Facilitation and delivery of online GMB workshops
During the three workshops the facilitator made sure everyone’s ideas were heard and included in the discussions on what to include in the system map. They shared different perspectives about how the food and beverage industry influence their food choices, and the different ideas they thought could tackle unhealthy diets in adolescence. Adolescents became familiarised with system thinking and system dynamics concepts, developed a shared understanding of a complex issue and portrayed it in a system map that depicted the most important factors in a causal structure as well as their interactions at various levels (see Fig. 4). The system map created by adolescents had 70 causal links which connected 37 elements and had 7 feedback loops. The 37 elements were grouped into 6 themes or pathways, represented by the different colours in the map. Adolescents understood feedback loops as the circular nature of cause and effect, and they exemplified loops as the “chicken or egg” metaphor. Based on the map, they were also familiar with reinforcing loops—an action that creates a result which produces more of the same action, resulting in continued growth or decline; and balancing feedback loops – an action that creates a result which produces the opposite direction of the initial action, redirecting the system towards equilibrium [22].
This was a 1-h workshop where we discussed the validated system map created by adolescents (Map 4) and shared the policy/action ideas they suggested. During the workshop participants added factors to the map based on their expert knowledge and their views and identified areas of current policy intervention as well as unexplored areas with the aim to identify potential leverage points. They did not remove or changed any of the arrows or factors in the map. Participants were encouraged to suggest any additional factors they thought were important and not included in the system map made by the adolescents. These were included in real time using STICK-E. Participants validated verbally that the system map created by the adolescents was in agreement with their mental models. The key feedback loops in the map were articulated and the modeller/facilitator confirmed participants’ understanding of the correspondence between model structure and system behaviour. This led to the final overarching system map of the commercial determinants of dietary behaviour in adolescence. During the workshop we explored the possibility for participants to use the system map as a communication tool to incorporate the commercial determinants of dietary behaviour into current public health thinking, and identify whether it had the potential to influence policy making efforts.
Practicalities of adapting GMB workshops to an online format
Online delivery of a workshop requires a platform that is both safe (with respect to confidential information and ensuring non-invited people are not able to log on) and sufficiently flexible to allow for interactive activities (e.g. drawing graphs over-time, mapping the system in real time) in an engaging layout [23]. At the time of the workshops the University of Bristol considered BlueJeans to be the most secure platform. We also needed an engaging platform where we could build and share the system map in real time. STICK-E is a platform that was designed to facilitate community knowledge exchange and promote a shared understanding of complex problems and fulfilled our needs for the workshops.
We initially budgeted costs for room hiring (£150 per workshop × 2), refreshments (£150 per workshop × 2), stationary materials (£50), and facilitator and note-taker travel costs (£7 per day × 2). We did not include travel costs for participants since the workshops were going to be held near or at their school or council offices. Delivering the workshops online allowed us to save approximately £664 since we did not have to hire any rooms for the workshops, provide refreshments, spend on travelling costs, or purchase any stationary material.
We developed the online agenda aiming to minimise participants’ burden and cater for dates and times that would work for each one of them. For example, some adolescents were still in term time when the workshops happened, and we had to offer out-of-office hours and weekends so they could choose a date and time that was convenient for them. Similarly, policymakers had very limited time available due to the duties they had in responding to the COVID-19 pandemic and we had to design it to fit into a one-hour long workshop. Piloting the workshops was an essential part of the planning and adapting phase. Even though the GMB scripts were a good guide to design the online workshops, we had to test, from a participant’s perspective, that the workspace, the transition between platforms and the different workshops activities were engaging and closely connected. We piloted the workshops with postgraduate students from the University of Bristol and Cambridge. This allowed us to readjust the timings of some activities, for example, extend by 15 min the time allocated to do the system map in workshop 2. We were able to recruit 11 adolescents and 6 policymakers and practitioners.
Running GMB workshops requires multiple roles (e.g. facilitator, modeller, recorder or note-taker) to balance the group process and generate the best possible results [24]. We had two roles during the workshops: modeller/facilitator and note-taker.
The modeller/facilitator was responsible for hosting and moderating the discussions and to guide the group to build the system map. She was trained in GMB methods, had substantive knowledge in the problem being mapped, and had strong group facilitation skills. She participated in all 3 workshops with the adolescents and the workshop with the policymakers. Participants can have different levels of engagement with technology and online platforms and the modeller/facilitator needed to find the balance between letting participants share and expand on their views and keeping within the boundaries of the problem being addressed. Time pressure, participants’ screen fatigue and engagement were important factors to account for in an online context since it limits the facilitator’s capacity to read nonverbal cues which are easier to manage in face-to-face interactions. To compensate for this the facilitator had to check-in regularly and having an initial individual workshop with each of the adolescents helped in building a good rapport with them before the group activity and enhanced an active participation throughout workshop 2 and 3. Having an additional facilitator would have been useful to keep detailed observation of participants’ engagement and interaction. Some participants were more comfortable in speaking up, while others were more reticent. To allow for all participant to speak up the facilitator was proactively asking specific participants to share their thoughts. Online workshops tend to demand more energy from participants than face-to-face workshops, and it was an important factor when designing the workshop agenda.
The note-taker only participated in workshop 2 and was responsible for recording key interactions between participants, as well as non-verbal expressions and key phrases. This added context to the recordings and allowed us to underline key points mentioned by the participants. She was also able to pause the workshop to clarify any terms or narratives that were not clear. After the workshop the modeller/facilitator and the note-taker worked together to consolidate the notes and make sure that participants’ conversations (verbal and non-verbal expressions) and key points were included in the final system map.
Almost all the adolescents (10/11), and all the policymakers and practitioners responded to the survey (6/6). Overall, participants enjoyed the workshops, felt engaged and satisfied with what they had to contribute and believed they had learned something new. In terms of achieving the intended aims of the workshops, participants felt that they were able to put forward ideas for discussion, recognised there were many different points of view, were prompted to think more creatively about the problem being addressed and slightly challenged their previous ways of thinking about the problem.
In terms of methodological evaluation of the system mapping workshops, the survey indicated that the method was well suited for young people and practitioners and that they were given freedom to introduce new topics and cognitive frames. The policymakers discussed the potential for the system map to be used as a communication tool to visualise the complexity, but also the potential leverage points for intervention in policy making efforts.
Validation of the map occurred through internal consensus, first as a group, and then individually by adolescents. When adolescents wanted to add elements or change direction of association during the workshops, changes were made in real time. We considered full validation of the map to be when the entire group agreed with the map. We did not encounter any disagreement or non-validation from the adolescents neither during the group nor the individual workshops.
The map validated by adolescents was shown to policymakers and public health practitioners, and they further validated it by verbally confirming the factors and interrelations highlighted by the adolescents. After policymakers and public health practitioners validated the map, we used this as the basis for further discussion of the complexity of the influence of the food and beverage industry on adolescents’ dietary behaviour. Policymakers highlighted the difficulty of simplifying the complexity of the issue into a diagram, but also the methodological value of visualising the factors and interconnections in a map to uncover causal links and use it as a decision-making tool.
Participants provided feedback that key strengths of the workshops were that the purposes of every workshop were clear and they had clarity on what was expected from them, that the discussions during the workshops were free and open and that their views were listened to without feeling pressure to agree with the group, and that nothing important was left unsaid. Below are some quotes from the adolescents’ feedback illustrating this:
The researcher was very friendly and listened well, giving everyone a chance to speak in group workshops and asking if there was anything you wanted to say in the 1-1 workshop! I am very positive about my experience.
Adolescent participant 1.
I think that the meetings were very relaxed and I really enjoyed them and I was made to feel like what I was saying was helpful which was encouraging.
Adolescent participant 2.
Policymakers and public health practitioners also enjoyed the workshop. However, in terms of timings they felt that they needed more time to discuss the map and the adolescents’ policy ideas:
You did a brilliant job of running an engaging session! You kept slide content minimal and talked through everything very clearly - clearly a well-planned session. It's definitely hard to get the timing right for a session like this - I think that we could easily have gone in for another hour, but I know that time is always limited. I think for next time, may not need as much time on the introductions, and then you can maximise the time available to discuss your objectives. Top work :)
Public health practitioner/policymaker 1.