{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T06:15:31Z","timestamp":1783577731368,"version":"3.55.0"},"reference-count":77,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T00:00:00Z","timestamp":1783555200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Health Serv."],"abstract":"<jats:p>Health systems interventions are increasingly designed to address complex challenges in quality, safety, access, and equity. Yet many fail to achieve sustained impact, often due to misalignment between intervention mechanisms, organisational context, and broader system dynamics. Although theory is widely promoted to strengthen intervention design, frameworks from behavioural science, implementation science, and systems thinking are frequently applied in isolation, limiting their collective explanatory and practical value. This focused narrative review adopts a design-first perspective\u2014defined as the prospective use of theory to inform intervention development rather than its retrospective use to explain outcomes, to synthesise and compare key theoretical approaches used to inform the development of complex health system interventions. Drawing on a narrative synthesis of 46 review articles (33 identified through database searching and 13 through citation chasing of foundational sources) published between 2010 and 2026, we examine how behavioural science, implementation science theories and frameworks, and systems thinking approaches contribute complementary insights across the micro- (individual\/interpersonal), meso- (team\/organisational) and macro- (system\/policy) levels of complexity. We argue that effective intervention development requires a layered design architecture that explicitly aligns micro-level behavioural mechanisms, meso-level organisational and implementation processes, and macro-level system dynamics. We also argue that the boundaries between these traditions are increasingly fluid, and that hybrid frameworks and the integration of design thinking with implementation and systems science, represent a particularly fertile area for advancing intervention design. By integrating these traditions, we propose a pluralistic and structured approach to intervention design that strengthens causal clarity while accommodating adaptation and contextual variability. Advancing such integrative practice is essential for improving the effectiveness, scalability, and sustainability of health system interventions.<\/jats:p>","DOI":"10.3389\/frhs.2026.1820296","type":"journal-article","created":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T05:34:57Z","timestamp":1783575297000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Designing complex health system interventions: an integrated theory-informed approach"],"prefix":"10.3389","volume":"6","author":[{"given":"Shobhana","family":"Nagraj","sequence":"first","affiliation":[{"name":"Department of Public Health and Primary Care, University of Cambridge","place":["Cambridge, United Kingdom"]},{"name":"East London NHS Foundation Trust","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesca","family":"Maraschin","sequence":"additional","affiliation":[{"name":"Department of Public Health and Primary Care, University of Cambridge","place":["Cambridge, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,7,9]]},"reference":[{"key":"B1","first-page":"155","article-title":"Priorities in health","volume-title":"Chapter 7, Pillars of the Health System","author":"Jamison","year":"2006"},{"key":"B2","doi-asserted-by":"publisher","first-page":"625","DOI":"10.1136\/bmj.323.7313.625","article-title":"Complexity science: the challenge of complexity in health care","volume":"323","author":"Plsek","year":"2001","journal-title":"Br Med J"},{"key":"B3","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1186\/s12916-018-1089-4","article-title":"Studying complexity in health services research: desperately seeking an overdue paradigm shift","volume":"16","author":"Greenhalgh","year":"2018","journal-title":"BMC Med"},{"key":"B4","doi-asserted-by":"publisher","first-page":"n2061","DOI":"10.1136\/bmj.n2061","article-title":"A new framework for developing and evaluating complex interventions: update of medical research council guidance","volume":"374","author":"Skivington","year":"2021","journal-title":"Br Med J"},{"key":"B5","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1136\/bmj.n1679","article-title":"Adapting interventions to new contexts\u2014the ADAPT guidance","volume":"374","author":"Moore","year":"2021","journal-title":"Br Med J"},{"key":"B6","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1186\/1748-5908-8-18","article-title":"Towards a general theory of implementation","volume":"8","author":"May","year":"2013","journal-title":"Implement Sci"},{"key":"B7","doi-asserted-by":"publisher","first-page":"23","DOI":"10.1177\/1356389018803219","article-title":"From complex social interventions to interventions in complex social systems: future directions and unresolved questions for intervention development and evaluation","volume":"25","author":"Moore","year":"2019","journal-title":"Evaluation"},{"key":"B8","doi-asserted-by":"publisher","first-page":"132","DOI":"10.1016\/j.ssmph.2016.12.005","article-title":"What theory, for whom and in which context? 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