Engaging Coalitions in Community-Based Childhood Obesity Prevention Interventions: A Mixed Methods Assessment

Next Steps in Efforts to Address the Obesity Epidemic

Obesity prevalence continues to rise globally at alarming rates, with adverse health and economic implications. In this state-of-the-art review, we provide an analysis of selected evidence about the current knowledge in the obesity literature, including a synthesis of current challenges in obesity and its determinants. In addition, we review past and current efforts to combat the obesity epidemic, highlighting both successful efforts and areas for further development. Last, we offer insights into the next steps to address the obesity epidemic and advance the field of obesity through both research and practice by (a) adopting a systems perspective, (b) fostering cross-sector and community collaborations, (c) advancing health equity, (d) narrowing the research-to-practice and research-to-policy gaps with multidisciplinary approaches, and (e) embracing complementary approaches for concurrent obesity prevention and treatment.

Measurement and evaluation of community engagement in complex, chronic medical conditions: HIV and obesity as exemplar conditions

Objective To systematically review, describe, and compare quantitative measures of community engagement in obesity and HIV prevention research. Materials & Methods A systematic review adhering to PRISMA and PROSPERO guidelines was conducted, searching seven databases. Screening and quality assessment were carried out by four reviewers independently. Studies were included if they explicitly used community engagement for obesity or HIV prevention and quantitatively measured community engagement. Extracted data included descriptions of community engagement, measurement constructs, and statistical results. Results Of 8922 studies screened by title and abstract and 1326 studies screened by full text, 13 studies were included from obesity prevention and 42 studies from HIV prevention. The studies used a range of terms for community engagement, highlighting differing approaches and challenges in measurement. Quantitative measures of community engagement varied across the studies. When change over time in community engagement was analyzed, an increase in engagement was generally found, and when an association between engagement and health was tested, a positive association was generally found. Conclusion Despite diverse measurement approaches, drawing parallels between obesity and HIV prevention offers new pathways to strengthen community engagement evaluations through the iteration of existing measures across the two fields.

Umbrella review of systematic reviews to inform the development and translation of community-based childhood obesity prevention interventions

Community-based interventions (CBIs) can be effective and feasible for the prevention of childhood obesity. The aim of this umbrella review is to determine if systematic reviews report sufficient information to guide replication or adaptation of CBIs to a variety of contexts and aid in further development of childhood obesity prevention CBIs. Six databases were searched for systematic reviews including obesity prevention CBIs involving 0-18 year olds and reporting weight-related outcomes. Two researchers screened results. Evidence-to-decision frameworks guided which details may be required for decision-makers to design and carry-out a CBI, including information on intervention characteristics, outcome reporting and translation factors. From 3935 search results, 40 studies were included. The most frequently reported relevant pieces of information were behaviors targeted (100% of systematic reviews), intervention duration (90%) and settings involved (97.5%). Less frequently reported factors included specific actions implemented (48%), intervention intensity (30%) and organizations, or contributors involved (40%). There was a low level of reporting of equity considerations (27.5%), adverse events (20%), and costs/cost-effectiveness (17.5%). Multilevel interventions for child obesity prevention have demonstrated effectiveness, yet additional documentation of successful intervention processes is needed.

Investigate-Design-Practice-Reflect: An Iterative Community-Engaged Action Process to Improve Population Health

BACKGROUND

Community-based coalitions are a common strategy for community engagement efforts targeting the improvement of a variety of population health outcomes. The typical processes that coalitions follow to organize efforts include steps that are sequential, slow, and time intensive. These processes also limit local decision-making to the selection of evidence-based policies or programs.

METHODS

We present a process control theory-based Community Action Process, Investigate-Design-Practice-Reflect (IDPR), where community hubs (i.e., coalitions) organize agile efforts in a non-sequential, rapid, and efficient manner to harness local assets and data to make decisions regarding the provision and production of population health services. Using qualitative methods, we illustrate and analyze the use of IDPR in a one community case study as part of Wellscapes, a Type 3-hybrid implementation-effectiveness community randomized controlled trial to improve children's population health physical activity.

RESULTS

We found community members followed the IDPR Community Action Process to rapidly design, organize, deliver, and receive feedback on a community-based, children's population physical activity prototype, an afterschool Play-in-the-Park opportunity for all children.

DISCUSSION

Following IDPR afforded the community coalition timely learning through feedback within a process that coordinated decisions regarding what community services met community needs (provision decisions) and how to organize the production of the population health services (production decisions).

Applying Community-based System Dynamics to promote child health equity: the case of healthy and fit kids in Milwaukee, WI

Background

Child health equity is influenced by complex systemic factors, including structural racism, socioeconomic disparities, and access to resources. Traditional public health interventions often target individual behaviors, but there is a growing need for systems approaches that address these root causes. This study examines coalition members' perspectives on promoting child health equity in Milwaukee as a result of participating in an intervention that includes Community-based System Dynamics (CBSD).

Methods

In this case study, we used a mixed-methods approach to describe 10 coalition members' perspective shifts over 6 months, after participating in CBSD activities. These activities generated a causal-loop diagram to map the systemic factors influencing child health. Data collection included pre-post interviews and surveys. The data analysis involved thematic analysis of the qualitative data from interviews, which was then integrated with the open-ended survey responses. The themes identified were cross-referenced with the causal-loop diagram factors to validate and refine the understanding of systemic influences on child health.

Results

Post-intervention, coalition members shifted their focus from individual health behaviors to systemic drivers, particularly structural racism and socioeconomic disparities. The causal-loop diagram helped identify leverage points and fostered a readiness for local collective action and policy advocacy.

Conclusion

Integrating CBSD into public health coalitions can shift focus from individual behaviors to systemic causes, enabling more effective interventions. This approach offers valuable insights for promoting child health equity through holistic, community-driven strategies and public policy reforms.

A Qualitative Study of Health Equity's Role in Community Coalition Development

Opioid overdose deaths are dramatically increasing in the United States and disproportionately affecting minority communities, with the increasing presence of fentanyl exacerbating this crisis. Developing community coalitions is a long-standing strategy used to address public health issues. However, there is a limited understanding of how coalitions operate amid a serious public health crisis. To address this gap, we leveraged data from the HEALing Communities Study (HCS)-a multisite implementation study aiming to reduce opioid overdose deaths in 67 communities. Researchers analyzed transcripts of 321 qualitative interviews conducted with members of 56 coalitions in the four states participating in the HCS. There were no a priori interests in themes, and emergent themes were identified through inductive thematic analysis and then mapped to the constructs of the Community Coalition Action Theory (CCAT). Themes emerged related to coalition development and highlighted the role of health equity in the inner workings of coalitions addressing the opioid epidemic. Coalition members reported seeing the lack of racial and ethnic diversity within their coalitions as a barrier to their work. However, when coalitions focused on health equity, they noted that their effectiveness and ability to tailor their initiatives to their communities' needs were strengthened. Based on our findings, we suggest two additions to enhance the CCAT: (a) incorporating health equity as an overarching construct that affects all stages of development, and (b) ensuring that data about individuals served are included within the pooled resource construct to enable monitoring of health equity.

Scoping review of obesity interventions: Research frontiers and publication status

Obesity and overweight are significant global health issues, and numerous obesity intervention studies have been conducted. Summarizing current knowledge of interventions aims to inform researchers and policymakers to keep up-to-date with the latest scientific advancements and trends. In this review, we comprehensively retrieved and screened 4,541 studies on obesity intervention published between 2018 and 2022 in the Web of Science Core Collection, and objectively presented research frontiers using bibliometric analysis. The research frontiers of intervention are mainly focused on dietary, exercise, pharmacological interventions, bariatric surgery, environmental, and cognitive interventions. Time-restricted eating is the hottest research topic, followed by probiotics and Roux-en-Y gastric bypass. Gut microbiota is located in the "Basic and transversal themes" quadrant with a high centrality and low density, which has great development potentiality. Obesity intervention is becoming increasingly common,and we advocate for researchers to undertake more focused research endeavors that consider the specific characteristics of diverse populations or patients.

Applying a Social Determinants of Health Framework to Guide Digital Innovations That Reduce Disparities in Chronic Disease

ABSTRACT

Chronic diseases are among the top causes of global death, disability, and health care expenditure. Digital health interventions (e.g., patient support delivered via technologies such as smartphones, wearables, videoconferencing, social media, and virtual reality) may prevent and mitigate chronic disease by facilitating accessible, personalized care. Although these tools have promise to reach historically marginalized groups, who are disproportionately affected by chronic disease, evidence suggests that digital health interventions could unintentionally exacerbate health inequities. This commentary outlines opportunities to harness recent advancements in technology and research design to drive equitable digital health intervention development and implementation. We apply "calls to action" from the World Health Organization Commission on Social Determinants of Health conceptual framework to the development of new, and refinement of existing, digital health interventions that aim to prevent or treat chronic disease by targeting intermediary, social, and/or structural determinants of health. Three mirrored "calls to action" are thus proposed for digital health research: a) develop, implement, and evaluate multilevel, context-specific digital health interventions; b) engage in intersectoral partnerships to advance digital health equity and social equity more broadly; and c) include and empower historically marginalized groups to develop, implement, and access digital health interventions. Using these "action items," we review several technological and methodological innovations for designing, evaluating, and implementing digital health interventions that have greater potential to reduce health inequities. We also enumerate possible challenges to conducting this work, including leading interdisciplinary collaborations, diversifying the scientific workforce, building trustworthy community relationships, and evolving health care and digital infrastructures.

Community coalition efforts to prevent childhood obesity: two-year results of the Shape Up Under 5 study

BACKGROUND

Cross-sector collaborations and coalitions are promising approaches for childhood obesity prevention, yet there is little empirical evidence about how they affect change. We hypothesized that changes in knowledge of, and engagement with, childhood obesity prevention among coalition members can diffuse through social networks to influence policies, systems, and environments.

METHODS

We studied a community coalition (N = 16, Shape Up Under 5 "SUU5 Committee") focused on early childhood obesity prevention in Somerville, MA from 2015-17. Knowledge, engagement, and social network data were collected from Committee members and their network contacts (n = 193) at five timepoints over two years. Policy, systems, and environment data were collected from the SUU5 Committee. Data were collected via the validated COMPACT Stakeholder-driven Community Diffusion survey and analyzed using regression models and social network analysis.

RESULTS

Over 2 years, knowledge of (p = 0.0002), and engagement with (p = 0.03), childhood obesity prevention increased significantly among the SUU5 Committee. Knowledge increased among the Committee's social network (p = 0.001). Significant changes in policies, systems, and environments that support childhood obesity prevention were seen from baseline to 24 months (p = 0.003).

CONCLUSION

SUU5 had positive effects on "upstream" drivers of early childhood obesity by increasing knowledge and engagement. These changes partially diffused through networks and may have changed "midstream" community policies, systems, and environments.

Using Agent-Based Modeling to Extrapolate Community-Wide Impact from a Stakeholder-Driven Childhood Obesity Prevention Intervention: Shape Up Under 5

Objective: Whole-of-community interventions are a promising systems-based approach to childhood obesity prevention. A theorized driver of success is "Stakeholder-Driven Community Diffusion" (SDCD): the spread of knowledge about and engagement with obesity prevention efforts from a committee of stakeholder representatives. We focus on the potential of SDCD to affect the broader community. Methods: We use an agent-based model of SDCD to dynamically represent the interpersonal interactions that drive community diffusion of knowledge and engagement. We test its explanatory power using longitudinal data from a sample of community members and then use simulations to extrapolate from this limited sample to the unobserved community at large. We also consider counterfactual scenarios that show how changes in implementation strategy might have led to different patterns of community change. Results: Our model can reproduce real-world patterns of diffusion. Simulations show a substantial increase in knowledge (an approximate doubling) and a slight increase in engagement throughout the broader community. A relatively small amount of this change in knowledge (∼10%), and all the change in engagement is attributable to direct intervention effects on committee members. Conclusions: SDCD is premised on creating preconditions for sustainable change. Previous work has estimated impact on small samples closely linked to the stakeholder committee, but the degree to which this translates into the much broader diffusion envisioned by SDCD theory is unknown. This analysis demonstrates the potential of interventions to do just that. Additionally, the counterfactual scenarios suggest that simulation can help tailor implementation of SDCD interventions to increase impact.

Implementing a stakeholder-driven community diffusion-informed intervention to create healthier, more equitable systems: a community case study in Greenville County, South Carolina

This case study describes the application of a theory-informed, stakeholder-driven intervention with a group of 19 multi-sector stakeholders from an existing coalition to promote whole-of-community change that supports childhood obesity prevention. The intervention applied community-based system dynamics to design and implement activities that promoted insights into the systems driving childhood obesity prevalence and helped participants prioritize actions to influence those systems. This led to three new priority areas for the coalition: addressing food insecurity; building power among historically marginalized voices within the community; and supporting advocacy efforts to promote community-wide change beyond the coalition's previous focus on organizational-level policy, systems and environment change. The intervention spurred the application of community-based system dynamics to other health issues and in partner organizations, which demonstrates paradigm shifts about how to address complex public health issues in the community.

Community-Based Participatory Research: Partnering with College Students to Develop a Tailored, Wellness-Focused Intervention for University Campuses

College students face unique challenges with leading healthful lifestyles. Using a community-based participatory research approach, college student research partners at two land-grant universities collected data and developed a tailored intervention to improve the well-being of college students. To inform the design of the program, college students were trained to conduct a needs assessment that included a campus-wide survey on the health behaviors of college students, environmental audits of health policies and food pantries on campus, and stakeholder interviews with campus health professionals. Outcomes of the needs assessment data highlighted university students ranked their health as "good" but nutrition health as "fair/poor." Low or very low food security was self-reported by 36.9% of participants and had an overall diet quality score of 47.6 ± 10.1 out of 100. Health professional interview data indicated campuses provide healthful resources to students, but students are not aware those resources exist. Utilizing the needs assessment data previously mentioned, the nominal group technique was then used for student research partners to collaboratively determine the best intervention approaches and develop a wellness program. Student partners identified (1) education, (2) sharing of campus resources, and (3) incentives as important areas of intervention. Using the data collected, the student research partners developed a program titled, The College Cooking Connection, to address health-related quality of life in college students. Using a community-based participatory research approach to program planning, educators and researchers have a greater likelihood of addressing the current needs of the population they are targeting and developing a successful intervention to meet those health concerns. This study aims to partner with young adult university students to understand the college environment and allow the target community to be involved with the development of intervention programs for their campus.

Tracing coalition changes in knowledge in and engagement with childhood obesity prevention to improve intervention implementation

BACKGROUND

While most coalition research focuses on studying the effects of peer relationship structure, this study examines the coevolution of coalition structure and behavior across three communities in the U.S. with the goal of identifying coalition dynamics that impact a childhood obesity prevention intervention.  METHODS: Over two years (2018-2020), three communities within the U.S. participated in a childhood obesity prevention intervention at different times. This intervention was guided by the Stakeholder-Driven Community Diffusion theory, which describes an empirically testable mechanism for promoting community change. Measures are part of the Stakeholder-driven Community Diffusion (SDCD) survey with demonstrated reliability, which include knowledge of and engagement with childhood obesity prevention and social networks. Data from three coalition-committees and their respective networks were used to build three different stochastic actor-oriented models. These models were used to examine the coevolution of coalition structure with coalition behavior (defined a priori as knowledge of and engagement with obesity prevention) among coalition-committee members and their nominated alters (Network A) and coalition-committee members only (Network B).  RESULTS: Overall, coalitions decrease in size and their structure becomes less dense over time. Both Network A and B show a consistent preference to form and sustain ties with those who have more ties. In Network B, there was a trend for those who have higher knowledge scores to increase their number of ties over time. The same trend appeared in Network A but varied based on their peers' knowledge in and engagement with childhood obesity prevention. Across models, engagement with childhood obesity prevention research was not a significant driver of changes in either coalition network structure or knowledge.

CONCLUSIONS

The trends in coalition Network A and B's coevolution models may point to context-specific features (e.g., ties among stakeholders) that can be leveraged for better intervention implementation. To that end, examining tie density, average path length, network diameter, and the dynamics of each behavior outcome (i.e., knowledge in and engagement with childhood obesity prevention) may help tailor whole-of-community interventions. Future research should attend to additional behavioral variables (e.g., group efficacy) that can capture other aspects of coalition development and that influence implementation, and to testing the efficacy of network interventions after trends have been identified.

GroundsWell: Community-engaged and data-informed systems transformation of Urban Green and Blue Space for population health - a new initiative

Natural environments, such as parks, woodlands and lakes, have positive impacts on health and wellbeing. Urban Green and Blue Spaces (UGBS), and the activities that take place in them, can significantly influence the health outcomes of all communities, and reduce health inequalities. Improving access and quality of UGBS needs understanding of the range of systems (e.g. planning, transport, environment, community) in which UGBS are located. UGBS offers an ideal exemplar for testing systems innovations as it reflects place-based and whole society processes , with potential to reduce non-communicable disease (NCD) risk and associated social inequalities in health. UGBS can impact multiple behavioural and environmental aetiological pathways. However, the systems which desire, design, develop, and deliver UGBS are fragmented and siloed, with ineffective mechanisms for data generation, knowledge exchange and mobilisation. Further, UGBS need to be co-designed with and by those whose health could benefit most from them, so they are appropriate, accessible, valued and used well. This paper describes a major new prevention research programme and partnership, GroundsWell, which aims to transform UGBS-related systems by improving how we plan, design, evaluate and manage UGBS so that it benefits all communities, especially those who are in poorest health. We use a broad definition of health to include physical, mental, social wellbeing and quality of life. Our objectives are to transform systems so that UGBS are planned, developed, implemented, maintained and evaluated with our communities and data systems to enhance health and reduce inequalities. GroundsWell will use interdisciplinary, problem-solving approaches to accelerate and optimise community collaborations among citizens, users, implementers, policymakers and researchers to impact research, policy, practice and active citizenship. GroundsWell will be shaped and developed in three pioneer cities (Belfast, Edinburgh, Liverpool) and their regional contexts, with embedded translational mechanisms to ensure that outputs and impact have UK-wide and international application.

Mapping the Lay of the Land: Using Interactive Network Analytic Tools for Collaboration in Rural Cancer Prevention and Control

BACKGROUND

Cancer mortality rates in the United States are higher in rural than urban areas, especially for colorectal cancer. Modifiable cancer risks (e.g., tobacco use, obesity) are more prevalent among U.S. rural than urban residents. Social network analyses are common, yet rural informal collaborative networks for cancer prevention and control and practitioner uses of network findings are less well understood.

METHODS

In five service areas in rural Missouri and Illinois, we conducted a network survey of informal multisector networks among agencies that address cancer risk (N = 152 individuals). The survey asked about contact, collaborative activities, and referrals. We calculated descriptive network statistics and disseminated network visualizations with rural agencies through infographics and interactive Network Navigator platforms. We also collected feedback on uses of network findings from agency staff (N = 14).

RESULTS

Service areas had more connections (average degree) for exchanging information than for more time-intensive collaborative activities of co-developing and sustaining ongoing services and programs, and co-developing and sharing resources. On average, collaborative activities were not dependent on just a few agencies to bridge gaps to hold networks together. Users found the network images and information useful for identifying gaps, planning which relationships to establish or enhance to strengthen certain collaborative activities and cross-referrals, and showing network strengths to current and potential funders.

CONCLUSIONS

Rural informal cancer prevention and control networks in this study are highly connected and largely decentralized.

IMPACT

Disseminating network findings help ensure usefulness to rural health and social service practitioners who address cancer risks.

A Theory of Change for Community-Based Systems Interventions to Prevent Obesity

INTRODUCTION

Applying systems science in public health trials is a recent innovation in childhood obesity prevention. This paper aims to use systems science conventions to propose a theory of change for community-based interventions aiming to build capacity and use exemplars from systems science for obesity prevention to describe how this approach works.

METHODS

Participants were community-based researchers. A dynamic hypothesis was created in workshops conducted in 2020 and 2021 by identifying variables critical to building community capacity for systems thinking. These were used to develop stock and flow diagrams representing individual causal relationships, feedback loops, and the overall theory of change.

RESULTS

The resultant model identified 9 stocks and 4 pairs of central balancing and reinforcing feedback loops. These represented building commitment through relationships, mutual learning, strengthening collaboration, and embedding capacity. The model is described using examples from 3 trials involving 25 communities across Victoria, Australia.

CONCLUSIONS

This nonlinear and practice-based model illustrates the process of community-based obesity prevention. The model integrates >20 years of community-based intervention implementation experience, providing an overarching theory of how such interventions work to create change and prevent obesity.

Implementing Group Model Building With the Shape Up Under 5 Community Committee Working to Prevent Early Childhood Obesity in Somerville, Massachusetts

OBJECTIVE

To describe our process of using group model building (GMB) with the Shape Up Under 5 Committee; measure the effects on Committee members; and describe the community-wide health messaging campaign that resulted from the process.

DESIGN

Pilot study.

SETTING

Somerville, Massachusetts.

PARTICIPANTS

Members of the Shape Up Under 5 Committee, a multisector group of professionals.

INTERVENTION

Research team convened the Committee and facilitated GMB from October 2015 to June 2017.

MAIN OUTCOME MEASURES

Boundary objects produced during GMB activities; committee members' perspectives on early childhood obesity in their community; and Committee members' knowledge, engagement, and trust at the conclusion of each meeting.

RESULTS

Working together using GMB activities and with support from the research team, the Committee created a community-wide campaign that provided evidence-based messages to reach an entire city that emphasized diversity and reaching immigrants and community members who spoke languages other than English. More than 80% of Committee members reported changes in their perspectives related to early childhood obesity at the conclusion of the pilot test. Six perspective shift themes emerged from interviews and open-ended survey items: exposure to new perspectives about challenges community members face; increased awareness of others working on similar issues; increased knowledge about early childhood obesity; seeing value in creating a space to work across sectors; appreciating complexity and linkages between early childhood obesity prevention and other community issues; and how participation in committee influences members' priorities in their own work. Knowledge of and engagement with early childhood obesity prevention varied at the conclusion of each meeting, as did increases in trust among Committee members.

CONCLUSION

Group model building is a promising approach to support multisector groups working to address early childhood obesity in their community. Meeting activities may have had differential impacts on members' knowledge of and engagement with early childhood obesity.

Coalition-Committees as Network Interventions: Baseline Network Composition in Context of Childhood Obesity Prevention Interventions

Community coalitions can address local issues with deep, historic, and contextual understanding that enables customized implementation of evidence-based strategies. The individuals within the coalition, their partnerships, and the social context is likely an important component of unraveling the challenges of implementation so interventions reach people in need. We focus on the relevance of baseline coalition-committee network (CCN), the networks of purposely formed subcommittees within community coalitions, structure as one of the moderating, theoretical links between community coalition social networks and intervention success. We explore the baseline composition and characteristics of five CCNs at the beginning of childhood obesity prevention interventions. Using a combination of social network, multidimensional scaling, and correspondence analyses, we examine the structure and heterogeneity of five CCNs, each consisting of a core group of stakeholders in the coalition and sometimes the broader community itself. Cross-sectional analyses are used to examine the composition of coalition-committees related to network density, centralization, hierarchy, and coalition demographics and characteristics. Results indicate that CCNs are patterned in their structure and characteristics, and we discuss whether adjustments to childhood obesity prevention interventions according to baseline structure and characteristics could be advantageous for intervention implementation. Together, these findings can inform future longitudinal investigations into CCN network structure.

Evolution of a Coalition Network during a Whole-of-Community Intervention to Prevent Early Childhood Obesity

Background: Community coalitions often lead and coordinate "whole-of-community" childhood obesity prevention interventions. A growing body of work suggests that coalition network ties, which facilitate transmission of information and advocacy, may be a key part of how such leadership operates. This study provides an understanding of the structure of coalition networks and how this structure changes over time. Methods: We administered semiannual network surveys during a pilot whole-of-community intervention in Somerville, MA (2015-2017). Participants included 16 multisector coalition members and their nominated discussion partners ("first-degree alters") related to childhood obesity prevention. Coalition and first-degree alter respondents named up to 20 discussion partners and reported ties' interaction frequency and perceived influence. Networks were assessed with visualization, descriptive analysis, and exponential random graph models. Results: Total network included 558 stakeholders representing community-based organizations, parents, health care, childcare, universities, among others. Size and membership varied over time. We observed the largest network (n = 256) during intervention planning, and the largest proportion of stakeholders communicating frequently (daily/weekly) about childhood obesity prevention during the peak intervention period. Networks were sparsely interconnected (1%-3% of possible ties observed) and most and least centralized at baseline and follow-up, respectively. Over time, ties were increasingly perceived as influential and siloed within community groups. Conclusions: The network's extensive evolving membership may indicate access to a wide range of resources, ideas, and an ability to broadly disseminate intervention messages. The attenuating network hierarchy over time may have supported more equal participation and control over intervention efforts. Future research should assess generalizability of network patterns, network influences on implementation processes, and possible network interventions.

Rural community systems: Youth physical activity promotion through community collaboration

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A community systems approach is important to identify social and geographic health impacts.

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Community stakeholders residing within the city had higher trust and collective efficacy scores.

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These stakeholders had roles directly leading physical activity opportunities for youth.

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Youth physical activity was greater in the community with stakeholders in administrative roles.

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Unique community variables should be studied to elucidate system drivers of physical activity.

A common way to address rural population health issues is through community stakeholders working together. Youth physical activity (PA) happens in adult-led in-school and out-of-school group opportunities that vary across communities and generally occur in isolated settings. This study explores similarities and differences in rural community system structure and collaborative process variables that help to conceptualize the collaborative impact influencing population youth PA outcomes. Stakeholders (Community 1, n = 23; Community 2, n = 26) and youth (Community 1, n = 205; Community 2, n = 213) were recruited in 2018–2019 as part of Wellscapes, a hybrid implementation-effectiveness community randomized trial. A stakeholder survey (n = 49) measured community system structures and collaboration processes. Youth completed the Youth Activity Profile to measure PA levels. More Community 1 respondents than Community 2 resided within city limits (73.9% vs. 34.6%). Collective efficacy was significantly greater in Community 1 (M = 4.0, SD = 0.5) than in 2 (M = 3.2, SD = 0.4), p < 0.05. Perceptions of trust scored significantly greater in Community 1 (M = 4.1, SD = 0.3) than in 2 (M = 3.3, SD = 0.5), p < 0.05. Though both communities met rural definitions and had stakeholder investment, Community 1 had a greater proportion of PA-implementing stakeholders and more residing within city limits which may have influenced that community’s higher scores in collective efficacy and trust. Community 2 had more stakeholders in administrator roles and yielded greater youth PA levels. Unique and common variables of rural communities should be considered in understanding system factors that impact youth PA.

An action-oriented framework for systems-based solutions aimed at childhood obesity prevention in US Latinx and Latin American populations

Childhood obesity in US Latinx and Latin American populations is a persistent, complex public health issue and, as such, requires solutions grounded on systems science theory and methods. In this paper, we introduce an action-oriented framework to design, implement, evaluate, and sustain whole-of-community systems changes for childhood obesity prevention in US Latinx and Latin American populations. Our framework covers six action steps: (1) foster multisectoral team; (2) map the system, its context, and drivers; (3) envision system-wide changes; (4) effect system-wide changes; (5) monitor, learn, and adapt; and (6) scale and sustain. We also propose 10 principles that put human and environmental rights and systems thinking at the center of these systems-based solutions. For each action step, we provide a list of concrete activities, methods, approaches, and examples that can be used to guide and inform the work needed to achieve the expected outputs. Finally, we discuss how a wider adoption of systems science for childhood obesity prevention among US Latinx and Latin American populations can be encouraged and sustained.

LiveWell in early childhood: results from a two-year pilot intervention to improve nutrition and physical activity policies, systems and environments among early childhood education programs in South Carolina

BACKGROUND

Early childhood education (ECE) settings are critical intervention targets for obesity prevention. This study evaluated a pilot two-year community-based participatory research (CBPR) project designed to assist ECE center directors and caregivers in policy, systems and environmental (PSE) change for improving healthy eating (HE) and physical activity (PA).

METHODS

A two-year CBPR study was conducted in 10 licensed ECE centers in Greenville, South Carolina. The intervention consisted of five steps: [1] baseline data collection and self-assessment using the Nutrition and Physical Activity Self-Assessment for Child Care (Go-NAP SACC), [2] tailored goal setting and action planning, [3] technical assistance and access to resources, [4] post intervention data collection and re-assessment, and [5] celebration of success. Main outcome measures (HE and PA environments, practices and policies) were assessed using the Environment and Policy Assessment and Observation (EPAO) tool at baseline and 24 months. One classroom of 3-5-year-olds was randomly selected for observation from each center (mean of 12 children per classroom). Means and standard deviations were calculated for total PA, total nutrition and each subscale of PA and nutrition. Paired sample t-tests were calculated to assess changes in EPAO scales from baseline to post intervention.

RESULTS

Ten ECE centers enrolled in the pilot study and eight completed the two-year intervention. Center-based goals were accomplished across all 8 ECE centers over the two-year intervention: 16 child nutrition goals, 6 outdoor play goals, 11 physical activity goals and 8 screen time goals across the entire sample. Nutrition policy and PA policy significantly improved (p < 0.05), with greater improvements in PA (10.0 point increase, p = .048) as compared to nutrition (3.3 point increase, p = 0.02).

CONCLUSIONS

Utilizing a CBPR approach, this two-year nutrition and PA PSE intervention in ECE centers improved ECE center HE and PA policies.

Closing the gap between practice and science in school- and community-based participatory physical literacy promotion: study protocol of the StuPs project

BACKGROUND

The role of physical activity in the promotion of children's well-being and health is widely known. However, research indicates that the time spent physically exercising and participating in organized sport activities is decreasing among children. Although there is currently no gold standard for promoting sustainable physical activity in children, community-based approaches, particularly those that are multicomponent, appear to be the most successful. The project StuPs: a school- and community-based participatory approach for promoting physical activity in children and their families aims to develop a community-based approach to promoting physical activity by increasing physical literacy among elementary school children and their household members.

METHODS

The project is built upon the intervention mapping approach and consists of two periods with an overall duration of 3 years. Period I will last 9 months and include an assessment of needs, wants, strengths, and weaknesses regarding physical activity and health promotion at the community- and school-based level according to the keywords "capacity building" and "physical literacy." Based on the knowledge gained in this stage, measures for capacity building to promote healthy lifestyles and physical literacy in children will be developed using the community-based participatory research and capacity building approach. In Period II, the measures will be applicated, implemented and evaluated using a pre-/post-design to assess efficacy.

DISCUSSION

Although the efficacy of using community-based and capacity building approaches to reach children is promising, there remains a gap regarding best practices for changing existing structures and habits over the long term and in the sense of promoting physical literacy.

Consolidated Framework for Collaboration Research derived from a systematic review of theories, models, frameworks and principles for cross-sector collaboration

Cross-sector collaboration is needed to address root causes of persistent public health challenges. We conducted a systematic literature review to identify studies describing theories, models, frameworks and principles for cross-sector collaboration and synthesized collaboration constructs into the Consolidated Framework for Collaboration Research (CFCR). Ninety-five articles were included in the review. Constructs were abstracted from articles and grouped into seven domains within the framework: community context; group composition; structure and internal processes; group dynamics; social capital; activities that influence or take place within the collaboration; activities that influence or take place within the broader community; and activities that influence or take place both in the collaboration and in the community. Community engagement strategies employed by collaborations are discussed, as well as recommendations for using systems science methods for testing specific mechanisms of how constructs identified in the review influence one another. Researchers, funders, and collaboration members can use the consolidated framework to articulate components of collaboration and test mechanisms explaining how collaborations function. By working from a consolidated framework of collaboration terms and using systems science methods, researchers can advance evidence for the efficacy of cross-sector collaborations.

Every School Healthy: Creating Local Impact Through National Efforts

BACKGROUND

Whole school, whole community, whole child (WSCC) approaches to education address contexts beyond school that influence young people's academic and life outcomes. These recommended approaches demand mobilization of an array of actors, but such mobilization is challenging. Little research has explored strategies for convening national experts to support local communities.

METHODS

This paper presents a case narrative of Every School Healthy (ESH), a grant-funded effort to support organizations/school districts in 6 communities building WSCC initiatives by engaging national youth development organizations as expert advisors to ESH and communities. A thematic analysis of the narrative yielded 3 key learnings.

RESULTS

Three themes emerged as key learnings regarding implementation of national-local initiatives: (1) baseline assessment of local communities should be conducted to identify opportunities for maximizing strengths; (2) national organizations must be flexible with the expertise they bring to the initiative; (3) national organizations should prioritize community-cultivated solutions and meet communities where they are.

CONCLUSIONS

The 3 themes presented in this case narrative offer insights for effectively mobilizing national organizations to support healthy, equitable school environments at the local level.

Rugged landscapes: complexity and implementation science

BACKGROUND

Mis-implementation-defined as failure to successfully implement and continue evidence-based programs-is widespread in public health practice. Yet the causes of this phenomenon are poorly understood.

METHODS

We develop an agent-based computational model to explore how complexity hinders effective implementation. The model is adapted from the evolutionary biology literature and incorporates three distinct complexities faced in public health practice: dimensionality, ruggedness, and context-specificity. Agents in the model attempt to solve problems using one of three approaches-Plan-Do-Study-Act (PDSA), evidence-based interventions (EBIs), and evidence-based decision-making (EBDM).

RESULTS

The model demonstrates that the most effective approach to implementation and quality improvement depends on the underlying nature of the problem. Rugged problems are best approached with a combination of PDSA and EBI. Context-specific problems are best approached with EBDM.

CONCLUSIONS

The model's results emphasize the importance of adapting one's approach to the characteristics of the problem at hand. Evidence-based decision-making (EBDM), which combines evidence from multiple independent sources with on-the-ground local knowledge, is a particularly potent strategy for implementation and quality improvement.

Protocol for the measurement of changes in knowledge and engagement in the stepped wedge cluster randomised trial for childhood obesity prevention in Australia: (Reflexive Evidence and Systems interventions to Prevent Obesity and Non-communicable Disease (RESPOND))

BACKGROUND

Community-based interventions have shown promise in addressing the childhood obesity epidemic. Such efforts rely on the knowledge of key community members and their engagement with the drivers of obesity in their community. This paper presents the protocol for the measurement and evaluation of knowledge and engagement among community leaders within a whole-of-community systems intervention across 10 large intervention communities in Australia.

METHODS

We will investigate the role of stakeholder knowledge and engagement in the implementation and effectiveness of the stepped wedge cluster randomised trial in ten communities in Victoria, Australia. Data will be collected using the Stakeholder-driven Community Diffusion Survey (SDCD) to measure levels of knowledge and engagement prior to commencement (2019), across the three separate levels of governance within the intervention at five time points. Primary outcomes will be baseline overall knowledge and engagement scores across the three levels of governance and change in overall knowledge and engagement over time.

DISCUSSION

We hypothesise there will be heterogeneity between intervention sites on levels of knowledge and engagement and that these differences will be associated with variability in implementation success.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618001986268 . Registered on 11 December 2018.

Capacity Building in Community Stakeholder Groups for Increasing Physical Activity: Results of a Qualitative Study in Two German Communities

Community capacity building is an essential approach for health promotion, combining a participatory approach with the view to community ownership. Little research focuses on practical capacity building strategies and monitoring. Our paper looks into involving stakeholders in facilitated group discussions as a specific strategy for fostering capacity building processes. These processes focused on physical activity (PA) promotion in two German communities (ACTION4men). Along the dimensions of capacity building suggested in literature (e.g., problem solving, resource mobilization, leadership), we implemented two participatory stakeholder groups (1/community). These groups were motivated to develop and implement PA interventions for men >50 years. For measuring capacity building processes, a semi-standardized monitoring instrument was used to document all group meetings. Additionally, we conducted semi-standardized interviews with group participants and drop-outs to capture their perspectives on capacity building. All documents were analyzed using thematic analysis. We successfully established stakeholder groups that planned and implemented a range of local measures meant to increase PA among older men. In one community, the process was sustainable, whereby the group continued to meet regularly over years. Capacity building was successful to a certain degree (e.g., regarding participation, problem assessment, and resource mobilization), but stalled after first meetings. Capacity building processes differed between the two communities in terms of leadership and sustainability. The developed interventions mainly addressed the access to organized sport courses, rather than tackling walkability or active transport. The theoretical capacity building approach was successful to develop and implement programs aimed at promoting PA. The actual capacity building processes depend upon the composition of stakeholder groups and inherent power relations.

Co-Designing an Intervention to Prevent Overweight and Obesity among Young Children and Their Families in a Disadvantaged Municipality: Methodological Barriers and Potentials

Design-based research (DBR) is an innovative methodology for co-creation, but potentials, challenges, and differences between methodological ideals and the real-life intervention context are under-researched. This study analyzes the DBR process in which researchers, professionals, and families co-design a family-based intervention to prevent childhood overweight and obesity in a rural municipality. It involves interviews with six key stakeholders in the co-design process. Data were coded and analyzed using systematic text condensation, while the theory of the "social effectiveness of interventions" developed by Rod et al. (2014) was used as an analytical tool for unpacking the co-creation process and exploring methodological barriers and potentials. The DBR approach contributed with a feeling that everyone's perspective was important, and the professionals got a new perspective on the families' experiences with healthy living they did not previously consider. We also found that the iterative design process did not fully align with the organizational structures in the municipality or with the needs of stakeholders, leading to friction in the partnership. This study emphasizes the complexity of using an anti-hierarchical approach within a hierarchical context, and the importance of being aware of how the DBR approach shapes the partnership, as well as of how the social dynamics within the partnership shape the design process.

Activating a Community: An Agent-Based Model of Romp & Chomp, a Whole-of-Community Childhood Obesity Intervention

OBJECTIVE

Successful whole-of-community childhood obesity prevention interventions tend to involve community stakeholders in spreading knowledge about and engagement with obesity prevention efforts through the community. This process is referred to by the authors as stakeholder-driven community diffusion (SDCD). This study uses an agent-based model in conjunction with intervention data to increase understanding of how SDCD operates.

METHODS

This agent-based model retrospectively simulated SDCD during Romp & Chomp, a 4-year whole-of-community childhood obesity prevention intervention in Victoria, Australia. Stakeholder survey data, intervention records, and expert estimates were used to parameterize the model. Model output was evaluated against criteria derived from empirical data and experts' estimates of the magnitude and timing of community knowledge and engagement change.

RESULTS

The model was able to produce outputs that met the evaluation criteria: increases in simulated community knowledge and engagement driven by SDCD closely matched expert estimates of magnitude and timing.

CONCLUSIONS

Strong suggestive evidence was found in support of a hypothesis that SDCD was a key driver of the success of the Romp & Chomp intervention. Model exploration also provided additional insights about these processes (including where additional data collection might prove most beneficial), as well as implications for the design and implementation of future interventions.

Design and methods of Shape Up Under 5: Integration of systems science and community-engaged research to prevent early childhood obesity

Shape Up Under 5 (SUU5) was a two-year early childhood obesity prevention pilot study in Somerville, Massachusetts (2015-2017) designed to test a novel conceptual framework called Stakeholder-driven Community Diffusion. For whole-of-community interventions, this framework posits that diffusion of stakeholders' knowledge about and engagement with childhood obesity prevention efforts through their social networks will improve the implementation of health-promoting policy and practice changes intended to reduce obesity risk. SUU5 used systems science methods (agent-based modeling, group model building, social network analysis) to design, facilitate, and evaluate the work of 16 multisector stakeholders ('the Committee'). In this paper, we describe the design and methods of SUU5 using the conceptual framework: the approach to data collection, and methods and rationale for study inputs, activities and evaluation, which together may further our understanding of the hypothesized processes within Stakeholder-driven Community Diffusion. We also present a generalizable conceptual framework for addressing childhood obesity and similar complex public health issues through whole-of-community interventions.