From Reflexive Thematic Analysis to Soft Systems Methodology: an approach to translating expert perspectives into implementation design in South African HIV therapies

Abstract Introduction : Qualitative studies of healthcare issues often identify barriers and facilitators, yet fewer demonstrate how to translate these findings into structured implementation design. This article addresses that methodological gap by showing how Reflexive Thematic Analysis and Soft Systems Methodology were combined to produce implementation-oriented outputs from expert interview data, within a study of Long-acting injectable antiretroviral therapy implementation in South Africa. Long-acting injectable antiretroviral therapy has the potential to reduce some of the social and practical barriers associated with daily oral treatment. Still, its feasibility in large public health systems depends as much on service reliability as on clinical promise. In South Africa, where HIV care is delivered at scale, implementation questions extend beyond medicines to include cold-chain control, appointment-linked stock flow, follow-up for missed visits, workflow design, and governance. Methods : This article focuses on the methodological lessons derived from the qualitative study examining the feasibility of long-acting injectable antiretroviral therapy in South Africa. Semi-structured interviews were conducted with 15 HIV experts based in South Africa, drawn from clinical, pharmacy/regulatory, and academic settings. Interviews were audio-recorded, transcribed, anonymised, and analysed using Reflexive Thematic Analysis. The resulting themes were then translated through a stepwise Soft Systems Methodology process, involving CATWOE analysis, root definitions, conceptual activity models, model–reality comparison, feasible changes, and measures of effectiveness, efficiency, and equity. Results : Seven themes captured the dominant implementation concerns and enabling conditions for delivery in South Africa’s public sector: infrastructure and cold-chain reliability; patient acceptability and stigma; cost and procurement; provider training and workflow readiness; follow-up and resistance risk; policy and regulatory alignment; and data and system integration. These themes converged on three interacting minimal systems: missed-dose rescue, end-to-end cold-chain continuity, and task-shifted injection workflow. Using missed-dose rescue as the main worked example, the study demonstrates how a qualitative safety concern was translated into a system definition with explicit actors, responsibilities, controls, and measurable outputs. The method generated implementation-oriented outputs, including conceptual models, prioritised change logic, and measurable indicators. Conclusions : The study presents a transparent qualitative-to-systems pipeline for translating expert perspectives into structured implementation design. By making the route from thematic interpretation to systems modelling explicit, the approach addresses concerns about inconsistent reporting of Soft Systems Methodology in healthcare. It offers a practical way to strengthen implementation-oriented qualitative research in complex service settings.