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

The use of participatory systems mapping as a research method in the context of non-communicable diseases and risk factors: a scoping review

CONTEXT

Participatory systems mapping is increasingly used to gain insight into the complex systems surrounding non-communicable diseases (NCDs) and their risk factors.

OBJECTIVES

To identify and synthesize studies that used participatory systems mapping in the context of non-communicable diseases.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Peer-reviewed studies published between 2000 and 2022.

STUDY SELECTION

Studies that focused on NCDs and/or related risk factors, and included participants at any stage of their system's mapping process, were included.

CATEGORIES FOR ANALYSIS

The main categories for analysis were: (1) problem definition and goal-setting, (2) participant involvement, (3) structure of the mapping process, (4) validation of the systems map, and (5) evaluation of the mapping process.

RESULTS

We identified 57 studies that used participatory systems mapping for a variety of purposes, including to inform or evaluate policies or interventions and to identify potential leverage points within a system. The number of participants ranged from 6 to 590. While policymakers and professionals were the stakeholder groups most often included, some studies described significant added value from including marginalized communities. There was a general lack of formal evaluation in most studies. However, reported benefits related mostly to individual and group learning, whereas limitations described included a lack of concrete actions following from systems mapping exercises.

CONCLUSIONS

Based on the findings of this review, we argue that research using participatory systems mapping would benefit from considering three different but intertwined actions: explicitly considering how different participants and the power imbalances between them may influence the participatory process, considering how the results from a systems mapping exercise may effectively inform policy or translate into action, and including and reporting on evaluation and outcomes of the process, wherever possible.

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.

Success of community-based system dynamics in prevention interventions: A systematic review of the literature

Systems thinking approaches are increasingly being used to help communities understand and develop responses to preventing complex health problems. Less is known about how success is characterized and what influences success in these approaches. We present a systematic review of how concepts of success are understood and evaluated in the peer reviewed literature of studies using systems thinking in community prevention. We searched five databases for peer-reviewed literature published between 2000 and 2022, with search terms related to systems thinking, prevention and community. Studies were included if they; reported using community-based systems thinking to prevent a public health problem; described the engagement and empowerment of community members to address a public health issue; and, were published in English. Thirty-four articles were identified from 10 countries. Twenty-one aimed to prevent a chronic disease (e.g., obesity) and 16 measured success using specific tools, 10 of which used semi-structured interviews or surveys. Measures of success included implementation processes, cultural appropriateness, the number or type of actions implemented, effectiveness of community action, and changes in individual thinking or mental models, population health outcomes, data collected, or systems level measures. Implementation factors influencing success included the capacity to engage participants, composition and experience of facilitators, strength of coordination teams, allocation of resources, adaptation to participant feedback, use of multiple systems approaches, workshop process providing time and methods to allow new insights, flexible delivery, and diversity of perspectives. Findings from each of the articles indicated that approaches increased a range of outcomes including community action, strategic thinking, future planning and evaluation, community buy-in, community voice, contribution and leadership, in addition to developing shared visions and goals and creating new, ongoing collaborations, among many others. Measures of success varied, suggesting more empirical reporting of proposed outcomes of system science in communities would be valuable. While the measurement of success in the use of systems thinking in community-based prevention efforts is limited, there are helpful examples we can look to for future measurement of success.

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.

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.

Validation and refinement of the Stakeholder-driven Community Diffusion Survey for childhood obesity prevention

BACKGROUND

Whole-of-community interventions hold promise in addressing childhood obesity. The COMPACT Stakeholder-driven Community Diffusion theory posits that stakeholders' knowledge of childhood obesity prevention efforts and engagement with the issue contribute to successful intervention implementation. Building on completed formative research and pilot testing, we describe the validation and refinement of knowledge and engagement measures.

METHODS

We assessed content validity using a modified Delphi process with science (n=18) and practice-based (n=16) experts. Next, we refined the survey based on input from science- and practice-based experts, cognitive response testing, and item analysis of extant survey data. Field testing of the refined survey involved community stakeholders in Greenville County, South Carolina (n=50), East Boston, Massachusetts (n=30), and Tucson, Arizona (n=84) between 2019 and 2020. Construct validity was assessed with confirmatory factor analysis (CFA). Two-week test-retest reliability was assessed among a subsample of 14 paired respondents in South Carolina.

RESULTS

Experts rated existing knowledge domains (intervention factors, roles, sustainability, problem, resources) and engagement domains (dialogue/mutual learning, flexibility, influence/power, leadership/stewardship, trust) highly for their importance in addressing childhood obesity. Expert input resulted in 11 new knowledge items and 7 new engagement items that mapped onto existing domains. Correspondingly, two domain names were modified: implementation/sustainability and trust/trustworthiness. We also eliminated 8 extant items (4 knowledge and 4 engagement) and adapted item language for comprehension and consistency. Further modifications based on CFA results and item analyses resulted in 23 knowledge items across four domains (roles and resources merged) and 23 engagement items across five domains. Modified knowledge and engagement scales had adequate fit and strong item factor loadings (most >0.7 and all >0.5). Knowledge (α=0.86-0.87) and engagement (α=0.75-0.90) subscales had high internal scale consistency. Knowledge intraclass correlation coefficients (ICCs) for test-retest agreement of subscale scores ranged from 0.50 for intervention factors to 0.86 for roles/resources. For engagement subscale scores, ICCs ranged from 0.70 for trust/trustworthiness to 0.96 for leadership/stewardship.

CONCLUSIONS

Findings from this multi-method survey development process increase our confidence of the knowledge and engagement measures' content validity, construct validity, and reliability.

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.

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.