuanced complexity. However, in agreement with Cavill and colleagues(22) and Murphy and colleagues(39), we found this to be particularly effective when the process began with a base-map and in our case was supported by multiple-methods(37, 38). More specifically, sequentially evolving our map over-time as a response to weaknesses in the data proved to be useful in painting a comprehensive picture of the system which represents PA participation in Suffolk. Finally, the next steps within our research and the system-consortium is maintaining momentum. Beyond the scope of reporting within the current paper, the systems-consortium, have begun to work on action points outlined within our leverage point, these are not limited to developing a shared vision and strategy and championing understanding of the system. One example of this is the recent Suffolk 2024-2027 ‘Move More to Feel Better’ PA and Movement Strategy(60), a policy this research directly contributed towards. As highlighted above, a next step for the research is utilising social network analysis to understand and engage who is missing from the systems-consortium. Conclusion This research adds to the growing body of evidence applying whole-systems approaches to the promotion of PA(19-21). Our research demonstrates an approach to establishing a systems-consortium, developing an understanding of the system, and identifying leverage points within it. With context specific adaptions, our approach could be adopted by other actors seeking to adopt a whole-systems approach to change. Future developments with our system include growing and maintaining the systems-consortium, creating a sustainable means to continue mapping the system and identifying leverage points within it, implementing changes within the system, and monitoring and evaluating these modifications. Abbreviations PA Physical Activity Declarations Ethics approval Ethical approval from the project was granted by the University of Essex Ethics Board (ETH2223-2022). This research conforms to, and was conducted in accordance with, the Declaration of Helsinki. All participants provided written informed consent. Consent for publication Individual data in the form of workshop output and transcribed conversations were collected from participants. In all cases, the collection of this data was completed with full written informed consent. The collection of this data conforms to regulations outlined by the University of Essex’s Ethical Board (ETH2223-2022), GDPR and the Declaration of Helsinki. Availability of data and materials Our systems-map is publicly available on KUMU™ ( www.tinyurl.com/SuffolkPA ). The data used to generate this, previous iterations of the map, and data generated through the identification of leverage points, including our workshop is available via a request to the authors of the paper. Competing interests The authors declare that they have no competing interests. Funding This research was funded and support by University of Essex internal research impact funding and support from the University of Suffolk. The partners within the systems-consortium or Active Suffolk played no role in the collection, analysis, interpretation or presentation of data beyond what is apparent within the study. Authors' contributions All authors contributed to the research design, data collection, analysis, interpretation and manuscript. All authors read and approved the final manuscript. Acknowledgements The authors wish to acknowledge and thank Active Suffolk for their valuable assistance and contributions during this research. Special thanks goes to Georgina Winter of Active Suffolk for coordinating and supporting the development of our systems-consortium. Thanks also to Ellie Rossiter, Emily O’Neil and Dr Ruby Farr (University of Suffolk) for their support during workshops. References Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. The Lancet Global Health. 2018;6(10):e1077-e86. Sport England. Active Lives 2021-2022 Dataset. 2023. Department of Health and Social Care. UK Chief Medical Officers' Physical Activity Guidelines. DHSC; 2019. 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Supplementary Files AF1.pdf Search Terms Used within Scoping Review AF2.pdf Leverage Points from Workshop Ranked on Importance, Impact and Feasibility Cite Share Download PDF Status: Published Journal Publication published 15 Jan, 2025 Read the published version in International Journal of Behavioral Nutrition and Physical Activity → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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F.","email":"","orcid":"https://orcid.org/0000-0003-0960-4014","institution":"University of Suffolk","correspondingAuthor":false,"prefix":"","firstName":"V.","middleName":"F.","lastName":"Gladwell","suffix":""}],"badges":[],"createdAt":"2024-07-09 11:58:37","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4711882/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4711882/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12966-024-01688-2","type":"published","date":"2025-01-16T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60173466,"identity":"45065011-c896-49ed-bfa6-34b6b43b420b","added_by":"auto","created_at":"2024-07-12 15:21:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":175522,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVisual Overview of Research Design\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4711882/v1/b673adec0dcc1e42ec2c2f57.png"},{"id":60173465,"identity":"57322b33-c31e-4459-8e44-ba9cc595dffe","added_by":"auto","created_at":"2024-07-12 15:21:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":663283,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSystems-Map Representing Physical Activity within Suffolk\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4711882/v1/413effedaad081c0a1bc6dd5.png"},{"id":60173468,"identity":"cbafb2d3-dd6a-4239-aa0d-3bdda8ba4f09","added_by":"auto","created_at":"2024-07-12 15:21:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3643224,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDiscussion Workshop Poster\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4711882/v1/1f9e4d0b50c4f56679b3d473.png"},{"id":75653187,"identity":"7373c028-be2e-4085-96f8-b478a6a8351d","added_by":"auto","created_at":"2025-02-06 18:43:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6504576,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4711882/v1/df461946-7461-4bd2-8e4c-86b98fe9cabe.pdf"},{"id":60173464,"identity":"49485700-5c31-424c-ba16-60c8a7765aca","added_by":"auto","created_at":"2024-07-12 15:21:37","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":7765,"visible":true,"origin":"","legend":"\u003cp\u003eSearch Terms Used within Scoping Review\u003c/p\u003e","description":"","filename":"AF1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4711882/v1/c6e8aeaf3c858672b0d36f6f.pdf"},{"id":60173469,"identity":"be3c9845-b22b-4274-b3ff-a1ea6310e0a3","added_by":"auto","created_at":"2024-07-12 15:21:37","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":34221,"visible":true,"origin":"","legend":"\u003cp\u003eLeverage Points from Workshop Ranked on Importance, Impact and Feasibility\u003c/p\u003e","description":"","filename":"AF2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4711882/v1/4905245d6526c5bb7d517a9f.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e‘It's About Collaboration’: A Whole-Systems Approach to Understanding and Promoting Movement in Suffolk\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eConsistent with long-term trends, across the UK, and the globe(1), 36.9% of adults(2) residing in England are physically inactivity (i.e., do not meet physical activity (PA) guidelines; \u0026gt;150 minutes of moderate intensity PA per-week)(3, 4). PA is a modifiable risk-factor for a multitude of non-communicable diseases(5), poor mental health and wellbeing(6, 7), reduced quality of life(6, 7), and all-cause mortality(5, 8, 9). From an economic perspective, it is estimated £7.4 billion is spent per-annum on the consequences of inactivity within the UK alone(10). For these reasons, addressing the complex behavioural challenges surrounding inactivity has remained a concern for regional and national stakeholders and policymakers for upwards of 60 years(11-14).\u003c/p\u003e\n\u003cp\u003eHistorically, population-level interventions, programmes, and schemes aiming to improve PA participation have reduced implementation to parsimoniously modifying single or multiple determinants on the individual (e.g., motivation), interpersonal (e.g., social support), or environmental (e.g., access to facilities) level in an effort to elicit change in the \u003cem\u003e‘intention’\u003c/em\u003e of behaviour(15-17). Albeit promising over the short- to medium-term and when defined within a \u003cem\u003e‘place’\u003c/em\u003e, \u003cem\u003e‘setting’\u003c/em\u003e or \u003cem\u003e‘population’ \u003c/em\u003eor underpinned by strong participatory research and behavioural theory, these efforts often require high agency, exacerbate inequalities, and report poor long-term acceptability, feasibility and effectiveness at a population-level(16, 18). In addressing this challenge, more recently, public health policy approaches (e.g., Uniting the Movement, Local Delivery Pilots) have moved towards \u003cem\u003e‘whole systems-based’\u003c/em\u003e thinking, methods, and place-based working practices to try to change and sustain population PA behaviours(19-21).\u003c/p\u003e\n\u003cp\u003eSystems-thinking represents a broad set of approaches which rather than limit the intricacy underpinning a behaviour, seek to understand, embrace, and challenge its complexity(19-21). More specifically, these approaches consider PA as a product of a dynamic, adaptive, non-linear, evolving, and time-variant system, which is represented by a series of interdependent behavioural determinants (e.g., individual, interpersonal, social actors, political, structural, environmental) across multiple levels of influence(19-21). Central to systems-thinking, above non-linear \u003cem\u003e‘cause and effect’\u003c/em\u003e behavioural theories which focus on the \u003cem\u003e‘intention to change’\u003c/em\u003e, is that a whole-system is adaptive, in that it is influenced by feedback, interventions and actions within it, the social power of actors, and structural changes within and external to its boundaries(20, 21). \u003c/p\u003e\n\u003cp\u003eSystems-maps are a commonly adopted tool to illustrate this nuanced complexity(20, 22, 23). More specifically, these maps provide visual insight into how factors across the systems influence each other(20, 22, 23), assist in the identification of points of leverage(24-26), and complement evaluation and monitoring(27, 28). Good evidence(23, 26, 29, 30) indicates maps can be produced from a variety of primary and secondary forms of qualitative (e.g., workshops, interviews, focus groups, co-production, reviews) and quantitative (e.g., surveys, analysis) sources of data. Notwithstanding, evidence suggests adopting methods which are participatory, may produce additional benefits such as building a shared agreement on the nature of the problem, identifying roles within the system, and co-producing policy and strategy responses(20, 29). \u003c/p\u003e\n\u003cp\u003eWithin any system, leverage points are present(24, 25). These are factors which are vital for meaningful change, and which if modified can impact upon the function of the system(24, 25). To assist stakeholders, policymakers, and researchers to understand and identify different types of leverage points, various models, theories, and frameworks exist, which are not limited to the Meadows 12(31), Public Health 12(25) and Action Scales Model(24), and various markers from social network analysis(32) (e.g., degree, betweenness, eigenvector). Broadly, leverage points are identified, formulated, and evaluated to the extent in which they influence the system(24, 25). Across multiple models, leverage points can be clustered into a hierarchy of paradigms and beliefs (e.g., deeply held philosophy at the foundation of the system – value of movement), goals (e.g., purpose, targets, and ambition of the system – aim to increase movement), systems structures (e.g., environmental, social, economic change – low traffic neighbourhoods), feedback loops, and events (e.g., behavioural interventions – daily mile, cycle to work schemes)(20, 24, 25, 31). Across this hierarchy, leverage points which modify attitudes, norms, and rules (i.e., beliefs, goals) offer a culture change and therefore greater leverage (24). In contrast, leverage points such as interventions (e.g., events) often operate in isolation and present short-term solutions to problems within the system(24). \u003c/p\u003e\n\u003cp\u003eGlobal (i.e., WHO Action Plan, Eight Investments Which Work)(13, 33), UK (i.e., Uniting the Movement)(34), regional and local (e.g., Suffolk Core20PLUS5(35) policy emphasises the importance of place-based systems change when attempting to improve population PA participation. Suffolk, UK is one example of a place-based system, whereby defined regional geographical and policy boundaries exist(35). The county is a disparate mix of rural (i.e., village) settings, amongst coastal and high-density urban dwelling population hubs (e.g., Ipswich, Bury St Edmunds)(35). Amongst differences in geography, there are meaningful health inequalities such as variation in age, multiple deprivation, life expectancy, access to health services, housing, and education across the county(35). Moreover, Suffolk has disproportionately greater mortality related to cardiorespiratory events, poor mental health, COPD, and cancer(35), an increasingly aging population, and reduced healthcare provision, infrastructure, and investment(35). \u003c/p\u003e\n\u003cp\u003eThis interlinking complexity places greater emphasis on the importance of the prevention of conditions via lifestyle-based health behaviours (e.g., PA)(19-21). Indeed, current regional government strategy stresses the need for direct and indirect support for population change in lifestyle behaviours(35). This need and complexity underscores the importance of systems-thinking and whole-systems working across the county(19-21). For this reason, our research team began working with Active Suffolk (www.activesuffolk.org), the Active Partnership (see www.activepartnerships.org), to develop a systems-map that represents PA participation in Suffolk and identify leverage points for change. This was a process which stakeholders or policymakers across the county were yet to explore. \u003c/p\u003e\n\u003ch2\u003eObjectives \u003c/h2\u003e\n\u003cp\u003eThe objective of this research was to explore PA participation across Suffolk through a systems-thinking approach by: (i) understanding what determines participation in PA in Suffolk (ii) mapping the system and (iii) identifying leverage points within it and (iv) inviting partners to develop solutions and actions points for change. \u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eDesign and Overview\u003c/h2\u003e\n\u003cp\u003eTo determine the factors influencing participation in PA, formulate the system and identify leverage points within it, we worked alongside Active Suffolk to develop a broad consortium of partners. These actors represented (i) regional government and public bodies, (ii) local government and public bodies, (iii) regional PA stakeholders and charities, (iv) deliverers and provisions, (v) advocacy groups, (vi) participant representatives, (vii) primary, secondary and public health bodies, and (viii) education and young people. The consortium engaged in two phases of the research to varying degrees (Figure 1). Phase 1 sought to understand the determinants and map the system that underpins PA participation within the county. Phase 2 identified leverage points and actions via a mixed-methods analysis and a group workshop. Ethical approval was provided by the University of Essex (ETH2223-2022). Participants provided written informed consent to participate in the research.\u003c/p\u003e\n\u003ch2\u003eSystems Map Development (Phase 1)\u003c/h2\u003e\n\u003ch3\u003e\u003cstrong\u003eOverview and Systems-Map Development\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eTo understand the complexity underpinning PA participation (i.e., walking and cycling for transport, sport, exercise, play and leisure) we utilised a pluralistic(36) sequential process, using a \u003cem\u003e\u0026lsquo;methods approach\u0026rsquo;\u003c/em\u003e to triangulate data into our (37, 38) systems-map (constructed via KUMU\u0026trade;). Multiple-methods were used to explore determinants within the map from varying perspectives(37, 38), \u0026nbsp;complementing philosophies that systems are non-linear, adaptive, and a changeable phenomenon. \u0026nbsp;An initial map was generated on KUMU\u0026trade; informed by; existing literature(20, 22, 39), an analysis of Active Lives data(2), and insight work (e.g., GAPPA mapping(13, 33)) and ripple effects mapping conducted within the system. This map formed a foundation for participatory mapping workshops, a scoping review of evaluation reports, policy and strategy, and interviews. Further, given systems are non-linear, adaptive, and changeable(19-21), we additionally trained one insight officer (Active Suffolk) in understanding the system and how to update the systems-map via KUMU\u0026trade;.\u003c/p\u003e\n\u003cp\u003eThis approach enabled \u0026nbsp;over multi-iterations to layer, compare, and contrast data, which provided insight into divergence, inconsistency, or deficiency in the map(38, 40).(19-21) This provided understanding into where additional data would provide greater clarity on a given determinant or link. Where such a complication arose, additional data was collected to remove this paucity. To build our map we utilised inductive reasoning to identify, specify, and critically appraise determinants (e.g., circles on map; nodes) and the links between these.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eParticipatory Systems Mapping Workshops and Sense Making\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eTo evolve the systems-map to a local context, we conducted two systems-mapping workshops. A half-day face-to-face participatory systems mapping(23)\u0026nbsp;workshop was conducted with a heterogeneity of actors across the Suffolk PA system to explore the initial determinants influencing PA participation (workshop 1). Participants (\u003cem\u003en\u003c/em\u003e=26) were sampled to represent the heterogeneity of organisations involved in the consortium and invited via email. Participants represented regional government and public bodies (23%), local government and public bodies (7.5%), regional PA stakeholders and charities (4%), deliverers and provisions (12%), advocacy groups (15.5%), participant representatives (7.5%), primary, secondary and public health bodies (23%), and education and young people\u0026apos;s organisations (7.5%). During the first workshop, the map was modified by actors through sequential stages which considered each determinant, link, and theme (i.e., group of determinants). Following a final discussion of the map, actors suggested additional data and mapping were required to; (i) understand the enablers and challenges unique to Suffolk; (ii) perspective of residents across the county.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo deepen local understanding, we conducted an independent systems-workshops with residents of Suffolk. We adopted a modified version of our initial systems-workshop to deliver a half-day face-to-face participatory systems mapping(23)\u0026nbsp;workshop to understand the determinants of participation from the perspective of individuals residing within the county (workshop 2). The workshop was coordinated by a local charity, comprising working-age and older-adults (\u003cem\u003en=\u003c/em\u003e33; Age: 65.7\u0026plusmn;9.8, 45% females), \u0026nbsp;and represented a range of localities, and social-demographic factors (e.g., deprivation, living arrangements). Unlike the workshop one, we adopted a simplified sequential process to development. Working in small groups (\u003cem\u003en\u003c/em\u003e=5-6) and on a large sheet of paper, participants defined PA. This definition formed the centre of map. Following the process, participants listed PA enablers and challenges around their definition. Organically, and following direction from a facilitator, participants linked these enablers and challenges (e.g., crime linked to feelings of low self-confidence exercising in green space). This exercise of linkage created further conversations, and the development and adaption of additional nodes. Finally, participants were invited to visit other maps and discuss the challenges and enablers they faced. This process led to further revision of the maps. Maps were collated and layered onto the broader systems-map for Suffolk following workshop two.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSystems-workshops are limited by the extent of the actors and organisations present(23). For this reason, the research team conducted interviews (\u003cem\u003en\u003c/em\u003e=4) and small-group discussions (\u003cem\u003en\u003c/em\u003e=6) with partners across the consortium to make sense of the system, identify additional determinants of participation, and gain feedback on the systems-map. These sessions lasted about one-hour, were conducted via online video communication software (Zoom\u0026trade;) or face-to-face and involved between three and eight partners in the case of group discussions. Within each session, the researcher provided an overview of the map, an insight into the functionality of KUMU\u0026trade;, and themes within the map (e.g., built environmental factors). Following this overview, participants were asked to reflect on how the map represented; (i) their organisation and its function/operations; \u0026nbsp;(ii) Suffolk broadly. Critical feedback provided insight into the creation of new nodes, and revision of existing nodes within the map. Data were transcribed verbatim, deductively coded, and layered onto our evolving systems-map(37, 38).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eDocument, Policy, and Strategy Review\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eTo expand on our understanding of the system we conducted a scoping review of existing documents (e.g., evaluation reports, insight reports), strategy, and policy across each of the systems sectors outlined above. To identify \u0026nbsp;grey evidence, we used Google Scholar, Overton, and independent searches of each systems-partners\u0026apos; website. Due to relevancy, searches were limited to 2010 to date, and included search terms formulated from the initial systems map, in combination with regional locations and PA (see additional file 1). To expand our review, indexing (i.e., searches for documents within included evidence) and sibling-searches (i.e., related evidence conducted by the same author/organisation) were conducted. For inclusion, evidence had to be; (i) presented within written, audio, or visual format; (ii) be related to PA; (iii) be related to Suffolk. In total, 187 documents were included within the review. This evidence was deductively coded against the existing system-map(37, 38)\u003c/p\u003e\n\u003ch2\u003eLeverage Point Identification and Actions (Phase 2)\u003c/h2\u003e\n\u003ch3\u003e\u003cstrong\u003eInitial Analysis and Framing Workshop Three\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThere remains no gold-standard to identify and specify leverage points within a system aiming to understand a public health phenomenon(41). Therefore, to identify leverage points with our system, we utilised a quantitative and qualitative approach, which served as a precursor to a workshop with consortium members (workshop 3). Similar to previous approaches(26, 42) we \u0026nbsp;adopted quantifiable leverage measures(32) to unpick the complexity of our map. Using KUMU\u0026trade; in-built metrics tool, we analysed the map across its \u003cem\u003e\u0026lsquo;eigenvector\u0026rsquo;\u003c/em\u003e (i.e., how well connected a factor is with other well-connected elements), \u003cem\u003e\u0026lsquo;degree\u0026rsquo;\u003c/em\u003e (i.e., the number of connections), and \u003cem\u003e\u0026lsquo;betweenness\u0026rsquo;\u0026nbsp;\u003c/em\u003e(i.e., bottle-necking between factors)(32). Following the identification of up-stream determinants with a high eigenvector, betweenness, and closeness values, we applied the Action Scales Model(24). This was selected due to its parsimony, accessibility, and our need to translate findings to systems-partners in a clear and understandable style(24). This conceptual tool integrates the complexity of the Meadows 12(31) (and as such the Public Health 12(25)), alongside the Iceberg Model(43) and Intervention Level Framework(44). The model indicates leverage can be conceptualised into four progressively influential points of change (see Nobles et al(24) for a more detailed overview), specified as; \u003cem\u003e\u0026lsquo;events\u0026rsquo;\u003c/em\u003e (i.e., the outcomes, behaviours, symptoms of the system); \u003cem\u003e\u0026lsquo;structures\u0026rsquo;\u003c/em\u003e (i.e., the environmental and social factors which shape events within the system); \u003cem\u003e\u0026lsquo;goals\u0026rsquo;\u003c/em\u003e (i.e., the rules, policies, strategies, and ambitions within the system); \u0026nbsp;\u0026lsquo;\u003cem\u003ebeliefs\u003c/em\u003e\u0026rsquo; (i.e., deeply held values, norms, and attitudes within the system).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe analysis process was sequential and conducted independently by three members of the research team (AB, KC, RSE). Researchers met to critically discuss each of the leverage points within the system. These discussions were expanded with the broader research team, whereby an internal verification process was carried out and a long-list of 54 leverage points was developed. Following these steps, this long-list was discussed by three members of the research team (AB, RSE, PF) and two members of Active Suffolk staff with local insight. Leverage points within the long list were debated on the extent in which they held the capacity to cause larger systems change. For the purposes of the leverage point workshop (workshop 3), we outlined 13 points within the system where change may be effectively leveraged.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eLeverage Point Workshop (Workshop 3)\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eWorkshop three built upon the initial analysis and invited actors to rank leverage points and develop strategies, methods, and approaches to leverage change. Participants involved in the workshop were sampled to represent the range of organisations across the Suffolk PA system and \u0026nbsp;were invited to a half-day leverage points workshop via email (n=21). These actors were sampled from regional government and public bodies (15%), local government and public bodies (35%), regional PA stakeholders and charities (15%), deliverers and provisions (20%), and primary, secondary and public health bodies (20%).\u003c/p\u003e\n\u003cp\u003eDelivered in sequential steps, the research team provided an overview of the system representing PA within Suffolk, key features of the systems maps (e.g., themes), leverage points, the Action Scale Model(24), and the analysis of leverage points conducted prior to the workshop. Following this overview, in three groups of seven, using cards, participants were asked to rank leverage points considering their; (i) feasibility; (ii) potential impact; (iii) importance within Suffolk. The research team collated this output and outlined the top four leverage points to modify within the county (i.e., based on total sum of importance). Following this, participants self-assigned themselves a leverage point to discuss, develop solutions for, and modify (four groups of \u003cem\u003en\u003c/em\u003e=4-6). Supported by a facilitator from the research team and inspired by the process outlined within the Action Scale Model(24), participants considered how, where, when, what, and why changes should occur. Finally, participants presented their solutions to the broader group, and the context and considerations this operates within. This was followed by questions and debate by the broader group. These presentations and conversations formed the basis of action points for on-going systems change (noted on post-it-notes). Conversations and observations by the research team were recorded via voice recorder or notes. These were transcribed verbatim, and analysed through a deductive thematic analysis(45). Finally, following the workshop, we analysed the correlation between combined feasibility and impact scores, impact and importance, and feasibility and importance scores using Spearman rank correlations.\u003c/p\u003e\n\u003ch2\u003eFindings\u003c/h2\u003e\n\u003ch2\u003ePhase 1: Overview of the Systems-Map\u003c/h2\u003e\n\u003cp\u003eAn overview of the systems-map is provided in Figure 2, with an interactive version accessible on KUMU\u0026trade; (www.tinyurl.com/SuffolkPA) including definitions for each node. The map is constructed from 90 nodes that are segregated into nine themes (biological, financial, and psychological individual factors, interpersonal factors, systems partners, built, natural and social environmental factors, and policy and structural determinants). These factors influence four individual modes of PA (cycling, walking, active leisure/play, sport), which contribute to overall PA. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePhase 2: Overview of Leverage Points and Initial Analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eA complete presentation of each node, and its respective eigenvector, degree, and betweenness is available via KUMU\u0026trade;, within the \u0026lsquo;table\u0026rsquo; function. Table 1 outlines the twenty most influential nodes ranked on eigenvector (excluding modes of activity). In addition, critical discussions based on the Action Scales Model additionally highlighted \u0026lsquo;urban design and density\u0026rsquo;, \u0026lsquo;speed volume of traffic, driver behaviour and culture\u0026rsquo;, \u0026lsquo;shared facilities (e.g., sport, community, recreation)\u0026rsquo;, \u0026lsquo;multiple deprivation and socioeconomic status\u0026rsquo;, \u0026lsquo;cycling culture\u0026rsquo;, \u0026lsquo;organisational values and beliefs\u0026rsquo;, \u0026lsquo;funding (e.g., health, fitness professionals\u0026rsquo; schemes, interventions, programmes), and \u0026lsquo;social media\u0026rsquo; as important nodes for leverage within the system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Leverage Point Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNode (Factor)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEigenvector\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBetweenness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eASM Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eSport Facilities, Clubs and Opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eInclusive/Diverse Facilities/Opportunities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-Confidence, Capability and Competence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eAir Quality\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eWalking Infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eClimate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eRecreation Infrastructure, Spaces and Places\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eWalking Culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eBeliefs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eMotivation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eLocal Governing Policies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical Activity History\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003ePromotion/Marketing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003ePerceived Available Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eCrime and Anti-social Behaviour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eLocal Social and Cultural Norms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eBeliefs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eCommunity Resources, Training and Support\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical Health Status and Function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eCommunity Centres/Spaces\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eShared Policy/Strategy/Vision/Working\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.69387755102041%\" valign=\"top\"\u003e\n \u003cp\u003eProximity to Destinations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\" valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNotes:\u0026nbsp;\u003c/em\u003eASM (Action Scales Model). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCritical discussions between the research team and Active Suffolk against each leverage points feasibility, impact, and importance within Suffolk led to the following nodes being brought forward to the leverage point workshop designed to combine scientific research with local systems-knowledge and insight.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 2: Findings of Leverage Point Workshop (Workshop 3)\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eRanking Leverage Points within the System\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eFollowing critical discussion within groups, participants ranked leverage points within the system on their feasibility, impact, and importance (Table 2; see Attachment 2 for a more detailed overview). Group rankings across each leverage point and the total sum of importance were used to underpin the top-4 solutions below. Leverage points of seemingly greater impact (Median: 19, IQR: 12) were ranked poorly in terms of feasibility to change (Median: 20, IQR: 12), but not significantly (rho=-.20, p=.49). Further, leverage points with high importance (Median: 17, IQR: 12) typically represented a greater degree of leverage within the Action Scales Model(24), but were not correlated with feasibility (rho=.42, p=.14) or impact (rho=.39, p=.17). Observations from the research team indicate participants representing strategic organisations or involved in policymaking tended to preference \u0026lsquo;beliefs\u0026rsquo; and \u0026lsquo;goals\u0026rsquo;, whilst organisations with a meaningful delivery capacity placed emphasis on \u0026lsquo;events\u0026rsquo; within the system.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eDeveloping Solutions to Leverage Change, Actions, and Next Steps\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eSolutions related to (i) local governing policies, (ii) shared policies, strategies, vision, and working relationships, (iii) shared facilities (school, sport, community, recreation), and (iv) funding were developed by four sub-groups. An example of a group\u0026rsquo;s solutions, challenges, context, and considerations when leverage change is outlined within Figure 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Leverage Points from Workshop Ranked on Impact, Feasibility and Overall Importance\u003c/strong\u003e\u003c/p\u003e\n\u003ctable\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"479\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeverage Point (Ranked by Total Importance)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"99\"\u003e\n \u003cp\u003e\u003cstrong\u003eASM Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"348\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eImpact\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFeasibility\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOverall Importance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e1. \u0026nbsp; \u0026nbsp; \u0026nbsp; Local Governing Policies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e2. \u0026nbsp; \u0026nbsp; \u0026nbsp; Shared Policies, Strategies, Vision, and Working Relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e3. \u0026nbsp; \u0026nbsp; \u0026nbsp; Shared Facilities (School, Sport, Community, Recreation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e4. \u0026nbsp; \u0026nbsp; \u0026nbsp; Funding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e5. \u0026nbsp; \u0026nbsp; \u0026nbsp; Inclusive/Diverse Facilities/Opportunities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e6. \u0026nbsp; \u0026nbsp; \u0026nbsp; Self-Confidence, Capability and Competence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e7. \u0026nbsp; \u0026nbsp; \u0026nbsp; Recreation Infrastructure, Spaces and Places\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e8. \u0026nbsp; \u0026nbsp; \u0026nbsp; Local Social and Cultural Norms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eBeliefs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e9. \u0026nbsp; \u0026nbsp; \u0026nbsp; Community Resources, Training and Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e10. \u0026nbsp; Promotion/Marketing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e11. \u0026nbsp; Walking Culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eBeliefs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e12. \u0026nbsp; Cycling Culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eBeliefs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"479\"\u003e\n \u003cp\u003e13. \u0026nbsp; Crime And Anti-Social Behaviour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"99\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"149\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u0026nbsp;\u003c/em\u003eASM (Action Scales Model).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe Importance of Collective Working, Relationships, Vision, and Strategy\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWithin the broader group discussion in workshop 3, participants acknowledged the importance of shared working relationships, a collective vision, and strategy. Whilst not complex to establish such relationships or a core \u0026lsquo;vision\u0026rsquo; (i.e., to get people active) within the consortium, it was deemed challenging to get organisations to functionally work together in the long-term (e.g., creating a shared strategy on PA).\u003c/p\u003e\n\u003cp\u003eCentral to this challenge was that organisations often held divergent models of delivery, organisation, or policymaking that frequently conflicted or challenged each other. In proposing a solution to this challenge, one stakeholder discussed the importance of \u003cem\u003e\u0026lsquo;collective buy-in\u0026rsquo;\u0026nbsp;\u003c/em\u003ewhere all deliverers, organisers, unexpected actors, and public health partners are provided a space and voice to co-produce strategic goals and collaborate on a shared strategy:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;It\u0026apos;s about collaboration. It\u0026apos;s about understanding how we can all contribute. It\u0026apos;s about understanding that shared vision, shared goals and recognizing that everybody has something different to add\u0026rsquo;\u003c/p\u003e\n\u003cp\u003eSenior Policymaker (Stakeholder)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA Co-Produced Strategy and Vision\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAny co-produced strategy should be applicable at a local, district/ward and regional level, and a product of shared evidence. One solution presented by a group was a 20-year prediction of health and wellbeing in the county. In such evidence, a scenario would be presented whereby the current predicted state of health would be compared against a 20-year plan with collective change and direction surrounding PA (i.e., mapping PA within the priorities of the integrated care system). The use of shared evidence and proposed collective working was deemed essential in the ownership and function of a whole-systems approach. This \u003cem\u003e\u0026lsquo;golden thread\u0026rsquo;\u003c/em\u003e of evidence was deemed important given: (i) it raises the priority of PA within public health conversations; (ii) current health and wellbeing policymakers such as the integrated care system/board operate in a 20-year timeline currently. Central to engaging such policymakers such as regional health and wellbeing boards with any vision or strategy was switching the delivery and organisation model from being reactionary to preventative (i.e., not reacting to events in the system, but adapting structures, goals, or beliefs):\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;It\u0026rsquo;s about switching the emphasis to prevention. I\u0026apos;m preaching to the converted, but prevention rather than reacting to the problems that we\u0026apos;ve got. We felt perhaps in the physical activity strategy there could be a shared vision that is underpinned by some principles and evidence that everyone could buy into. That would be good\u0026rsquo;\u003c/p\u003e\n\u003cp\u003eSenior Operations Director (Local Council)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSharing Facilities and Resources\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA challenge related to evidence, knowledge, and insight was highlighted by the group focusing on shared facilities. Due to its rural and expansive nature, Suffolk is a region with a large quantity of facilities, spaces, and places to participate in PA. Often owned or managed by schools, education providers, councils, and unexpected providers (e.g., religious groups), there remains no collective audit or database of such facilities. An area, the group acknowledged was important in terms of a collective strategy surrounding the shared use and management of facilities. With such a strategy, participants discussed the importance of supporting unexpected providers with funding and resources to open outside of normal-working hours:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;There are facilities that are there that are probably underused. So we\u0026apos;re talking about school halls, not necessarily sports centres as such, but school halls, church halls, \u0026nbsp;community facilities, things like that, that need to be used, but they probably have a little bit of an issues. They don\u0026apos;t know how to open up, or they don\u0026apos;t have the resources to open up. We talked about what do we want to get from those facilities? So is it traditional sport? Is it physical activity? Is it really, really soft approaches? We then focus a lot of our time onto the strategy stuff. So can we produce? Suffolk wide strategies that help for those facilities to open. So is there something to not necessarily force facilities into opening?............But actually, if we can force that happen with a collective approach, but this is actually going to be mutually beneficial.\u003c/p\u003e\n\u003cp\u003eRegional Sports Provider (Regional Governing Body)\u003c/p\u003e\n\u003cp\u003eThis underscores the importance of inviting the owners, managers, or administrators of such facilities to any level of strategic development and consortium. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFunding was deemed as a key leverage point within the system. For example, participants acknowledged for any meaningful change to occur in PA behaviour, the way in which funding is allocated and spent across systems partners needed to be modified. Indeed, funding for PA, was deemed to focus on short-term projects (e.g., events in the system), be reactionary, rather than preventative, and rarely collaborative. To many extents, partners commented that this approach to funding within the system, promoted competition among organisations, rather than encouraging whole-systems working. Consistent with other leverage points, a collective vision and collaborative model was proposed. This centred on long-term pooling resources, shared capacity, and collective investments. Key was funding \u003cem\u003e\u0026lsquo;what works\u0026rsquo;\u0026nbsp;\u003c/em\u003eand acknowledging \u003cem\u003e\u0026lsquo;what doesn\u0026rsquo;t\u003c/em\u003e\u0026rsquo; through shared insight, evaluation, and monitoring:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Sharing what we do and then agreeing to replicate our work with each other, to in a sense, expand the projects we\u0026apos;re working on, across and between the district boundaries. If we decide to work like that, we could do it. It could be really exciting\u0026rsquo;\u003c/p\u003e\n\u003cp\u003eOperations Manager (Stakeholder)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSolutions and Actions Points to Promote Change\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eActions signalled steps for individual, organisational, and shared commitments to leverage change (see Table 2). Broadly, these \u0026lsquo;actions\u0026rsquo; reflected a need to leverage change within \u0026lsquo;goals\u0026rsquo; in the system, such as sharing policies, resources, insight, evidence, and capacity, working together on projects and funding applications, and collaborating to co-produce a collective vision and strategy. Actions also reflected a need to raise awareness, build an evidence base, create a step change in the priorities of public health (i.e., moving PA up the agenda) for strategic policymakers (e.g., heads of local government, integrated care system and/or board).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was a theme of influencing \u003cem\u003e\u0026lsquo;good will\u0026rsquo;\u003c/em\u003e or \u003cem\u003e\u0026lsquo;hearts and minds\u0026rsquo;\u0026nbsp;\u003c/em\u003eof these policymakers via promoting the success of collaborated projects (e.g., fit villages), and a shared voice, vision, and strategy for the future. In addressing this, the consortium underpinning the current project was proposed as a solution to create advocacy. However, while this group has the positives of a flat hierarchical structure (i.e., equal partners), it was acknowledged that there remains no leader managing and coordinating the system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Actions for Change\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAction (Type of Organisation)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Organisation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeverage Point\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eASM Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInclude physical activity, exercise and/or sport within strategy or priorities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDeliverer/organiser\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLocal governing policies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCollaborate with other districts, organisations, and wider partners\u0026ndash; share information about projects and grant funding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOrganiser\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared vision, direction, relationships, and ethos within and across organisations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnderstand, advocate, and support the use of shared spaces, places, and facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStakeholder/deliverer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePromote \u0026lsquo;work\u0026rsquo; and good stories across county\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChampion insight and impact\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAdvocate for physical activity across the county\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDevelop an advocacy/support group for policymakers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDevelop a volunteer and resident voice group for physical activity across the county\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOrganiser\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShare knowledge and skills with other organisations to improve access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOrganiser\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEngage, challenge and work with the integrated care system (NHS) to build advocacy for physical activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProvide collaborative leadership on funding\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFunding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCoordinate a countywide physical activity strategy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared policies, strategies, vision, and working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDevelop \u0026lsquo;future\u0026rsquo; evidence/position \u0026ndash; Suffolk in 20 years report\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOrganiser/stakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLocal governing policies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u0026nbsp;\u003c/em\u003eASM (Action Scales Model). Actions are grouped into common themes. NHS (National Health Service).\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003eThe objective of this research was to explore PA participation across Suffolk through a systems-thinking approach by: (i) understanding what determines participation in PA in Suffolk (ii) mapping the system and (iii) identifying leverage points within it and (iv) inviting partners to develop solutions and actions points for change. A complex systems-map of the determinants of PA in Suffolk was developed comprising of 90 nodes that converge around nine factors. Through a participatory approach the four most important leverage points identified were; (i) local governing policies; (ii) shared policies, strategies, vision, and working relationships; (iii) shared facilities (school, sport, community, recreation); (iv) funding were deemed most important to change. Actions to leverage change included raising awareness with partners beyond the system, sharing policies, resources, insight, evidence, and capacity, and collaborating to co-produce a collective vision and strategy. These findings complement and extend \u0026nbsp;the growing body of evidence, which has utilised a pluralism of methodologies to understand the dynamic system underpinning participation in PA(19-21)\u0026nbsp;and chart leverage points for change within this complexity(22, 39, 42, 46-48). This research provides important insight into the steps underpinning a shift towards a whole-systems and place-based approach to working.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur analysis shares many of the same intrapersonal- (e.g., motivation), interpersonal- (e.g., social support), environmental- (e.g., facilities) and policy-determinants (e.g., funding) identified at a global, national, and regional-level within systems- and ecological approaches aiming to understand PA behaviour(20, 22, 39, 42, 46-49). Moreover, \u0026nbsp;many of the same organisations present within the policy space surrounding PA (e.g., regional government, healthcare organisations, providers)(42)\u0026nbsp;were present in our analysis, as were the connections between these organisations(47), and the themes in which policy is shaped around(39)\u0026nbsp;(e.g., environment, society, systems, people). However, a system is a dynamic, adaptive, time-variant and emergent web(19-21), which responds to feedback, and is shaped by factors internal and external (e.g., national governmental policy) to its boundaries(20). Therefore, while systems-maps within a context (e.g., PA promotion) share many similarities(20, 22, 39, 42, 46-49), how factors (nodes) interact(19-21), how change is intentionally and unintentionally brought about, and how the social power of actors influences change is unique(20, 21). This is particularly prominent in the case of leverage points(20, 24, 25, 31), where we found the extent in which change can be influenced is underscored by its feasibility, perceived importance, and potential impact by actors within the system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterestingly, in all cases, participants ranked leverage points which reflect goals or structures (e.g., policy, resources) in the Action Scales Model(24)\u0026nbsp;as the most important to change. Modifying goals or structures within the system, is thought to influence larger whole-systems change (e.g., changing a policy has an impact on many, rather than a few)(24, 25). However, leverage points related to beliefs within the system such as cultural change, paradigms, or norms, were more often ranked poorly in terms of their feasibility to change. In agreement with Power and colleagues(47), changes upstream within the system such as a shift in paradigms, norms and culture may take sustained efforts, time and engagement(24, 25). For these reasons, leverage points reflecting beliefs may appear to be unfeasible and low in impact to actors within the system. Therefore, it remains important for future research to unpick the long-term complexities of leveraging change within the PA space(50). This is particularly important, given a shared belief in the system may support the likelihood of policies to be collectively shaped and implemented(24, 25)\u0026nbsp;in the long-term.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrevious research seeking to encourage movement through a systems-approach found similar leverage points(42, 51). For example, systems representing recreational participation have likewise found the importance of goals (e.g., serving the needs of young people) and varying forms of structural change (e.g., urban design, safety, policy change to support movement, laws, regulation)(42, 51-53). These studies also underscore the importance of feedback loops and delays (e.g., appeal of facilities growing as more people use them)(42, 51-53), points in which the systems-consortium also recognised and discussed in regard to implementing a shared strategy. More specifically, consistent with research, it was recognised that it would take time to build consensus and an develop an effective whole-systems approach(17, 25, 54, 55), but a shared vision would bring in new partners, grow the system, and therefore the extent to which change could be brought about.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current research identified several specific and important leverage points across the system which could enhance PA in Suffolk. Modifications to local governing policies, a shared strategy and vision, and collaborative working which transcend across the region, and into localities and districts of the county may have the capacity to cause downstream change to models of funding and the sharing of resources and facilities, points of leverage also identified within our research. However, the emphasis placed on these leverage points is consistent with the growing body of national and global strategies(19-21)\u0026nbsp;and research(17, 25, 54, 55)\u0026nbsp;which underscores the importance of whole-systems approaches in addressing complex societal complications and the importance of organisations working functionally in the long-term. The identification of these leverage points is also consistent with a recent evaluation of a whole-systems approach to promoting PA within an English county(46). In addressing this challenge, research broadly indicates the importance of a central organisation to bring system actors together, drive change, and manage organisational differences, understanding the needs of each actor, their motivation and similarities in approach and strategy, and highlighting the co-benefits of systems-working (e.g., shared priorities)(46, 54, 56, 57).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the case of our approach and sharing similarities with previous projects implemented within UK policy (e.g., local delivery pilots), this responsibility fell to the Active Partnership (i.e., Active Suffolk)(46, 58). In agreement with Nobles and colleagues evaluation of \u003cem\u003e‘We Move Together’\u003c/em\u003e(46), in the case of the present system, bringing actors together was acceptable and pragmatic, given there was already a broad emphasis placed on the importance of the needs for systems-based approaches surrounding public health and PA promotion within regional governmental policy (e.g., Core20PLUS5)(35). Notwithstanding of this, participants within our research highlighted the absence of voices from within related areas of public health, and the broader integrated care system. The representation of voices, including the right people within a whole-systems approach, and exploring how these individuals interact (e.g., the strength of their relationships) has been previously acknowledged as a challenge to effective working and implementation(46). Future research therefore may consider the application of modes of social-network analysis(23, 59)\u0026nbsp;in exploring the interaction between actors across the system, and the identification of organisations not present within whole-systems approaches to promotion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research is likewise consistent with research unpicking whole-systems approaches, in that our participants emphasised rather than seeing divergence in strategy and policy, focus should be directed towards similarities and co-benefits(17, 25, 54, 55). With our research, the concept of a shared vision, collective evidence base and strategy may also create a ripple-effect in that it reduces the clash of mindsets and ways of working observed in previous research(17, 25, 54, 55), and draws actors towards a central way of working, collective buy in, and ownership. This is particularly important in terms of funding and sharing resources and facilities across the county, where approaches were reported to be transactional, reactionary, non-collaborative, short-term, and focused on events within the system, rather than resourcing broader upstream changes(24-26). These factors can promote competition and create divergence, rather than encouraging collective working(17, 39, 46, 56). Consistent with previous research(17, 39, 46, 56), our research underscored the importance of funding and resource sharing through effective systems-leadership and collaboration on research and insight, advocacy, and knowledge and information sharing (e.g., resource availability, funding opportunities). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eReflections and Recommendations\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis novel research adds to the growing body of evidence into using whole-system approaches to identify and leverage change to promote increases in PA. The following recommendations and actions are made based on the findings of this research:\u003c/p\u003e\n\u003ch3\u003eRecommendations \u0026amp; Actions\u003c/h3\u003e\n\u003col\u003e\n \u003cli\u003eA whole-system, participatory approach is required to ensure the correct people and local knowledge and insight are brought together to drive and advocate for change.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eA shared vision is required to bring in new partners, grow the system and work towards long-term whole-system change. This will require time to identify and utilise the similarities between organisations and promote the co-benefits of working together.\u003c/li\u003e\n \u003cli\u003eResources, such as system maps that help to identify leverage points require regularly updating to reflect the dynamic and evolving nature of the system.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIndividuals and organisations should be bold and open to not always doing the same and should not only consider leveraging change where it is most feasible but also where it may lead to the most impact.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIt is important that policy to increase PA behaviour incorporates, encourages, and enables a system thinking approach.\u003c/li\u003e\n \u003cli\u003eIn order for a systems approach to be embedded and sustained, it is important to train and upskill partners across the system in relevant approaches and tools (e.g., systems-mapping, identifying and modifying leverage points).\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch2\u003eLimitations and Steps for Future Research\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWhile our research adds to the limited base of academic research seeking to explore whole-systems approaches within the promotion of PA, several methodological, pragmatic, and contextual reflections and considerations should be noted. Foremost, within our research and involvement in the broader system workshops, we adopted the Action Scale Model(24)\u0026nbsp;over the Public Health 12(25). Whilst we found the Public Health 12(25)\u0026nbsp;to be an effective and nuanced tool in the identification and appraisal of leverage points, the parsimony of the Action Scales Model(24)\u0026nbsp;proved to be useful in supporting actors across the system, often without a grounding in behaviour science, to identify and understand leverage points across the system. We therefore recommend researchers consider the Action Scale Model(24)\u0026nbsp;in their practice, whilst also utilising the Public Health 12(25)\u0026nbsp;as and when actors are confident in systems-based approaches and the identification of leverage points. To some extent, this may be achieved by following our approach of training a key actor(s) (e.g., research and insight officers) within the system. Whilst the acceptability and feasibility of this process is on-going, and not reported in this paper in detail, we have found this process to be useful in sequentially developing our understanding of the system and improving the knowledge of key organisations within it (e.g., Active Partnership, Local Government). Further, whilst a range of data sources contributed to the development (and maintenance) of our systems-map, consistent with a body of research(22, 23, 39, 47)\u0026nbsp;we found participatory mapping to be the most useful and rich tool in both developing our understanding and our actors’ understanding of the system and its the nuanced complexity. However, in agreement with Cavill and colleagues(22)\u0026nbsp;and Murphy and colleagues(39), we found this to be particularly effective when the process began with a base-map and in our case was supported by multiple-methods(37, 38). More specifically, sequentially evolving our map over-time as a response to weaknesses in the data proved to be useful in painting a comprehensive picture of the system which represents PA participation in Suffolk. Finally, the next steps within our research and the system-consortium is maintaining momentum. Beyond the scope of reporting within the current paper, the systems-consortium, have begun to work on action points outlined within our leverage point, these are not limited to developing a shared vision and strategy and championing understanding of the system. One example of this is the recent Suffolk 2024-2027 \u003cem\u003e‘Move More to Feel Better’\u0026nbsp;\u003c/em\u003ePA and Movement Strategy(60), a policy this research directly contributed towards. As highlighted above, a next step for the research is utilising social network analysis to understand and engage who is missing from the systems-consortium.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis research adds to the growing body of evidence applying whole-systems approaches to the promotion of PA(19-21). Our research demonstrates an approach to establishing a systems-consortium, developing an understanding of the system, and identifying leverage points within it. With context specific adaptions, our approach could be adopted by other actors seeking to adopt a whole-systems approach to change. Future developments with our system include growing and maintaining the systems-consortium, creating a sustainable means to continue mapping the system and identifying leverage points within it, implementing changes within the system, and monitoring and evaluating these modifications. \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysical Activity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval\u003c/p\u003e\n\u003cp\u003eEthical approval from the project was granted by the University of Essex Ethics Board (ETH2223-2022). This research conforms to, and was conducted in accordance with, the Declaration of Helsinki. All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eIndividual data in the form of workshop output and transcribed conversations were collected from participants. In all cases, the collection of this data was completed with full written informed consent. The collection of this data conforms to regulations outlined by the University of Essex\u0026rsquo;s Ethical Board (ETH2223-2022), GDPR and the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eOur systems-map is publicly available on KUMU\u0026trade; (\u003ca href=\"http://www.tinyurl.com/SuffolkPA\"\u003ewww.tinyurl.com/SuffolkPA\u003c/a\u003e). The data used to generate this, previous iterations of the map, and data generated through the identification of leverage points, including our workshop is available via a request to the authors of the paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research was funded and support by University of Essex internal research impact funding and support from the University of Suffolk. The partners within the systems-consortium or Active Suffolk played no role in the collection, analysis, interpretation or presentation of data beyond what is apparent within the study.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the research design, data collection, analysis, interpretation and manuscript. All authors read and approved the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors wish to acknowledge and thank Active Suffolk for their valuable assistance and contributions during this research. Special thanks goes to Georgina Winter of Active Suffolk for coordinating and supporting the development of our systems-consortium. Thanks also to Ellie Rossiter, Emily O\u0026rsquo;Neil and Dr Ruby Farr (University of Suffolk) for their support during workshops. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGuthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1\u0026middot;9 million participants. The Lancet Global Health. 2018;6(10):e1077-e86.\u003c/li\u003e\n \u003cli\u003eSport England. 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In: Office for Health Improvement and Disparities, editor.: UK Goverment; 2022.\u003c/li\u003e\n \u003cli\u003eWoods CB, Kelly L, Volf K, Gelius P, Messing S, Forberger S, et al. The Physical Activity Environment Policy Index for monitoring government policies and actions to improve physical activity. European Journal of Public Health. 2022;32(Supplement_4):iv50-iv8.\u003c/li\u003e\n \u003cli\u003eRam\u0026iacute;rez Varela A, Hallal PC, Mej\u0026iacute;a Grueso J, Pedi\u0026scaron;ić Ž, Salvo D, Nguyen A, et al. Status and Trends of Physical Activity Surveillance, Policy, and Research in 164 Countries: Findings From the Global Observatory for Physical Activity\u0026mdash;GoPA! 2015 and 2020 Surveys. Journal of Physical Activity and Health. 2023;20(2):112-28.\u003c/li\u003e\n \u003cli\u003eMilton K, Cavill N, Chalkley A, Foster C, Gomersall S, Hagstromer M, et al. Eight investments that work for physical activity. 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BMC Public Health. 2019;19(1):8-.\u003c/li\u003e\n \u003cli\u003evan Sluijs EMF, Ekelund U, Crochemore-Silva I, Guthold R, Ha A, Lubans D, et al. Physical activity behaviours in adolescence: current evidence and opportunities for intervention. The Lancet. 2021;398(10298):429-42.\u003c/li\u003e\n \u003cli\u003eKoorts H, Rutter H. A systems approach to scale-up for population health improvement. Health Research Policy and Systems. 2021;19(1):27-.\u003c/li\u003e\n \u003cli\u003eRutter H, Cavill N, Bauman A, Bull F. Systems approaches to global and national physical activity plans. Bulletin of the World Health Organization. 2019;97(2):162-5.\u003c/li\u003e\n \u003cli\u003eRutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, et al. The need for a complex systems model of evidence for public health. The Lancet. 2017;390(10112):2602-4.\u003c/li\u003e\n \u003cli\u003eCavill N, Richardson D, Faghy M, Bussell C, Rutter H. Using system mapping to help plan and implement city-wide action to promote physical activity. Journal of Public Health Research. 2020;9(3):278-84.\u003c/li\u003e\n \u003cli\u003eBarbrook-Johnson P, Penn AS. Systems Mapping: How to build and use causal models of systems. Springer Nature; 2022.\u003c/li\u003e\n \u003cli\u003eNobles JD, Radley D, Mytton OT. The Action Scales Model: A conceptual tool to identify key points for action within complex adaptive systems. Perspectives in Public Health: SAGE Publications Ltd; 2021.\u003c/li\u003e\n \u003cli\u003eBolton KA, Whelan J, Fraser P, Bell C, Allender S, Brown AD. The Public Health 12 framework: interpreting the \u0026lsquo;Meadows 12 places to act in a system\u0026rsquo; for use in public health. Archives of Public Health 2022 80:1. 2022;80(1):1-8.\u003c/li\u003e\n \u003cli\u003eSmith N, Georgiou M, King AC, Tieges Z, Chastin S. Factors influencing usage of urban blue spaces: A systems-based approach to identify leverage points. Health \u0026amp; Place. 2022;73:102735.\u003c/li\u003e\n \u003cli\u003eHall J, Bingham DD, Seims A, Dogra SA, Burkhardt J, Nobles J, et al. A whole system approach to increasing children\u0026rsquo;s physical activity in a multi-ethnic UK city: a process evaluation protocol. BMC Public Health. 2021;21(1).\u003c/li\u003e\n \u003cli\u003eRenger R. System evaluation theory (SET): A practical framework for evaluators to meet the challenges of system evaluation. Eval J Australas. 2015;15(4):16-28.\u003c/li\u003e\n \u003cli\u003evan den Akker A, Fabbri A, Alardah DI, Gilmore AB, Rutter H. The use of participatory systems mapping as a research method in the context of non-communicable diseases and risk factors: a scoping review. Health Research Policy and Systems. 2023;21(1):69.\u003c/li\u003e\n \u003cli\u003eBaugh Littlejohns L, Near E, McKee G, Rasali D, Naiman D, Faulkner G. A scoping review of complex systems methods used in population physical activity research: do they align with attributes of a whole system approach? Health Research Policy and Systems. 2023;21(1):18.\u003c/li\u003e\n \u003cli\u003eMeadows DH. Thinking in systems: A primer: chelsea green publishing; 2008.\u003c/li\u003e\n \u003cli\u003eMurphy RJ, Jones P. Leverage analysis: A method for locating points of influence in systemic design decisions. FormAkademisk-forskningstidsskrift for design og designdidaktikk. 2020;13(2):1-25.\u003c/li\u003e\n \u003cli\u003eOrganization WH. Global action plan on physical activity 2018-2030: more active people for a healthier world: World Health Organization; 2019.\u003c/li\u003e\n \u003cli\u003eSport England. Uniting the Movement. Sport England; 2021.\u003c/li\u003e\n \u003cli\u003eSuffolk County Council. Core20PLUS in Suffolk: Suffolk Annual Public Health Report 2022. Suffolk County Council; 2022.\u003c/li\u003e\n \u003cli\u003eChamberlain K, Cain T, Sheridan J, Dupuis A. Pluralisms in qualitative research: From multiple methods to integrated methods. Qualitative Research in Psychology. 2011;8(2):151-69.\u003c/li\u003e\n \u003cli\u003eDenzin NK. Sociological methods: A sourcebook: Routledge; 2017.\u003c/li\u003e\n \u003cli\u003eFlick U. Mantras and myths: The disenchantment of mixed-methods research and revisiting triangulation as a perspective. Qualitative inquiry. 2017;23(1):46-57.\u003c/li\u003e\n \u003cli\u003eMurphy JJ, Mansergh F, Murphy MH, Murphy N, Cullen B, O\u0026rsquo;Brien S, et al. \u0026ldquo;Getting Ireland Active\u0026rdquo;\u0026mdash;Application of a Systems Approach to Increase Physical Activity in Ireland Using the GAPPA Framework. Journal of Physical Activity and Health. 2021:1-10.\u003c/li\u003e\n \u003cli\u003eFarmer T, Robinson K, Elliott SJ, Eyles J. Developing and implementing a triangulation protocol for qualitative health research. Qualitative Health Research. 2006;16(3):377-94.\u003c/li\u003e\n \u003cli\u003eLeventon J, Abson DJ, Lang DJ. Leverage points for sustainability transformations: nine guiding questions for sustainability science and practice. Sustainability Science. 2021;16(3):721-6.\u003c/li\u003e\n \u003cli\u003eKoorts H, Salmon PM, Swain CTV, Cassar S, Strickland D, Salmon J. A systems thinking approach to understanding youth active recreation. International Journal of Behavioral Nutrition and Physical Activity. 2022;19(1).\u003c/li\u003e\n \u003cli\u003eHarris SG. \u0026quot; The Fifth Discipline: The Art and Practice of the Learning Organization\u0026quot;, by Peter M. Senge. Human Resource Management. 1990;29(3):343.\u003c/li\u003e\n \u003cli\u003eMalhi L, Karanfil \u0026Ouml;, Merth T, Acheson M, Palmer A, Finegood DT. Places to Intervene to Make Complex Food Systems More Healthy, Green, Fair, and Affordable. Journal of Hunger and Environmental Nutrition. 2009;4(3-4):466-76.\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V. Conceptual and design thinking for thematic analysis. Qualitative Psychology. 2022;9(1):3-26.\u003c/li\u003e\n \u003cli\u003eNobles J, Fox C, Inman-Ward A, Beasley T, Redwood S, Jago R, et al. Navigating the river(s) of systems change: a multi-methods, qualitative evaluation exploring the implementation of a systems approach to physical activity in Gloucestershire, England. BMJ Open. 2022;12(8):e063638.\u003c/li\u003e\n \u003cli\u003ePower DD, Lambe BM, Murphy NM. Using systems science methods to enhance the work of national and local walking partnerships: practical insights from Ireland. Eur J Public Health. 2022;32(Suppl 1):i8-i13.\u003c/li\u003e\n \u003cli\u003eGuariguata L, Unwin N, Garcia L, Woodcock J, Samuels TA, Guell C. Systems science for developing policy to improve physical activity, the Caribbean. Bull World Health Organ. 2021;99(10):722-9.\u003c/li\u003e\n \u003cli\u003eBauman AE, Reis RS, Sallis JF, Wells JC, Loos RJF, Martin BW, et al. Correlates of physical activity: Why are some people physically active and others not? The Lancet. 2012;380(9838):258-71.\u003c/li\u003e\n \u003cli\u003eBrannan M, Bernardotto M, Clarke N, Varney J. Moving healthcare professionals \u0026ndash; a whole system approach to embed physical activity in clinical practice. BMC Medical Education. 2019;19(1).\u003c/li\u003e\n \u003cli\u003eLuna Pinzon A, Stronks K, Dijkstra C, Renders C, Altenburg T, den Hertog K, et al. The ENCOMPASS framework: a practical guide for the evaluation of public health programmes in complex adaptive systems. International Journal of Behavioral Nutrition and Physical Activity. 2022;19(1):33.\u003c/li\u003e\n \u003cli\u003eWilliams AJ, Wyatt K, Stevens K, Price L. A complexity-informed in-depth case study into the sustainability and impact of a culture of health: The TR14ers community youth dance group. PLOS ONE. 2023;18(10):e0293274.\u003c/li\u003e\n \u003cli\u003eNau T, Perry S, Giles-Corti B, Bellew W, Bauman A, Smith BJ. Mapping and analysis of laws influencing built environments for walking and cycling in Australia. BMC Public Health. 2023;23(1):108.\u003c/li\u003e\n \u003cli\u003eBird EL, Evans D, Gray S, Atherton E, Blackshaw J, Brannan M, et al. Opportunities to engage health system leaders in whole systems approaches to physical activity in England. BMC Public Health. 2022;22(1):254.\u003c/li\u003e\n \u003cli\u003eSharpe RA, Taylor T, Fleming LE, Morrissey K, Morris G, Wigglesworth R. Making the case for \u0026ldquo;whole system\u0026rdquo; approaches: Integrating public health and housing. International journal of environmental research and public health. 2018;15(11):2345.\u003c/li\u003e\n \u003cli\u003eBigland C, Evans D, Bolden R, Rae M. Systems leadership in practice: thematic insights from three public health case studies. BMC Public Health. 2020;20(1):1735.\u003c/li\u003e\n \u003cli\u003eEvans D, Bolden R, Jarvis C, Mann R, Patterson M, Thompson E. How do you develop systems leadership in public health? Insights from a scoping study. Public Health. 2021;196:24-8.\u003c/li\u003e\n \u003cli\u003eGwilym O, Katie F, Benjamin B. Evaluating the impact on physical inactivity of Together an Active Future, a partnership approach to physical activity promotion. A difference-in-differences study. Journal of Epidemiology and Community Health. 2024;78(2):115.\u003c/li\u003e\n \u003cli\u003eBlake C, Rigby BP, Armstrong-Moore R, Barbrook-Johnson P, Gilbert N, Hassannezhad M, et al. Participatory systems mapping for population health research, policy and practice: guidance on method choice and design. University of Glasgow; 2024.\u003c/li\u003e\n \u003cli\u003eActive Suffolk. Move More to Feel Better: A Physical Activity and Movement Strategy for Suffolk for 2024-2029. Active Suffolk; 2024.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"University of Essex","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Exercise, health, intervention, leverage points, physical activity, sport, wellbeing","lastPublishedDoi":"10.21203/rs.3.rs-4711882/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4711882/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePopulation-levels of physical activity have remained stagnant for years. Previous approaches to modify behaviour have broadly neglected the importance of whole-systems approaches. Our research aimed to (i) understand, (ii) map, (iii) identify the leverage points, and (iv) develop solutions surrounding participation in physical activity across an English rural county.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA systems-consortium of partners from regional and local government, charities, providers, deliverers, advocacy groups, and health and social care, and public health engaged in our research, which consisted of two-phases. Within Phase 1, we used secondary data, insight-work, a scoping review, participatory workshops, and interviews in a pluralistic style to map the system-representing physical activity. Phase 2 began with an initial analysis using markers from social network analysis and the Action Scales Model. This analysis informed a participatory workshop, to identify leverage points, and develop solutions for change within the county.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe systems-map is constructed from biological, financial, and psychological individual factors, interpersonal factors, systems partners, built, natural and social environmental factors, and policy and structural determinants. Our initial analysis found 13 leverage points to review within our participatory workshop. When appraised by the group, (i) local governing policies, (ii) shared policies, strategies, vision, and working relationships, (iii) shared facilities (school, sport, community, recreation), and (iv) funding were deemed most important to change. Within group discussions, participants stressed the importance and challenges associated with shared working relationships, a collective vision, and strategy, the role of funding, and management of resources. Actions to leverage change included raising awareness with partners beyond the system, sharing policies, resources, insight, evidence, and capacity, and collaborating to co-produce a collective vision and strategy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings highlight the importance and provide insight into the early phase of a whole-systems approach to promoting physical activity. Our whole-systems approach within Suffolk needs to consider methods to (i) grow and maintain the systems-consortium, (ii) create a sustainable means to map the system and identify leverage points within it, and (iii) monitor and evaluate change.\u003c/p\u003e","manuscriptTitle":"‘It's About Collaboration’: A Whole-Systems Approach to Understanding and Promoting Movement in Suffolk","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 15:21:33","doi":"10.21203/rs.3.rs-4711882/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"585a09ff-35e5-4152-86c7-0edd618a96b8","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":34399488,"name":"Health Policy"},{"id":34399489,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2025-02-06T18:43:36+00:00","versionOfRecord":{"articleIdentity":"rs-4711882","link":"https://doi.org/10.1186/s12966-024-01688-2","journal":{"identity":"international-journal-of-behavioral-nutrition-and-physical-activity","isVorOnly":false,"title":"International Journal of Behavioral Nutrition and Physical Activity"},"publishedOn":"2025-01-16 00:00:00","publishedOnDateReadable":"January 16th, 2025"},"versionCreatedAt":"2024-07-12 15:21:33","video":"","vorDoi":"10.1186/s12966-024-01688-2","vorDoiUrl":"https://doi.org/10.1186/s12966-024-01688-2","workflowStages":[]},"version":"v1","identity":"rs-4711882","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4711882","identity":"rs-4711882","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}