Developing a whole systems action plan promoting Dutch adolescents’ sleep health

Abstract

Background

Inadequate sleep health is a public health problem among Dutch adolescents with detrimental effects on their physical and mental well-being. System approaches are increasingly being used to understand and address public health problems. Therefore, a recent study created a comprehensive Causal Loop Diagram (CLD) that integrated all relevant determinants of adolescent sleep health, underlying system dynamics and potential leverage points. Building on that, the current study aims to design a ‘whole systems action plan’ to promote sleep health of Dutch adolescents, combining systems science with a participatory approach.

Methods

Five (multi)stakeholder sessions with adolescents (N = 40, 12–15 years), parents (N = 14) and professionals (N = 13) were organized to co-create actions addressing preselected leverage points derived from the previously mapped CLD. Subsequently, three sessions with multidisciplinary representatives of regional and national oriented (health) organizations (N = 27) were held using the World Café Methodology to identify intervention actions as well as potential implementers. The Action Scales Model (ASM), a tool to understand and change the system at different levels (i.e., event, structure, goal, belief) of the system, was used to create a coherent whole systems action plan.

Results

The created whole systems action plan consisted of 66 (sets of) actions across different ASM levels (i.e., event, structure, goal, belief) targeting 42 leverage points across five subsystems: school environment N = 24; mental wellbeing N = 17; digital environment N = 9; family & home environment N = 9; personal system N = 7. Per action potential implementers were identified, which included amongst others schools and public health services. The previously mapped CLD visualizing system dynamics shaping adolescent sleep health were supplemented with how dynamics can be changed via the actions identified.

Conclusions

The resulting whole systems action plan provides a subsequent step in applying a whole systems approach to understand and promote adolescent sleep health. Combining a systems approach, using the ASM, and a co-creation approach was found to be mutually reinforcing and helpful in developing a comprehensive action plan. This action plan can guide strategic planning and implementation of actions that promote systemic change. With this, it is important to ensure coherence between actions being developed and implemented to increase the potential for lasting systems change.

Introduction

Inadequate sleep health is a pervasive and prominent public health problem among today’s adolescents. It significantly impacts important health, social, and educational outcomes, such as a healthy weight development, emotional wellbeing, social and neurocognitive development and regulation, and academic performances [1]. Given the vital role of sleep health in adolescence, a critical period of growth and social emotional development, deteriorating sleep characteristics in adolescents raise concerns. For example, in a study among 24 European and North American countries, adolescents meeting the recommended 8–10 h of good quality sleep on school days ranged between 32 and 86% [2]. In the Netherlands, adolescent sleep health is equally worrisome with more than half of 14—17-year-olds meeting this sleep duration recommendation [3] and 24% of 12–16 year-olds adolescents rating their sleep quality as poor [4]. To target these current sleep health trends effective interventions are needed [5].

However, effectively stimulating adolescent sleep health is a complex challenge due to the dynamic interplay between biological, economic-, physical, sociocultural, and political determinants [5, 6]. Thus far, preventative interventions do not consider this complexity and instead often promote healthy adolescent sleep by focusing solely on a small set of individual determinants (e.g., psychological determinants) within one setting (e.g., school setting) most often via sleep education or mindfulness/relaxation training [7]. To achieve significant, lasting changes in sleep health however, intervention efforts need to address the coherent and dynamic complexity that is shaped by the many multi-level interacting sleep health determinants and the underlying mechanisms that shape them [6]. Therefore, rather than applying linear intervention approaches that single out a small set of determinants in isolation, changing sleep health requires a holistic, ‘whole systems approach’ (WSA) [8,9,10].

Whole systems approaches aim to provide a broader understanding of certain (health) outcomes or behaviors and to coherently transform the entire complex web of interacting factors that underlie it [9, 11]. Some recent WSA’s have been created in context of obesity prevention [12], yet none currently exist with regards to sleep health. Recently, Heemskerk et al. [6] provided first steps in creating a WSA by developing a causal loop diagram (CLD) to gain insight into the determinants, underlying mechanisms and broader system dynamics at play with regards to adolescent sleep health. This CLD was shaped by combining a thorough review of current research evidence with the perceptions of Dutch adolescents, parents, and a range of professionals that work closely with adolescents. The CLD revealed 6 subsystems, 23 feedback loops, and approximately 60 leverage points for action within the system to enact systems change, and thus, to potentially intervene on to promote adolescent sleep health.

The in-depth understanding of the system and potential key leverage points presented in the CLD of Heemskerk et al. [6] provided important direction for future intervention efforts. Developing a coherent set of actions, i.e., a whole systems action plan, that target these systems dynamics as a whole, rather than addressing isolated parts, is a relevant next step in the creation of a WSA [10, 12]. However, when identifying various leverage points and considering different ways to address them, it remains challenging to select combinations of leverage points that collectively have the greatest potential to impact and bring about system change. This is where the Action Scales Model (ASM) can serve as an asset [13]. The ASM helps to conceptualize, identify and appraise actions within complex adaptive systems. It describes four levels to understand and intervene within a system (i.e., events, structures, goals and beliefs). The deepest level of the system entails the system actors’ beliefs and driving forces that determine the system’s purpose (i.e., goals). From that, the system’s structure (i.e., the organization of the system causing events to occur) and events (i.e., observable system outcomes) emerge to achieve those system goals. Deeper levels of the system (e.g., goals and beliefs) hold more potential to achieve durable, impactful system changes, but are often more difficult to change and require more effort than changing the other levels (e.g., events, structures). To achieve system change, the ASM posits that actions could be leveraged across these four levels depending on the context. Inasmuch, applying the ASM can be a valuable next step in a WSA by providing guidance on (1) which leverage points to focus upon (i.e., targeting different system levels and mechanisms) and (2) how to ensure that a coherent set of reinforcing intervention efforts emerge which are most promising to actually bring system changes. Even more so, using the ASM with the target population (i.e., via co-creation approach) is thought to be a useful combination to yield appropriate, effective, impactful and sustainable solutions [13, 14].

With this in mind, to contribute to the broader literature on how to apply a WSA to address a complex public health problem and to specifically contribute to the field of adolescent sleep health, the aim of this study is to develop a ‘whole systems action plan’ to promote sleep health among Dutch adolescents using co-creation with relevant stakeholders and reliance on the Action Scales Model. In doing so, both the complexity of the system of factors that shape sleep health are considered while also being tailored to the needs of its end-users and implementers.

Methodology

Design

In this study, we build upon a previously developed CLD that was rigorously constructed using both literature and empirical data from all key stakeholders involved. This CLD aimed to capture the complex interplay of factors shaping adolescent sleep health and to identify leverage points for intervention. Thereby, this CLD served as a solid foundation for our current research. (see the CLD in Fig. 1: CLD reported by Heemskerk et al. [6]). To design a whole systems action plan, this study consisted of two phases. The first phase focused on identifying actions to impact the identified leverage points and enact the required systems changes, and thereafter in the second phase (potential) implementers and implementation strategies of said actions were identified.

Fig. 1

Causal loop diagram of adolescent sleep health, including all potential whole system action plan actions (adapted figure from Heemskerk et al. [6]

Co-Creation, action design, phase 1

Participatory co-creation sessions were held to identify actions. Co-creation is a widely used participatory method in health research involving collaboration between academics alongside other actors (e.g., end-users of interventions and implementers) in various phases of the development of health promotion programs instead of designing these programs using a top-down approach [14]. The term actor refers to a type of stakeholder (e.g., adolescent, parent or professional), while participant refers specifically to individuals from a certain actor group that participated in the study. Co-creation yields context-sensitive and knowledge-based practices that address the complexity of a health problem and the needs of the target group. As a result, this tailoring ensures that health promotion programs are more appropriate, suitable and well-received by their target audiences, which ultimately increases the likelihood of their long-term sustainment and effectiveness [15].

To ensure that the identified actions were not only fitting but also had an optimal potential for sustained systems change, the Action Scales Model (ASM) was applied to ensure that actions were developed across relevant system levels for each selected leverage point of this study. The ASM describes four interconnected system levels (i.e., events, structures, goals and beliefs) that facilitate understanding and intervening within a system to enact change. Understanding the system according to the ASM was part of the previous study [6]. To achieve system change action across different levels is required, whereby deeper levels (e.g., goals and beliefs) have more potential. However, these deeper levels are harder to change and demand more effort compared to the more surface levels (e.g., events and structures) [13]. Figure 2 illustrates the ASM levels and offers specific examples on how you can operationalize the levels.

Fig. 2

The action scales model levels* and examples** – adapted from Nobles et al. [13]

*Figure and explanations ASM levels adapted from: Nobles et al. [13]. **Operationalization of ASM concepts derived from heemskerk et al. [6]

Co-Creation, identifying implementers, phase 2

Using the insights of the first phase, co-creation sessions using the ‘World Café’ methodology was conducted for phase 2 of the project. This is a structured and participatory co-creation method used to facilitate open, meaningful, and collaborative discussions [16]. This phase was held to identify potential missed actions (e.g., additional actions and actions on deeper system levels), and to identify actor(s) and/or organization(s) that could potentially implement these actions.

Participants and recruitment

For phase 1, relevant actors in five identified subsystems of Heemskerk et al. [6] were invited to participate. The main relevant actor groups included adolescents (aged 12–15 years) with prevocational secondary education (in Dutch; VMBO)¹ [17], since this group report the poorest sleep health among Dutch adolescents [4]; parents or caregivers of an adolescent; and youth-, health-, digital technology and educational professionals, who were purposefully sampled based on the previous identified leverage points (by Heemskerk et al. [6]). Adolescents were recruited via a youth panel, via schools, and via social media channels. Parents (or caregivers) did not have to be the parents of the adolescents participated in the study, but rather any parent of an adolescent in general aged 12–15 years. They were recruited via different social media platforms and with help of professionals from the different participating Public Health Services. Professionals were recruited via a network of affiliated municipalities and Public Health Services of the project. We aimed to include 6–12 participants per co-creation session [14]. Participants received a gift card of 25 euros for participation per workshop.

In phase 2, the ‘World Café Session’, relevant actors at both local and national level who might be responsible for implementing and supporting the identified actions from phase 1 were recruited. These participants were recruited using the network of affiliated municipalities, Public Health Services, and practice-based organizations that had multidisciplinary backgrounds and/or worked at different (municipal) sectors (e.g., health promotion workers/public health advisors, youth healthcare professionals, policy advisors public (mental) health).

A total of 40 adolescents from pre-vocational secondary education (aged 12–15 years, mean age 14 years, 20 girls), 14 parents (11 female), and 40 professionals, 13 in phase 1 (e.g., teachers, sport coaches, mental health experts, digital health experts, parenting expert) and 27 in phase 2 (e.g., Healthy School Advisors, health promotion workers/public health advisors, parent–child advisors, youth psychologists/doctors, youth healthcare professionals, policy advisors public (mental) health, policy advisors healthy living environment, policy advisors youth and digital environment) participated in 8 multi-actor and single-actor co-creation sessions with attendance ranging from 9–18 participants per session. During the sessions with adolescents, we ensured that they formed the majority of participants and that all participants experienced the sessions as a safe space and open environment in which they were comfortable to share experiences and thoughts. All participants received information about the co-creation session prior to participation and provided active informed consent. With regards to the participating adolescents, their parents or caregivers provided passive informed consent.

Prior to study onset, ethical approval was granted by the institutional medical ethics committee of Amsterdam UMC (VUMC 2021.0783).

Procedure

Co-creation phase 1: Action design

Between April and June 2022, five co-creation sessions were conducted with the aim of identifying and co-creating program actions at the selected leverage points. Each session focused on a specific adolescent sleep health subsystem (i.e., school environment, mental wellbeing, digital environment, personal system, and family & home environment) [6] and lasted 2 h. Depending on relevance and content, we held either multi-actor sessions (e.g., school environment, mental wellbeing, digital environment) or single-actor sessions (e.g., family & home environment and personal system).

In the previous study of Heemskerk et al. [6], about sixty potential leverage points were identified. Investigating all of these was not feasible for the co-creation sessions. For that reason, the number of leverage points that were addressed in the creation of the action plan were reduced. First, some leverage points were combined because they essentially addressed the same points or complemented each other. Next, a prioritization was made by the research team resulting in 15 leverage points (see Table 1, Result section) based on their changeability and potential impact within the system. This selection was informed by evidence from the scientific literature and consultation with experts (i.e., their influence to strengthen or break a feedback loop or mechanism).

Table 1 Adolescent sleep health whole systems action plan

All co-creation sessions followed the same structure (Additional file I). Prior to these sessions, participants received a ‘sensitizer’ – namely, a short (online) questionnaire designed to stimulate participants to think about the topic before joining the co-creation session (i.e., “What should schools do regarding the topic of stress and sleep?”). This served for participants to think about their own experiences and formulate their own opinions before engaging in group discussions. Then, during each session, individuals first met in homogenous actor groups (i.e., adolescents grouped together, parents in another, and professionals also in their respective peer groups) to brainstorm and identify numerous actions aimed at targeting the previous identified leverage points for that specific subsystem (e.g., come up with solutions to change evening school notifications). Participants were actively stimulated to think of potential actions in context of the different system levels of the ASM model facilitated by prompt actions and questions. For example, based on the example shown in Fig. 2: “What can you do personally? What can teachers/school leaders/the local government/the Ministry of Education do? How can we change the school structure? How can we change the current norm/attitude about successful citizenship?”. Thereafter, participants prioritized what they felt to be the most impactful, promising, fitting actions per leverage point. Subsequently, three to four multi-actor groups were formed. Participants collectively chose one idea to further develop. Thereafter participants shared their ideas with others and received feedback and suggestions for improvement from other groups.

Throughout all the data collection efforts, we iteratively identified and learned from the sessions’ strengths and weaknesses to improve on their design [25]. This enhanced continual learning throughout the process. This, for example, refined session details with regards to the ideal number of participants for effective discussion or how to create the optimal atmosphere to empower all participants to engage.

Co-creation phase 2: Identifying potential implementers

Between June and October 2022, three co-creation sessions were held using the World Café Methodology, each lasting 2 h. Their aim was twofold:

• 1) identify and clarify additional actions/ideas targeting one or more leverage points;

• 2) identify who/what organization can structurally implement the conceived actions

Using the World Café methodology, participants gathered in a comfortable and informal setting where they received information about the process. After being divided into small groups at different tables, discussions took place in timed rounds (e.g., 20–30 min), focusing on a specific question or topic. Every table was focused on one of the five sleep subsystems. Printed posters were used to illustrating the previous identified system dynamics per subsystem [6] supplemented with the actions as identified in phase 1. Participants reflected on additional/existing ideas as well as potential implementers. Each round began with a context-specific question designed to steer the conversation (e.g., “please look at this part of the poster, do you miss an action to prevent late night school notifications?”). After each round, members moved to a new table while the ‘table host’- either a facilitator or participant- stayed behind to welcome the next groups and maintain the conversation’s flow. Finally, everyone reconvened to share and synthesize the most important insights and ideas emerged from the discussions (i.e., in this study the facilitator presented the results to the rest of the group whereafter participants could respond).

Data analysis

First, all actions of the phase 1 co-creation sessions were structured according to the leverage points they aimed to target. Thereafter, actions were thematically analyzed and similar or duplicate ideas were removed. All actions proposed were given equal weight, with no distinction between the actor groups. Actions that were not considered feasible (e.g., paying teenagers to go to bed earlier) were not included in the action plan. Third, the actions/ideas were written out in full and integrated into the previously developed Causal Loop Diagram using Kumu software (Kumu relationship Mapping Software 2024). With this, the actions were linked to the specific leverage point they aimed to address. Then, after each World Café session, actions/ideas and potential implementers were thematically analyzed and additional actions were added to the Causal Loop Diagram using Kumu. Additionally, the session notes were analyzed, from which additional actions were derived. All actions were categorized according to the Action Scales Model levels (i.e., event, structure, goal, belief) to gain insight into which levels of the system the actions were co-created for. Sets of actions across different ASM levels were numbered and integrated within the CLD at the points where they influence a factor or disrupt a mechanism. All phases of the analysis were conducted and discussed independently by at least two researchers.

Results

The results of the co-creation sessions, both phase 1 and phase 2, are visually depicted in Table 1. Specifically, a resulting whole systems action plan to promote sleep health of Dutch adolescents is presented whereby the reader can find an overview of all mechanisms and leverage points per subsystem, newly identified actions; their ASM classification; and (potential) implementers. This plan is visually depicted in Fig. 1 whereby the original CLD developed by Heemskerk et al. [6] is supplemented with actions identified during the co-creation sessions. In total 66 sets of actions emerged targeting the leverage points within the following subsystems: school environment [yellow] N = 24; mental wellbeing [mint green] N = 17; digital environment [orange] N = 9; family & home environment [purple] N = 9.; personal system [red] N = 7).

These actions are organized into coherent sets each jointly targeting a specific identified leverage point. Typically, such a set consists of actions across different ASM levels. Actions are numbered in the Figure and Table to ensure correspondence, and to further aid interpretation, are placed within the CLD at the points where they influence a factor or disrupt a mechanism. The sets of actions are visualized with colored dots representing the sub-actions and their ASM classification. For example, action #1 represents four sub-actions across the ASM level (i.e., event = blue, structure = orange, goal = green, belief = purple) (Fig. 1 & Table 1). Figure 3 visualizes the relationships, feedback loops and leverage points within the subsystem ‘school environment’. Figures of the other subsystems can be found in Additional file 2–5.

Fig. 3

Causal loop diagram of the school environment subsystem of adolescent sleep health, including all potential whole system action plan actions (adapted figure from Heemskerk et al. [6]

Whole systems action plan

While Table 1 and all figures comprehensively represent all aspects of the co-designed whole systems action plan for Dutch adolescent sleep health, we offer an example of how to interpret the results here as a guidance to the reader. Specifically, to start, it is important to select the leverage point of interest. For example, Heemskerk et al. [6] previously found that the leverage point ‘no digital communication from schools in the evening’ (subsystem: school environment) has considerable impact on adolescent sleep health, since they found that schools in the Netherlands often send messages to adolescents about grades, schedule changes and other school-related information late in the evening. A total of six sets of actions were identified to influence this leverage point, specifying for each sub-action which ASM level it targeted and what potential actor(s) would be best suited to implement each action in practice. For example, one broad set of actions focused on policies at the schools and was ultimately reflected across several sub-actions reflecting different ASM levels as denoted in Table 2.

Table 2 Sample Actions for Leverage Point “no digital communication from schools in the evening

To ensure sustainable change, coherence between the different system levels is required. However, this does not always mean that intervention efforts at all system levels are always needed. In this example, as shown in Table 2, simultaneous actions at four levels (i.e., event, structure, goal, belief) are needed in order to reduce the likelihood adolescents receiving late-night school notifications recurring in the future. In addition, regarding this specific leverage point, six sets of actions were identified. That said, ideally, the recommendation in this case would be to not select one set of actions, but rather to aim for the leverage point from as many angles as possible – thus leading to the greatest likelihood of change.

Discussion

Using a co-creation methodology with adolescents, parents, and professionals, together with the Action Scales Model, this study presents what is believed to be the first whole systems action plan for improving the sleep health of Dutch adolescents. This resulted in a coherent total of 66 designed actions and identified potential implementers within the Dutch context across five sleep health subsystems: school environment (N = 24), mental wellbeing (N = 17), digital environment (N = 9), family & home environment (N = 9), personal system (N = 7). Furthermore, we visualized how these actions are distributed across the four Action Scales Model levels.

A whole systems action plan to promote adolescent sleep health

Several recent studies have advocated for a more holistic approach by targeting multiple socio-ecological levels across diverse contexts (e.g., family, schools, digital) in order to promote adolescent sleep health [5,6,7, 26]. However, an umbrella review examining the scope of current sleep health interventions showed that, except for some studies targeting later school start times, most existing interventions target adolescents themselves as main actors to realize behavioral changes (i.e., sleep education, relaxation techniques, psychotherapy) [7] – highlighting the need to develop a more comprehensive way to effectively and sustainably impact adolescent sleep health, e.g., via a whole systems action plan.

As demonstrated in our current study, impacting adolescent sleep health requires a holistic approach and a coherent set of actions involving collaboration among multiple actors from different sectors on local and national level in line with the WHO’s Health in All Policies (HiAP) framework. This means focusing on promoting health and health equity through policies that extend beyond the public health and healthcare sector [27] in order to create more impactful, structural systems changes. Using such a HiAP approach, the ‘Educational’ policy domain, for example, can (potentially) contribute to e.g., delaying school starting times, supporting schools in creating healthy school environments and integrating sleep health into the school curriculum. Additionally, taking a ‘Health for All Policies’ point of view, improving sleep health can be used as a tool instead of a means and goal in itself to benefit other “sectors” such as education [28]. This way, improving sleep health can be framed in the political debate and in policy design as a tool to stimulate e.g. mental wellbeing, school engagement, school performance, school-related burnout, absenteeism, and bullying [29], all core targets for the ‘Educational’ and ‘Youth and Welfare’ domains. Emphasizing the co-benefits from improving health outcomes, such as sleep health, can serve as a stimulant for intersectoral collaboration.

Using the action scales model to facilitate systems change

To develop the whole systems action plan, we applied the Action Scales Model. We considered the ASM as a bridge between systems science and participatory approaches, facilitating both the process of identifying coherent sets of actions across different system levels and making systems science principles and methods achievable during our co-creation sessions. For example, we used the model prospectively by framing guiding questions aimed at prompting participants to consider actions across multiple system levels. This seemed especially useful considering that such systems thinking is quite unfamiliar for adolescents, parents and, generally, most professionals. However, we recommend developing tools to enhance the accessibility of the Action Scales Model (ASM) for a broader audience. This will enable a wider range of target groups, such as practitioners and policymakers, to utilize the model independently, without needing assistance from researchers and professionals familiar with it. Like many models, the ASM can be seen as somewhat arbitrary, depending on its application and interpretation (e.g., the subjectivity involved in level selection). For example, in this study, it became clear that actors involved identified policy as a primary method for altering structures within their context. Additionally, increasing awareness emerged as a crucial first step in transforming beliefs, norms and attitudes. By developing tools and encouraging more studies to apply and operationalize the ASM, we can make the model more accessible. This, in turn, empowers stakeholders to effectively implement the model in their fields, make informed decisions, and ultimately drive more impactful, evidence-based outcomes.

Using the ASM, it stood out that a larger number of actions were identified at the ‘event’ and ‘structure’ levels than were at the ‘goal’ and ‘belief’ levels. This is unsurprising as these are almost by definition the more visible and tangible system elements in comparison to the goals and beliefs that shape the deeper levels of the system. Moreover, developing a whole systems action plan is an extensive, iterative process. Initially, to properly understand a complex health behavior such as sleep health, the lived experiences of the target population and those closely involved with them are usually aimed to be understood. These lived experiences often involve tangible, visible elements or events and structures, as is the case with the often-used metaphor of ‘the tip of the iceberg’. Actions that address underlying goals and beliefs can then be determined by asking why these events and structures occur. However, the actors who have an influence on such deeper system goals and beliefs are often different actors than those who were initially brought in to uncover impactful events and structures. Therefore, they are often not yet involved in the earlier iterations of a whole systems action plan such as the one designed within our current study (e.g., legislators, policymakers, school boards). This explains why some underlying beliefs and system goals have not yet been concretely targeted in our whole system action plan and/or why some actions on these levels do not have concrete implementation actors connected to them yet. The design of a whole systems action plan should always be considered as iterative and long-term oriented with the intention of including more and more actors at the deeper levels.

Lastly, it is important to emphasize that the coherence across all potential actions is of relevance instead of quantifying the amount of actions or ensuring that all ASM levels are always targeted regardless of context. What matters most is that all relevant levers on all system levels are aligned to positively impact adolescent sleep health. This was illustrated in the aforementioned example of digital school communication in the late evening. It showed that not every set of actions required changes across all four ASM levels; sometimes, simply adjusting a particular structure was enough to initiate the necessary changes; however, in other cases, actions across multiple levels were required, depending on the specific situation. The ASM emphasizes the importance of alignment across all levels, ensuring that each level supports the system in moving cohesively in the same and desired direction.

Looking ahead

To our knowledge, this study is the first to create a whole systems action plan, informed by a previous comprehensive understanding of the system with multiple actors using the ASM, targeting adolescent sleep health. By doing so, it expands both the body of literature concerning the operationalization of whole systems approaches in addressing public health challenges [9] as well as on sleep health promotion in public health.

Our co-creative systems approach poses a considerable methodological strength, as it contributes to a comprehensive whole systems action plan that both addresses the root causes of poor adolescent sleep health and is closely aligned with the lived experiences of the target populations and the most relevant actor groups, ensuring that the proposed actions are both practical attainable and implementable. That was partly attributable to the multi-stakeholder approach of the co-creation sessions which facilitated consensus, resulting in actions that were not solely from either the adolescents or the adult actors, but rather collaborative efforts. By including both perspectives that are closely aligned with the adolescent and those focused on the implementation structures of actions and policies we feel that we have gained a fairly complete action plan. However, as mentioned above, developing an action plan remains an iterative process. We noticed that to co-create actions at deeper system levels (e.g., goals, beliefs), such as policies, involving additional actors (e.g., legislators, policymakers, school boards) is required. To further develop and refine effective implementation strategies for these type of actions, it would be desirable to include these key actors in a follow-up step.

Similar to our previous study mapping the system dynamics shaping adolescent sleep health within the Dutch context [6], we expect that the actions targeting the leverage points may be generalizable to other contexts but the content of the actions and coherence between the sub-actions and their ASM classification may differ dependent on the context (e.g., no action at belief level is needed in this context). With this in mind, for researchers interested in developing interventions promoting sleep health in communities other than the Dutch adolescent context, we recommend replicating our steps to understand the sleep health system of interest and develop a whole systems action plan addressing mechanisms within this system. In situations where resources and time are limited and replication not possible, we suggest that careful consideration be given to the context and that stakeholders with knowledge about the situation help select those leverage points that seem most context-agnostic and/or most consistent with the context at hand.

While we hope to see scholars replicate and extend this work in their own communities, for us, the next step is implementation of this plan. The action plan entails different actions across different settings. Its added value lies in viewing it as one whole to be executed coherently rather than addressing its isolated parts per setting. However, the action plan cannot be implemented all at once. It will be important to prioritize actions that are coherent, feasible and have significant leverage to transform the system into the desired situation. This involves examining the current ‘window of opportunity’, such as heightened public awareness, political support or momentum, available funding, or pressing needs that could guide and facilitate decisions about which leverage points and actions to focus on. However, there is not always a window of opportunity available. In such cases, it becomes essential to actively create one by developing and implementing strategic actions that establish the ‘problem stream’ and catalyze agenda setting, policy formulation and policy action. This process may involve raising awareness about pressing issues, shifting public opinion, and engaging stakeholders to highlight the urgency and significance of these challenges. After prioritizing, the action plan should be translated into an action program including a cohesive package with systematically developed interventions and implementation strategies. Preferably the development of these actions and implementation strategies should be based on theory and scientific evidence to increase the likelihood to achieve the desired change by using structured intervention development and implementation approach such as Intervention Mapping [30] or the Behavior Change Wheel [31].This also means considering the timeframe as a parameter for decision, especially since actions on event and structure level may be more achievable on the short term (e.g., providing adolescents with knowledge, awareness, positive attitude, self-efficacy and skills to improve their sleep health) while actions at goal and belief level may take up for several years (e.g., changing beliefs regarding performance culture). To do this, intersectoral collaboration will be essential [8, 9]. Even more, for sustainable implementation, it will be crucial to have a ‘problem owner’ or joint ownership to maintain momentum and drive the implementation of actions needed to improve adolescent sleep health [12]. An example of this can be observed in Whole Systems Approaches (WSAs) to obesity, such as the ‘Amsterdam Healthy Weight Approach’ [8] and the ‘Whole Systems Approach to Obesity [12]. Both are long-term, local authority-led, multi-sectoral WSA’s aimed at reducing overweight and obesity. These WSAs seek to strengthen and align with the existing strategies and infrastructures of local authorities. Adding to implementation, it will be important to evaluate how the actions contribute to systems change and to facilitate program adjustments as necessary in response to these systems changes in the future [8].

Conclusion

This study provides details on the development and content of a whole systems action plan promoting Dutch adolescent sleep health providing insights into which leverage points to target, how to do this, and who/what is needed to realize that. A coherent total of 66 actions and potential implementers were identified within the Dutch context across five sleep health subsystems: the school environment, mental wellbeing, digital environment, family & home environment, and the personal system. The combination of a systems approach, using the Actions Scales Model, and a co-creation approach was found to be mutually reinforcing and helpful in developing a coherent, feasible and comprehensive whole systems action plan. This study contributed to the expanding body of literature concerning the operationalization of whole systems approaches tackling public health challenges and can be used as a guidance for strategic planning and implementation of actions that promote systemic change within the adolescent sleep health system. With this, it is important to ensure coherence between actions being developed and implemented to increase the potential for lasting systems change.

Glossary

Causal mechanism

Refers to the process or set of processes explaining why certain outcomes (such as inadequate sleep health) occur as a result of specific inputs or conditions [32].

Causal Loop Diagram (CLD)

Visual representation of a system and its dynamics visualizing factors, their interrelationship and feedback loops [33].

Action Scales Model (ASM)

Framework for understanding and addressing complex problems by distinguishing multiple levels (i.e., events, structures, goals and beliefs) to analyze a system and to intervene within a system to initiate systems change [13].

Leverage points

Modifiable points within a system. When these points are altered, this could lead to changes in the functioning, and thus the (health)outcome, of the system [34].

Whole Systems Approach (WSA)

An approach to address complex problems by considering all interconnected factors and relationships within an entire system to develop holistic and sustainable solutions [9].

Whole Systems Actions Plan

A plan/strategy that addresses complex problems by integrating and coordinating actions coherently across different system levels, subsystems and settings to achieve systemic, sustainable systems change [12].