Systems thinking in public health interventions: a systematic review of barriers and facilitators

Systems thinking has been promoted to address complex public health challenges involving fragmented systems, multi-sectoral governance, and interacting social determinants of health. However, its application in real-world public health interventions and the conditions influencing implementation remain understudied. This systematic review examines how systems thinking has been operationalized in public health interventions, identifies key facilitators and barriers to implementation, and interprets these findings in relation to broader public health practice and ongoing health system reforms in Saudi Arabia.

We conducted a systematic review (2013-2025; final search November 2025) using PubMed, Scopus, Web of Science, CINAHL, and PsycINFO. Studies applying systems thinking in population- or community-level public health interventions with implementation findings were included; conceptual and non-intervention studies were excluded. Data on approaches, frameworks, facilitators, and barriers were extracted and narratively synthesized. Quality was appraised using the MMAT (2018). The review was registered (PROSPERO; registration number CRD420251267775).

Of 948 records identified, fifteen studies met the inclusion criteria, spanning communicable and non-communicable disease interventions across high-, middle-, and low-income countries. Systems thinking approaches included learning health systems, systems analysis and improvement approaches, community-based system dynamics, causal loop diagramming, and whole-system or multi-sectoral designs. Systems thinking was embedded within implementation processes, including iterative learning cycles, participatory system mapping, and quality improvement mechanisms. Key facilitators included stakeholder engagement and co-production, integration within existing health system structures, incremental capacity building, and leadership support. Barriers included challenges translating systems concepts into actionable interventions, workforce constraints, fragmented or non-interoperable data systems, rigid governance arrangements, and external disruptions such as COVID-19. Study designs were predominantly qualitative or mixed methods, with heterogeneity in evaluation approaches and limited long-term outcome assessment.

Systems thinking in public health is applied mainly as an implementation-embedded practice rather than an analytical tool. Its effectiveness depends on participatory processes, adaptive learning, and supportive governance and data systems. These findings provide practical insights for health system reform contexts, including Saudi Arabia, where systems thinking can support integrated and adaptive public health interventions.