Abstract
Aims:
Encouraging leisure-time physical activity has proved to be a hard-to-solve complex problem. Underpinning this complexity is the range of determinants of sedentary behaviour. We report on a participatory actor mapping exercise which sought to understand the people and organisations in the local system in which a novel exercise referral scheme in a suburban/semi-rural region of England has been introduced.
Methods:
The participatory actor mapping exercise was conducted in two phases in September 2023. The first phase generated a draft actor map visually illustrating the key organisations and individuals (actors) that make up the local physical activity promotion system. The map was aligned to a socio-ecological model in which actors were positioned within a category of determinants. In the second phase, the draft actor map was refined during two workshops with participants (n = 30) representing the key local organisations who sought to promote physical activity.
Findings:
The process of mapping revealed several factors influencing physical activity promotion: (1) differing views on the determinants of physical inactivity, and hence, a hesitancy towards addressing sedentary behaviour through a strategic systems approach; (2) an emerging system of actors with interdependent roles which sometimes act independently; (3) local commitment to encouraging increased leisure time activity but supported via a generalised approach to physical activity promotion; and (4) a peripheral role of the studied exercise referral scheme in the system for local physical activity provisions.
Conclusion:
The process of a participatory approach to actor mapping highlighted both opportunities and challenges for physical activity promotion. Although there were challenges around differing actors’ perspectives on sedentary behaviour and a lack of connection between actors, opportunities included an improved shared understanding of the complex issues of physical inactivity, and actor mapping provided a useful step towards adopting a systems approach with a common vision.
Plain Language Summary
Getting people to be more active in their free time is a difficult challenge. This is partly because there are many different reasons why people are inactive. In this study, researchers looked at a new exercise referral scheme in a suburban and semi-rural area of England. They wanted to understand who the key people and organisations are in the local system that support physical activity. The researchers used a method called actor mapping, which involved two steps. First, they created a draft map showing all the people and organisations involved in promoting physical activity. These were grouped by how they influence behaviour (e.g. individual, community, or policy level). Then, in workshops with 30 participants from local organisations, the map was discussed and refined. The mapping process revealed several key findings: People had different ideas about why physical inactivity happens, making it hard to agree on a joint strategy. Many local organisations are involved and rely on each other, but they often work separately. There is local support for getting people more active, but efforts tend to be broad rather than targeted. The new exercise referral scheme plays only a small role in the wider local system. In conclusion, using a participatory mapping approach helped show both the difficulties and the potential in promoting physical activity. Although there are challenges – such as differing views and a lack of co-ordination – this process helped build a shared understanding. It could be a helpful step towards working together as a system with a common goal.
Background
Encouraging people to be more active is complex. Sedentary behaviours are not the sole responsibility or product of the motivation and intention of individuals but the result of a complex web of interacting factors at policy, environmental/neighbourhood, social, economic, and cultural levels. 1 In 2007, the UK Foresight map presented a pioneering portrayal of the complex web of obesity causation through a causal loop model, identifying various thematic clusters which contribute to overweight and obesity, such as food production, social psychology, and the physical activity (PA) environment, which can collectively contribute to the ‘obesogenic’ environment. 2 A similar map is seen in the development of a systems framework to support the World Health Organization Global Action Plan on Physical Activity (GAPPA) 3 which identifies some key determinants of PA behaviour: transport and environmental factors, societal factors such as the car culture, and socio-political factors such as employment status. These wide-ranging factors and the interplay between individuals and the social norms and structures of the populations of which they are a part give rise to a complex system of opportunities and resources for PA promotion.
A whole system approach is defined by Carey et al. 4 as understanding the complex relationships and contexts that influence an issue and responding to this complexity by bringing stakeholders, including communities, together to develop ‘a shared understanding of the challenge’ and integrate action to bring about sustainable, long-term systems change (p. 6). The benefit of mapping the system around an issue is described in recent guidance 5 as providing insight into the wider contextual influences on an intervention, examining the relations between actors (people and organisations) in a system, and identifying leverage points for interventions. Ideas around complexity and systems thinking have begun to be explored in public health,6,7 and Public Health England supported a whole systems approach to obesity 8 and developed guidance on how to embark on system mapping. Recently, systems approaches have been recommended for increasing population levels of PA, recognising that physical inactivity is complex and cannot be addressed by focusing on individual agency and motivations and simple behavioural solutions.3,9,10
This article reports on a participatory actor mapping process which is just one of many methods used in systems mapping (see, for example, the literature11,12) where the intention is not only to identify the stakeholders in a process and assess their ability to influence the outcomes but also to demonstrate possible causality and relationships between factors influencing PA promotion at different socio-ecological levels. It was built with the purpose of understanding the system into which a novel exercise referral scheme (ERS) was being introduced and how this scheme related to other aspects (people, organisations, interventions) in the local PA system. This work was part of a wider evaluation of the local ERS (NIHR135540 as part of PHIRST NIHR131568) which is reported in a separate paper. 13
Participatory actor mapping is an evolving approach increasingly used to gain insight into complex systems surrounding population health issues. The term is used to indicate methods that involve stakeholders, usually through one or more workshops, to build a systems overview of a complex problem, usually to support decision-making processes or gain insight into a system of interest.14,15 Although participatory actor mapping is increasingly used to aid intervention design to identify where best to intervene and how an intervention could influence the system, 5 the process reported aimed to identify how the local PA system could better support an existing intervention based on a novel ERS achieving its goals for targeted PA promotion.
ERSs are a common intervention that seeks to address physical inactivity. This intervention sought to address barriers to the uptake into ERSs and inequalities associated with income, age and/or gender through a range of novel features: by being offered free of charge or subsidised by the local council; by accepting referrals not only from health professionals, as in other schemes, but also from social prescribers, the voluntary sector and self-referrals for increasing access; by offering a personalised programme with dedicated specialist support; and by running over a twice-longer period than the usual ERS duration of 12 weeks. Finally, to reflect its ambition to address known determinants of physical inactivity and their association with deprivation, the health and wellbeing coaches dedicated to the scheme were also expected to refer to other community services where needs related to health were identified and addressed, for example, housing, debt, and loneliness.
We report elsewhere 13 on the mixed-method process evaluation for this novel PA intervention identifying its reach, how well it was implemented and whether it was being taken up by the targeted underserved populations. Our aim here is to focus on the ‘dynamic properties of the context into which the intervention was introduced’ (Hawe et al., 15 p. 267). The objectives of the employed actor mapping process were to identify and visually represent the people, organisations, and structures that influence PA promotion in the local area, and through the participatory approach, to capture the stakeholders’ understandings and perspectives of the system around PA promotion to identify where and how the potential of the ERS can be fully enabled.
Methods
The actor mapping process comprised two main phases
Phase 1. We adopted an ecological perspective 16 in identifying the categories of determinants at individual biology and psychology, interpersonal, organisational, community, policy, and environmental levels that influence PA. 3 This approach emphasises the human–environment interactions within a complex socio-ecological model and facilitates better understanding of behaviours and decision-making processes and identification of determinants for change in the provision of ecoservices across the system. 17 Desktop research related to local health strategy documents, local profile analysis by Sport England, and informed by conversations with the local public health department, led to a draft actor map that identified the key actors (organisations, agencies, and groups) with the potential to support and promote engagement in PA in the local area.
Phase 2. The aim of this phase was to explore the views, experiences, and interactions of actors across the local system and establish the implications for uptake, engagement, impact, and delivery of PA initiatives. Stakeholders were identified as those with a local interest in PA and how it could be enabled among the most sedentary. This included individuals with lived experience of the ERS or as local residents; referring agents to the ERS; public health as commissioners of the ERS and with the remit for PA promotion; other sectors of the local authority such as transport, housing and the built environment and leisure services; and the private provider of leisure services (see Table 1).
Affiliation of the participants in Phase 2 of the actor mapping exercise
Two half-day workshops of 2.5 h with 30 key stakeholders were held with one face-to-face and the other online. The invitation to stakeholders described the purpose of the workshop as sharing views on how best to promote PA locally. The workshop began with an outline of the existing data on PA uptake in the area and the ERS scheme. The draft version of the actor map (Figure 1) was then presented to the stakeholders for discussion and refinement with nodes representing the different elements. Because our aim was to locate the intervention in the system and not to show the direction or strength of the relations between the different actors, connecting lines were not included, although many actor mapping processes may do this. 5 Instead, stakeholders were asked to reflect on what is surprising or interesting in the actor map and to clarify any different views on connections and influences.
Local physical activity (PA) actor map
Participants then worked in small subgroups (six to eight stakeholders) for 30 min with a facilitator from the research team and were asked to identify opportunities to improve the PA system’s overall performance by, for example, strengthening weak connections or filling gaps in the system, in response to the following prompt questions:
Which elements in the system in the local area are strongest or most influential in helping to promote PA?
Where are the inhibiting factors or barriers to PA promotion (e.g. people, relationships, information)?
Are there actors identified in the map that are missed opportunities? What would help them to take a more prominent role, for example, information or workforce capacity?
Each researcher-facilitator kept field notes of the discussion around each of the prompt questions observing the interactions and level of engagement and noting their perception of participants’ understanding. Subsequently, each subgroup’s feedback was provided to the wider group for further discussion resulting in the production of recorded flip charts (face-to-face workshop) or a summary slide (online workshop).
The recordings of participants’ text and speech from the full group and subgroups’ discussions in both workshops were transcribed and, together with the summary notes of the researcher-facilitators, organised into a database. A deductive content analysis 18 of all the data was used with a priori themes of the: complexity of the system; roles and connections in the system; and the ERS intervention and embeddedness or otherwise in the PA system. The field notes of the researcher-facilitators and their later reflections were included into the analysis to understand whether the process of participatory actor mapping can help illuminate how the intervention ‘couples with the context’ and the perceived position of the actors in the wider system (Hawe et al. 15 p. 271).
Findings
The content analysis of stakeholders’ views about the elements in the PA system and the actions to be taken revealed: (1) the complexity of the issues influencing the inactive and sedentary populations and the very different understandings of the determinants of PA; (2) the interconnected but sometimes unrelated parts of the PA system and relationships between the actors; and (3) the peripheral role for the provisions for PA such as a local PA scheme. The field notes and reflections of the research team further illuminated these findings and what the process of actor mapping triggered or revealed (see Table 2).
Findings from the deductive content analysis of data collected during the workshops with local stakeholders in the PA system.
Complexity Of The System
The issue of PA was understood as complex – there was agreement that inactivity is a complex issue not caused by any single element, but there was only some agreement about what might work to encourage the sedentary to be more active. Participants recognised that the social and built environment influence PA, but most discussion focused on individual motivation and the need for individuals to exercise self-discipline and responsibility:
Individuals need to take accountability and given our location, how we're set up, you know, it's great that we can offer facilitated walks, for example, but I find it really difficult to suggest that the majority of people can’t go out of their front door and access some green open space for themselves, for free and and we all understand the merits of healthy lifestyle, the benefits of a healthy lifestyle, not being overweight, not smoking, eating well, and I think sometimes we kind of skirt around the conversations of being accountable as individuals. So, I just kind of put that in my in my way as I would do. That’s the personal view for me and I feel quite strongly about that, that sometimes we . . . and I completely accept there were individuals that are in need and are completely accepting of that. But actually, for the majority of the population, they can do things for themselves, and they can be healthy and well and in non-supported activities. (Sports and leisure, online participant)
The process of mapping illustrated divergent views with some actors associating low PA with social disadvantage which restricts the ability to take part whether due to a lack of money, isolation, and limited or non-existent access to digital communications when information about PA opportunities is communicated across disparate websites.
Most participants identified GPs as key to promoting PA, but it was the social prescribers themselves who identified their own contribution which was not widely known and who described their specific expertise:
Usually, the trigger for me for that referral is the notes say from the clinician, says Mr X is struggling financially, unemployed, has had a mental health challenge or physical operation of some sort or is in recovery, looking for ways to boost his mood. (Social prescriber 1, face-to-face workshop participant)
60 to 70% of my referrals are around weight management and increasing physical activity is part of that. I mean, we get referrals from our like mental health practitioner who you know often tries to avoid giving out medication and tries to see what else we can do to, you know, for the individual to try first. (Social prescriber 2, face-to-face workshop participant)
Roles And Connections In The System
PA was perceived to be part of the function of several local government directorates (transport and sports and leisure being most mentioned as well as the amount of new building) as well as the National Health Service (NHS) and voluntary sector, and participants recognised their interdependent roles and actions on PA.
But there was less evidence of interactions in the system with elements in the system acting independently or being outsourced to private providers. For example, the public health department, in addition to commissioning a PA scheme, separately commissioned a weight management strategy and service which offered its own exercise classes. The sports and leisure directorate commissioned a sports and leisure strategy from an external consultancy. Several participants commented that these different elements all saw PA differently, whether as focused on sport and fitness or as part of an obesity strategy, but there was no overarching vision.
While several elements of the system are working to promote PA and several stakeholder participants were keen to point out their contribution, the actor mapping process enabled the participants to see how unrelated several actions were. For example, several identified the importance of addressing mental health and how PA can help with better mental health, yet how unconnected were different initiatives and activities. The map identified resident groups and well-distributed ‘happiness hubs’ that act as a support for isolated individuals, those with mental health problems or those on very low incomes and an extensive community map developed by the public health department, but although known about, there was surprise that these could appear in a system about PA promotion. Similarly, different participants added to the map several actors that they deemed important in PA promotion that included several big sports clubs, an environmental incentive scheme, and some GP practices that are seeking to become an ‘Active Practice’. 19
The ERS Intervention
Most of the discussion in both workshops about PA promotion referred to the amount of green space locally and it being a missed opportunity for inactive individuals. No one mentioned the ERS as an opportunity; it was described as a ‘health check at the gym’. By actor mapping and having decision-makers hear such views, a clear learning emerged for them related to the lack of co-ordination in the system:
There’s a need for a sort of pathway that would take people to physical activity, whether it be to improve their mental health or weight loss, or because they need to be more mobile or independent or for whatever reason it is not a planned one. So we see a lack of communication between services and knowledge about the other services that it that exist. (Commissioner, online)
The lack of awareness about the ERS among residents and other actors and knowledge about its details among referring agents surprised the commissioners:
I think we need to communicate properly because if our own social prescribers think it’s a health check and gym, that’s not what it is . . . perhaps there is a lack of understanding of what the service is and perhaps we need to do a little bit more in increasing people’s awareness. (Public health face to face workshop participant)
Discussion
This participatory actor mapping process was conducted as part of an evaluation of an intervention and not as part of intervention design. Other forms of engagement may equally help illuminate perspectives of stakeholders, but actor mapping is not only relatively easy to set up and accessible but also it facilitates a better understanding of the complexity of the issue. For the workshop participants, actor mapping was a different way of working. It helped stakeholders to understand the relationships between the parts and actors of the system, for example, how to reorient leisure services towards PA for sedentary and inactive population groups and how information flows between parts of the system and the actors within it.
Although there was little shared agreement about the number and diversity of actors in the PA system, the actor map and the prompt questions about enablers and barriers to PA promotion did help to identify opportunities or leverage points. First, there was some shift in the ways in which stakeholders viewed sedentarism, moving beyond a simple focus on individual behaviour enabled by the linking of the actor map to the socio-ecological model. Second, there was a move towards improved co-ordination with the setting up of a PA network. Through mapping out the actors within the system, stakeholders could see the key influence of GPs, and another leverage point identified locally was the Active Practice Charter which is slowly being adopted and offers a ‘real opportunity to embed physical activity into care pathways in a way that could support a whole systems approach and to directly address NHS culture which does not currently encourage a focus on physical activity’ (Bird et al. 20 p. 7). Another leverage point is the social prescribers who identified themselves as having a key role with important knowledge about PA. A review concludes that it is social prescribers who have exercise referral on their computer systems and who are more likely to be having conversations about the PA scheme with patients.21,22
The process helped stakeholders to reflect on the underlying structures locally and why the ERS as an intervention intended to address inequalities in PA and the determinants of sedentarism such as income or poor mental health23,24 was not well known about or linked into other organisations. It highlighted the importance of linking the component parts through intervention coproduction with stakeholders. Community residents are key stakeholders here, as are people from various organisations from across a range of sectors (e.g. Transport, Highways, Housing, Planning, Health Care and Integrated Care systems, and Public Health). Complex adaptive systems such as a PA system adapt over time in response to new policies, social norms, and commercial interests. For example, the outsourcing of leisure services in this area had centralised provision often reducing the opportunities for individuals and, in turn, focusing on sport and fitness.
Public Health England’s guide to implementing whole systems approaches to obesity 8 suggests that initial stages should include building the local picture followed by mapping the system. It illustrates the changes local authorities might expect to see when moving from traditional working to systems working and identifies certain key system ingredients. This study of a PA system echoes these recommendations, and Figure 2 shows the ‘traditional’ views of PA expressed by the actors in these workshops, the barriers to a whole systems approach and the changes that the local authority would need to implement to move towards a whole systems approach.
Moving towards a whole systems approach for physical activity (PA)
The process did highlight the opportunities afforded by participatory actor mapping. Stakeholders agreed that the workshops did give them a wider perspective of the factors influencing PA uptake and interventions that could promote PA. At a local level, the knowledge of many stakeholders of other actors was increased, and there was a raised awareness of the ERS. Key learning for the facilitation of actor mapping sessions was the importance of explaining to stakeholders the purpose of the workshop and what their valued contribution would be. There were also challenges to the process: we were focusing on locating an existing intervention in the system rather than identifying what might work. Actor mapping and system mapping may add more value if conducted at an early stage. Nevertheless, these stakeholders had not considered a PA system previously and so there was learning for them from this.
The actor mapping process for this evaluation took place in a half-day workshop (via two modes of delivery), and as with any participatory activity, getting stakeholder engagement was a challenge. We mitigated this by conducting document reviews ahead of the workshops bringing a draft actor map and structuring the workshops so that each one incorporated a boundaried discussion with three clear prompt questions. This approach is possible with actor mapping. While causal loop mapping 25 would have provided additional insights into relationships, it would have required a much longer activity and a greater call on stakeholders’ time.
Conclusion
Systems approaches can help to disentangle complex problems by focusing on the dynamic interactions and processes involved in shaping complex behaviour.26,27 This local approach used participatory actor mapping to bring stakeholders and decision-makers together to visually map out the different actors which may be involved in a system 28 and is advocated as a useful step to identify the context for future interventions and programmes. What emerged through the process adopted was that stakeholders were being pulled between different perspectives, and there was a lack of interconnectedness. It did demonstrate, however, the potential for a better shared understanding of the wider contexts for interventions influencing behavioural change and the important central underlying operational mechanisms for partnership working, for example, improving networks and developing a common agenda and relationships, a learning which underpins the new Sport England’s Places and Spaces approach for addressing the inequalities that exist among the least active through community-led solutions. 29
Footnotes
Conflict Of Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was carried out at PHIRST South Bank, based at London South Bank University. It is funded by the NIHR [Public Health Research (PHR) Programme NIHR NIHR131568/NIHR135540]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
