Assessing Systemic Barriers to Veteran Health Using Systems Thinking: Tools for Community Assessment and Action

<em>Background:&nbsp;</em>&nbsp; Despite decades of research and substantial federal investment, Veterans continue to experience disproportionate rates of suicide, substance use, and chronic disease relative to the general population. Communities striving to support Veteran wellness&nbsp;must&nbsp;learn how to&nbsp;leverage&nbsp;these&nbsp;research-based insights and best practices in their contexts yet often lack tools to do so.&nbsp;Systems thinking offers a way to represent the interactions between component parts of a system to better understand complex problems. Our&nbsp;objective&nbsp;was to&nbsp;develop&nbsp;systems tools that&nbsp;synthesize evidence to guide community&nbsp;action in support of Veteran health and safety.&nbsp; &nbsp; <em>Methods:</em>&nbsp; A prior literature review&nbsp;identified&nbsp;various&nbsp;community factors&nbsp;that support&nbsp;or&nbsp;undermine&nbsp;Veteran health and safety using the Vital Conditions framework.&nbsp;Working from it and other literature, we identified&nbsp;key system supports: policies, community services, system practices, and concrete resources supportive to Veteran health, along with system-wide characteristics and mental models hindering it. We developed two systems tools to visualize prominent barriers and supports: causal loop diagrams&mdash;iteratively refined through focus groups and interviews with Veterans, Veteran-serving community members, and experts&mdash;that visualize feedback structures underlying major themes pertaining to Veteran health; and an iceberg model for systems thinking, which synthesized and organized these barriers according to relative difficulty of change. Leverage points, or system supports well-positioned to address iceberg barriers and disrupt feedback loops, were matched to iceberg levels. Together, these tools are designed to support community-driven prioritization of action. &nbsp; <em>Results:&nbsp;</em>&nbsp; Causal loop diagrams supported dialogue around interconnected drivers of Veteran health, highlighting 14 feedback loops shaping system behavior. Key themes included health consequences of service, transition to civilian life, care-seeking and barriers to eligibility, and enrollment and utilization of healthcare services. The iceberg model highlighted 52 barriers that can serve as targets for change, and 93 leverage points were matched to those barriers across iceberg levels. &nbsp;