Enacting a Whole Systems Approach to National Level Physical Activity Strategy Development: ‘Realistic’ Lessons from Scotland

Whole systems approaches have become prominent within physical activity (PA) policy, mostly reported on as individual projects. There is however limited evidence regarding how such approaches can be facilitated at scale by nation-wide agencies. This paper examines Public Health Scotland’s Systems-based Approach to Physical Activity Promotion, designed to support national-level PA strategy development. Using a case study design, three Scottish regions were purposively selected. Data were gathered via: an online survey; interviews with regional PA leads; and key stakeholders focus groups. Analysis combined thematic analysis with Pawson and Tilley’s realistic evaluation framework. The work suggested that whilst previous efforts had often been insufficiently systematic, strong historical foundations of PA partnership working and strategy development provided crucial contemporary support. Despite COVID-19 disrupting ongoing strategic work, participants described the post-pandemic period as a positive ‘reset’ that created opportunities for innovation. The Public Health Scotland framework was valued for offering a structured, practical, and evidence-informed process that balanced centralised systems thinking with local flexibility. Participants also approved of the inclusivity of the workshops, cross-sector collaboration, and the credibility of Public Health Scotland facilitation. Challenges included the complexity of systems concepts, sustaining stakeholder engagement, securing representation from senior decision-makers, and concerns regarding implementation capacity and resources. Our paper suggests that nationally facilitated, systems-informed approaches can effectively support the development of robust local PA strategies. However, strategy production represents only an initial outcome. Sustained implementation support, leadership, and long-term system stewardship are also required to translate aspirations into lasting population-level increases in PA.