Integrating Systems Science and Community-Based Participatory Research to Achieve Health Equity

Dietary policies and programs in the United States: A narrative review

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School-based and youth targeted programs and policies were most frequently studied.

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Research has rather neglected older adult, Asian, Native Hawaiian and American Indian populations.

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Despite existing research indicating effectiveness, faith-based were understudied.

Prior reviews describing approach, methodological quality and effectiveness of dietary policies and programs may be limited in use for practitioners seeking to introduce innovative programming, or academic researchers hoping to understand and address gaps in the current literature. This review is novel, assessing the “where, who, and in whom” of dietary policies and programs research in the United States over the past decade – with results intended to serve as a practical guide and foundation for innovation. This study was conducted from October 2018 to March 2019. Papers were selected through a tailored search strategy on PubMed as well as citation searches, to identify grey literature. A total of 489 papers were relevant to our research objective. The largest proportion of papers described school-based strategies (31%) or included economic incentives (19%). In papers that specified demographics, the study populations most often included children, adults and adolescents (54%, 46%, and 42% respectively); and White, Black and Hispanic populations (77%, 76% and 70%, respectively). Results highlight opportunities for future research within workplace and faith-based settings, among racial/ethnic minorities, and older adults.

Partnerships, Processes, and Outcomes: A Health Equity-Focused Scoping Meta-Review of Community-Engaged Scholarship

In recent decades, there has been remarkable growth in scholarship examining the usefulness of community-engaged research (CEnR) and community-based participatory research (CBPR) for eliminating health inequities.This article seeks to synthesize the extant literature of systematic reviews, scoping reviews, and other related reviews regarding the context, processes, and research designs and interventions underlying CEnR that optimize its effectiveness. Through a scoping review, we have utilized an empirically derived framework of CBPR to map this literature and identify key findings and priorities for future research. Our study found 100 reviews of CEnR that largely support the CBPR conceptual framework.

Structural Interventions to Reduce and Eliminate Health Disparities

Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements. Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities. Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance health disparities research.

Tools and analytic techniques to synthesise community knowledge in CBPR using computer-mediated participatory system modelling

Participatory systems thinking methods are often used in community-based participatory research to engage and respond to complexity. Participation in systems thinking activities creates opportunities for participants to gain useful insights about complexity. It is desirable to design activities that extend the benefits of this participation into communities, as these insights are predictive of success in community-based prevention. This study tests an online, computer-mediated participatory system modelling platform (STICKE) and associated methods for collating and analysing its outputs. STICKE was trialled among a group of community members to test a computer-mediated system modelling exercise. The causal diagrams resulting from the exercise were then merged, and network analysis and DEMATEL methods applied to inform the generation of a smaller summary model to communicate insights from the participant group as a whole. Participants successfully completed the online modelling activity, and created causal diagrams consistent with expectations. The DEMATEL analysis was identified as the participant-preferred method for converging individuals causal diagrams into a coherent and useful summary. STICKE is an accessible tool that enabled participants to create causal diagrams online. Methods trialled in this study provide a protocol for combining and summarising individual causal diagrams that was perceived to be useful by the participant group. STICKE supports communities to consider and respond to complex problems at a local level, which is cornerstone of sustainable effective prevention. Understanding how communities perceive their own health challenges will be important to better support and inform locally owned prevention efforts.

Recruitment and retention of underrepresented populations in Alzheimer's disease research: A systematic review

INTRODUCTION

Alzheimer's disease and related dementias (ADRD) disproportionately impact racial and ethnic minority and socioeconomically disadvantaged adults. Yet, these populations are significantly underrepresented in research.

METHODS

We systematically reviewed the literature for published reports describing recruitment and retention of individuals from underrepresented backgrounds in ADRD research or underrepresented participants' perspectives regarding ADRD research participation. Relevant evidence was synthesized and evaluated for quality.

RESULTS

We identified 22 eligible studies. Seven studies focused on recruitment/retention approaches, all of which included multifaceted efforts and at least one community outreach component. There was considerable heterogeneity in approaches used, specific activities and strategies, outcome measurement, and conclusions regarding effectiveness. Despite limited use of prospective evaluation strategies, most authors reported improvements in diverse representation in ADRD cohorts. Studies evaluating participant views focused largely on predetermined explanations of participation including attitudes, barriers/facilitators, education, trust, and religiosity. Across all studies, the strength of evidence was low.

DISCUSSION

Overall, the quantity and quality of available evidence to inform best practices in recruitment, retention, and inclusion of underrepresented populations in ADRD research are low. Further efforts to systematically evaluate the success of existing and emergent approaches will require improved methodological standards and uniform measures for evaluating recruitment, participation, and inclusivity.

Embracing Causal Complexity in Health Disparities: Metabolic Syndemics and Structural Prevention in Rural Minority Communities

Chronic discrimination and associated socioeconomic inequalities have shaped the health and well-being of Black Americans. As a consequence of the intersection of these factors with rural deprivation, rural Black Americans live and work in particularly pathogenic environments that generate disproportionate and interacting chronic comorbidities (syndemics) compared to their White and/or urban counterparts. Traditional prevention research has been unable to fully capture the underlying complexity of rural minority health and has generated mostly low-leverage interventions that have failed to reverse adverse metabolic outcomes among rural Black Americans. In contrast, novel research approaches-such as system dynamics modeling-that seek to understand holistic system structure and determine complex health outcomes over time provide a robust framework to develop a more accurate understanding of the key factors contributing to type 2 diabetes. This framework can then be used to establish more efficacious interventions to address disparities among minorities in rural areas. This paper advocates for a unified complex systems epistemology and methodology in advancing rural minority health disparities research. Toward this goal, we (1) provide an overview of rural Black American metabolic health research, (2) introduce a complex systems framework in rural minority health disparities research, and (3) demonstrate how community-based system dynamics modeling and simulation can help us plow new ground in rural minority health disparities research and action. We anticipate that this paper can serve as a catalyst for a long-overdue discourse on the relevance of complex systems approaches in minority health research, with practical benefits for numerous disproportionately burdened communities.

The SMART Framework: Integration of Citizen Science, Community-Based Participatory Research, and Systems Science for Population Health Science in the Digital Age

Citizen science enables citizens to actively contribute to all aspects of the research process, from conceptualization and data collection, to knowledge translation and evaluation. Citizen science is gradually emerging as a pertinent approach in population health research. Given that citizen science has intrinsic links with community-based research, where participatory action drives the research agenda, these two approaches could be integrated to address complex population health issues. Community-based participatory research has a strong record of application across multiple disciplines and sectors to address health inequities. Citizen science can use the structure of community-based participatory research to take local approaches of problem solving to a global scale, because citizen science emerged through individual environmental activism that is not limited by geography. This synergy has significant implications for population health research if combined with systems science, which can offer theoretical and methodological strength to citizen science and community-based participatory research. Systems science applies a holistic perspective to understand the complex mechanisms underlying causal relationships within and between systems, as it goes beyond linear relationships by utilizing big data–driven advanced computational models. However, to truly integrate citizen science, community-based participatory research, and systems science, it is time to realize the power of ubiquitous digital tools, such as smartphones, for connecting us all and providing big data. Smartphones have the potential to not only create equity by providing a voice to disenfranchised citizens but smartphone-based apps also have the reach and power to source big data to inform policies. An imminent challenge in legitimizing citizen science is minimizing bias, which can be achieved by standardizing methods and enhancing data quality—a rigorous process that requires researchers to collaborate with citizen scientists utilizing the principles of community-based participatory research action. This study advances SMART, an evidence-based framework that integrates citizen science, community-based participatory research, and systems science through ubiquitous tools by addressing core challenges such as citizen engagement, data management, and internet inequity to legitimize this integration.

Implementation effectiveness of health interventions for indigenous communities: a systematic review

BACKGROUND

Translating research into practice is an important issue for implementing health interventions effectively for Indigenous communities. He Pikinga Waiora (HPW) is a recent implementation framework that provides a strong foundation for designing and implementing health interventions in Indigenous communities for non-communicable diseases around community engagement, culture-centred approach, systems thinking and integrated knowledge translation. This study addresses the following research question: How are the elements of the HPW Implementation Framework reflected in studies involving the implementation of a non-communicable disease health intervention in an Indigenous community?

METHODS

A systematic review was conducted using multiple databases. Studies were included if they involved the implementation or evaluation of a health intervention targeting non-communicable diseases for Indigenous communities in Australia, Canada, New Zealand or the United States of America. Published quantitative and qualitative literature from 2008 to 2018 were included. Methodological appraisal of the included articles was completed using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information. Data on the population, topic, methods, and outcomes were detailed for each individual study. Key data extracted included the HPW elements along with study characteristics, who delivered the intervention and health outcomes. Data analysis involved a qualitative synthesis of findings as guided by a coding scheme of the HPW elements.

RESULTS

Twenty-one studies were included. Health topics included diabetes, nutrition, weight loss, cancer and general health. The key themes were as follows: (a) two thirds of studies demonstrated high levels of community engagement; (b) from the culture-centred approach, two-thirds of studies reflected moderate to high levels of community voice/agency although only a third of the studies included structural changes and researcher reflexivity; (c) about a quarter of studies included multi-level outcomes and activities consistent with systems thinking, 40% had individual-level outcomes with some systems thinking, and 33% included individual-level outcomes and limited systems thinking; and (d) almost 40% of studies included high levels of end user (e.g., policy makers and tribal leaders) engagement reflective of integrated knowledge translation, but nearly half had limited end-user engagement.

CONCLUSIONS

The HPW Implementation Framework is a comprehensive model for potentially understanding implementation effectiveness in Indigenous communities. The review suggests that the studies are reflective of high levels of community engagement and culture-centredness. The long-term sustainability and translation of evidence to practice may be inhibited because of lower levels of systems thinking and integrated knowledge translation.

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Action Learning Cohort Series: An Innovative Community-Engaged Approach for Translating Research Into Practice

Cultivating strong partnerships among community and academic stakeholders expedites the translation of research findings into practice and communities by enhancing opportunities for research dissemination and implementation. However, the lack of systematic methods for community stakeholder engagement may decelerate the translational research process. The North Carolina Translational Research and Clinical Sciences Institute implemented an innovative approach to community engagement called the Action Learning Cohort (ALC) Series. The ALC Series, a workgroup extension of a professional conference, used action learning and systems thinking strategies to conceptualize and develop a product aimed at preventing, treating, and controlling hypertension in eastern North Carolina. We evaluated the acceptability and practicality of the ALC Series using survey, focus group, and interview pilot data. Action learning and systems thinking strategies led ALC stakeholders to develop and disseminate The Empathy Building Resource Guide: A Toolkit for Enhancing Patient-Provider Relationships in the Treatment, Management, and Prevention of Hypertension. Stakeholders rated the Series as satisfactory and acknowledged gains in knowledge and desire for engagement with fellow ALC stakeholders beyond the Series. The ALC Series approach is a potentially practical and acceptable model for systematically engaging community stakeholders in translating knowledge into a product that addresses health topics like hypertension.

System Dynamics Approaches and Collective Action for Community Health: An Integrative Review

System dynamics (SD) methods, from qualitative causal loop diagramming to quantitative simulation modeling, have the potential to be powerful tools for engaging community stakeholders interested in improving health. However, the extent to which SD drives collective action to improve community health is unclear. The objective of this review was to understand how often, why, and how SD has been used by cross-sector community collectives. Of 409 identified manuscripts describing application of SD to community health, only 31 (7.6%) documented cross-sector collective use of these tools. All 31 had as a purpose using SD to better understand community health problems, but only seven (22.6%) documented a collective action taken as the result. In nine of the 31 articles (29.0%), no learning, decisions, or action was documented. The most common form of collective participation in SD work among the seven collectives reporting resulting action was building the SD model, with implementing a new program or practice the most frequently mentioned collective action resulting. Cost and access were the most common system outcomes studied, and chronic diseases and prevention were commonly mentioned as the focal health outcomes. Overall, SD methods seem underutilized for engaging cross-sector collectives in addressing complex community health problems.

A scoping review of simulation modeling in built environment and physical activity research: Current status, gaps, and future directions for improving translation

Existing reviews have suggested that simulation studies of physical activity and environments are an emerging area, but none have explored findings in this area systematically. We used a scoping review framework to assess the use of simulation modeling to inform decision-making about built environment influences on physical activity. A systematic literature search was conducted in multiple databases in January 2018. Sixteen articles met the inclusion criteria. The studies evaluated interventions and features that were related to neighborhood safety (crime or traffic), active transportation, land use design, and walking and biking infrastructure. All of the studies focused on urban areas and most considered heterogeneity of outcomes based on local context. The majority of studies (70%) did not appear to have engaged or been used by practitioners or policy-makers to inform real-world decisions. There has been a growth of simulation modeling studies, but there remain gaps. The studies evaluated built environment interventions that have been recommended by expert panels, but more were of interventions related to active transportation; few considered recommended interventions to support recreational activity. Furthermore, studies have all focused on urban settings and there is a need to consider non-urban settings and how heterogeneity could reduce or exacerbate health disparities. More work to involve and evaluate practices for engaging stakeholders in model development and interpretation is also needed to overcome the translation of simulation research to practice gap, and realize its potential impact on the built environment and physical activity.

Aligning systems science and community-based participatory research: A case example of the Community Health Advocacy and Research Alliance (CHARA)

Partnered research may help bridge the gap between research and practice. Community-based participatory research (CBPR) supports collaboration between scientific researchers and community members that is designed to improve capacity, enhance trust, and address health disparities. Systems science aims to understand the complex ways human-ecological coupled systems interact and apply knowledge to management practices. Although CBPR and systems science display complementary principles, only a few articles describe synergies between these 2 approaches. In this article, we explore opportunities to utilize concepts from systems science to understand the development, evolution, and sustainability of 1 CBPR partnership: The Community Health Advocacy and Research Alliance (CHARA). Systems science tools may help CHARA and other CBPR partnerships sustain their core identities while co-evolving in conjunction with individual members, community priorities, and a changing healthcare landscape. Our goal is to highlight CHARA as a case for applying the complementary approaches of CBPR and systems science to (1) improve academic/community partnership functioning and sustainability, (2) ensure that research addresses the priorities and needs of end users, and (3) support more timely application of scientific discoveries into routine practice.

He Pikinga Waiora: supporting Māori health organisations to respond to pre-diabetes

BACKGROUND

Type 2 Diabetes (T2D) is a common long-term condition affecting the health and wellbeing of New Zealanders; one in every four New Zealanders is pre-diabetic. Māori, the Indigenous people of New Zealand, are at an increased risk of developing pre-diabetes and T2D and there are significant inequities between Māori and non-Māori for T2D complications. The purpose of this study was to explore the questions of how the strengths of Māori heath organisations may be leveraged, and how the barriers and constraints experienced by Māori health organisations may be negotiated, for the benefit of Māori; and from a systems perspective, to identify strategic opportunities that may be considered and applied by Māori health organisations, funders and policy makers to respond more effectively to pre-diabetes and reduce health inequities between Māori and non-Māori.

METHODS

Utilising case study methodology, a range of data sources were triangulated including nine semi-structured interviews, documents, and a diabetes system map to identify possible strategic opportunities for key stakeholders to respond more effectively to pre-diabetes.

RESULTS

Key themes and possible actions to improve health outcomes for Māori with pre-diabetes include: (1) Recognising Māori health organisations as conduits for the community voice and influential partners in the community to effect change; (2) Strengthened partnerships with Māori health organisations for community benefit and to support measurable, evidence-based change and service delivery, particularly when Māori knowledge systems are viewed alongside a Western scientific approach; and (3) Intersectoral integration of health and social services to support provision of whānau-centred care and influence the social determinants of health and local environment.

CONCLUSIONS

Māori health organisations are important actors in systems seeking to improve outcomes and eliminate health inequities. Support from funders and policy makers will be required to build on the strengths of these organisations and to overcome system challenges. To realise improved health outcomes for Māori, the value placed on whānau and community perspectives not only needs to be acknowledged in the implementation of health interventions, health and social policies and funding arrangements, but performance measures, service design and delivery must evolve to accommodate these perspectives in practice.

Linking process and effects of intersectoral action on local neighbourhoods: systemic modelling based on Actor-Network Theory

After 25 years of intersectoral practice to increase health promotion resources, there is little scientific literature linking analysis of processes to observation of effects. Applying Actor-Network Theory, this article examines how the effects of intersectoral action are produced and can be attributed to its processes. A prospective multiple case study (2013-2016) was conducted on Neighbourhood Committees (NCs) in Montreal (Canada). Three NCs were studied using four kinds of data: direct observation notes of meetings and events, documents, logbooks and interviews. Systemic modelling of local intersectoral action was used for data collection and analysis. The results show that the transformations in living environments were produced by sequences of a limited number of 'transitory outcomes' that mark the progression of intersectoral action up to its effects. The list of transitory outcomes identified make up three functions in the production of change: (i) network setup and governance; (ii) self-representing and influencing others; (iii) aligning necessary actors and resources. The production of effects follows a systemic model wherein unique configurations of transitory outcomes, adapted to the different contexts where interactions are occurring, represent the change processes that lead to the effects.

Social Network Gap Analysis Evaluation: A Case Study of the Southeastern Health Equity Council

Despite the growing emphasis on collaboration in public health, there remains a dearth of literature providing tools for the evaluation of coalitions and councils. This study employed social network gap analysis as an evaluation tool. Survey data collected from the Southeastern Health Equity Council members were used to assess connections among members as a whole, by committee, by state, and by health specialty area. Analysis of how well Southeastern Health Equity Council met the representation outlined in its strategic plan was also conducted. Recommendations for improving the network and opportunities to effectively recruit and advance the work of Southeastern Health Equity Council are discussed.

A Critical Exploration of Migraine as a Health Disparity: the Imperative of an Equity-Oriented, Intersectional Approach

PURPOSE OF REVIEW

Despite recognition of rising prevalence and significant burden, migraine remains underestimated, underdiagnosed, and undertreated. This is especially true among groups who have been historically, socially, and economically marginalized such as communities of color, women, people experiencing poverty, people with lower levels of education, and people who hold more than one of these marginalized identities. While there is growing public and professional interest in disparities in migraine prevalence, there is a paucity of research focusing on racial/ethnic and socioeconomic disparities, and the social and structural determinants of health and equity that perpetuate these disparities. From a health equity perspective, migraine research and treatment require an examination not only of biological and behavioral factors, but of these identities and underlying, intersecting social and structural determinants of health.

RECENT FINDINGS

Significant disparities in migraine incidence, prevalence, migraine-related pain and disability, access to care, and quality of care persist among marginalized and underserved groups: African Americans, Hispanics, people experiencing poverty, un- or under-employment, the un- and under-insured, people who have been exposed to stressful and traumatic events across the lifespan, and people experiencing multiple, overlapping marginalized identities. These same groups are largely underrepresented in migraine research, despite bearing disproportionate burden. Current approaches to understanding health disparities in migraine largely assume an essentializing approach, i.e., documenting differences between single identity groups-e.g., race or income or education level-rather than considering the mechanisms of disparities: the social and structural determinants of health. While disparities in migraine are becoming more widely acknowledged, we assert that migraine is more aptly understood as a health equity issue, that is, a condition in which many of the health disparities are avoidable. It is important in research and clinical practice to consider perspectives that incorporate a cultural understanding of racial, ethnic, and socioeconomic identity within and across all levels of society. Incorporating perspectives of intersectionality provides a strong foundation for understanding the role of these complex combination of factors on migraine pain and treatment. We urge the adoption of intersectional and systems perspectives in research, clinical practice, and policy to examine (1) interplay of race, gender, and social location as key factors in understanding, diagnosing, and treating migraine, and (2) the complex configurations of social and structural determinants of health that interact to produce health inequities in migraine care. An intentional research and clinical focus on these factors stands to improve how migraine is identified, documented, and treated among marginalized populations.

Enhancing translational researchers' ability to collaborate with community stakeholders: Lessons from the Community Engagement Studio

Community engagement is considered essential to effectively translate research into practice and is increasingly recognized as a key to successful clinical trial recruitment. Challenges to engaging community stakeholders in research persist and new methods are needed to facilitate meaningful stakeholder involvement. The Community Engagement Studio (CE Studio), a consultative model, has been used at every stage of the research process. Best practices drawn from the model could inform other methods of engagement. Using a mixed-methods approach that included evaluation surveys, impact surveys and interviews, we assessed the CE Studio program. We analyzed data from 75 CE Studios; 65 researchers and 591 community members completed surveys and 10 researchers completed interviews. Surveys indicate that 100% of researchers would request a CE Studio in the future, and 99.3% of community members would participate in a CE Studio again. We identified 6 practices to enhance community engagement in clinical and translational research: early input, researcher coaching, researcher humility, balancing power, neutral facilitator, and preparation of community stakeholders. These best practices may enhance the quality of existing community engagement approaches and improve the effectiveness of translational researchers' efforts to engage community stakeholders in their work.

A Qualitative, Systems Thinking Approach to Study Self-Management in Women With Migraine

BACKGROUND

A dearth of effective and affordable treatment options has rendered nonpharmacological self-management a crucial part of living with migraine-a debilitating neurobiological condition without cure that disproportionately disables vulnerable women.

OBJECTIVE

The aim of the study was to describe the development and use of a systems thinking, problem-structuring data collection approach that was applied to the study of migraine self-management with women in diverse social locations.

METHODS

Two systems mapping activities were developed for use in focus groups: one to unpack a migraine episode (system support map) and the other (connection circle [CC]) to construct a mental model of self-management. Later in the process, a strengths-based problem-solving tool was developed to replace the CC.

RESULTS

The CCs-often enlightening for affluent participants-left marginalized women feeling overwhelmed and defeated, as a solution to one challenge became the cause of another. Through constant comparison analysis, we recalibrated the approach using a theory, clinical experience, and participant feedback and replaced the CC with a strengths-based problem-solving activity highlighting relationships and trade-offs in a more agential, actionable way.

DISCUSSION

Bringing a critical lens and strengths-based approaches to work with vulnerable populations can replace traditional deficit thinking in healthcare, developing options for leveraging resources and understanding complex health behaviors without losing sight of systemic, distributional justice issues. These systems thinking tools can provide a way to extrapolate the complexities of actual self-management behaviors and challenges faced by vulnerable women with migraine versus what they may be instructed to do by a medical model that does not always account for the social and structural determinants of equity and health.

Mind maps and network analysis to evaluate conceptualization of complex issues: A case example evaluating systems science workshops for childhood obesity prevention

Across disciplines, it is common practice to bring together groups to solve complex problems. Facilitators are often asked to help groups organize information about and better understand the problem in order to develop and prioritize solutions. However, despite existence of several methods to elicit and characterize how individuals and groups think about and conceptualize an issue, many are difficult to implement in practice-based settings where resources such as technology and participant time are limited and research questions shift over time. This paper describes an easy-to-implement diagramming technique for eliciting conceptualization and a flexible network analysis method for characterizing changes in both individual and group conceptualization. We use a case example to illustrate how we used the methods to evaluate African American adolescent's conceptual understanding of obesity before and after participating in a series of four systems thinking workshops. The methods produced results that were sensitive to changes in conceptualization that were likely driven by the specific activities employed during the workshop sessions. The methods appear strong for capturing salient levels of conceptualization at both individual and collective levels. The paper concludes with a critical examination of strengths and weaknesses of the methods and implications for future practice and research.

Innovating for Transformation in First Nations Health Using Community-Based Participatory Research

Community-based participatory research (CBPR) provides the opportunity to engage communities for sustainable change. We share a journey to transformation in our work with eight Manitoba First Nations seeking to improve the health of their communities and discuss lessons learned. The study used community-based participatory research approach for the conceptualization of the study, data collection, analysis, and knowledge translation. It was accomplished through a variety of methods, including qualitative interviews, administrative health data analyses, surveys, and case studies. Research relationships built on strong ethics and protocols to enhance mutual commitment to support community-driven transformation. Collaborative and respectful relationships are platforms for defining and strengthening community health care priorities. We further discuss how partnerships were forged to own and sustain innovations. This article contributes a blueprint for respectful CBPR. The outcome is a community-owned, widely recognized process that is sustainable while fulfilling researcher and funding obligations.

Development and testing of a novel survey to assess Stakeholder-driven Community Diffusion of childhood obesity prevention efforts

BACKGROUND

Involving groups of community stakeholders (e.g., steering committees) to lead community-wide health interventions appears to support multiple outcomes ranging from policy and systems change to individual biology. While numerous tools are available to measure stakeholder characteristics, many lack detail on reliability and validity, are not context specific, and may not be sensitive enough to capture change over time. This study describes the development and reliability of a novel survey to measure Stakeholder-driven Community Diffusion via assessment of stakeholders' social networks, knowledge, and engagement about childhood obesity prevention.

METHODS

This study was completed in three phases. Phase 1 included conceptualization and online survey development through literature reviews and expert input. Phase 2 included a retrospective study with stakeholders from two completed whole-of-community interventions. Between May-October 2015, 21 stakeholders from the Shape Up Somerville and Romp & Chomp interventions recalled their social networks, knowledge, and engagement pre-post intervention. We also assessed one-week test-retest reliability of knowledge and engagement survey modules among Shape Up Somerville respondents. Phase 3 included survey modifications and a second prospective reliability assessment. Test-retest reliability was assessed in May 2016 among 13 stakeholders involved in ongoing interventions in Victoria, Australia.

RESULTS

In Phase 1, we developed a survey with 7, 20 and 50 items for the social networks, knowledge, and engagement survey modules, respectively. In the Phase 2 retrospective study, Shape Up Somerville and Romp & Chomp networks included 99 and 54 individuals. Pre-post Shape Up Somerville and Romp & Chomp mean knowledge scores increased by 3.5 points (95% CI: 0.35-6.72) and (- 0.42-7.42). Engagement scores did not change significantly (Shape Up Somerville: 1.1 points (- 0.55-2.73); Romp & Chomp: 0.7 points (- 0.43-1.73)). Intraclass correlation coefficients (ICCs) for knowledge and engagement were 0.88 (0.67-0.97) and 0.97 (0.89-0.99). In Phase 3, the modified knowledge and engagement survey modules included 18 and 25 items, respectively. Knowledge and engagement ICCs were 0.84 (0.62-0.95) and 0.58 (0.23-0.86).

CONCLUSIONS

The survey measures upstream stakeholder properties-social networks, knowledge, and engagement-with good test-retest reliability. Future research related to Stakeholder-driven Community Diffusion should focus on prospective change and survey validation for intervention effectiveness.

"Being connected" The experience of African American women with breast cancer: A community-based participatory research project: Part I

The objective was to understand the breast cancer experience of African American (AA) women using a community-based participatory research framework. Qualitative data were collected from five focus groups with 29 participants in four urban cities. "Being Connected" was the major theme that explained the importance of people in their lives as they coped with the diagnosis, treatment, and life after therapy. Faith, talking, information, support, and living with changes were important factors in the process. The breast cancer experience was situated with the AA culture and community and unique aspects were identified for clinical practice in the care of these women.

Designing an Agent-Based Model Using Group Model Building: Application to Food Insecurity Patterns in a U.S. Midwestern Metropolitan City

Recent advances in computing resources have increased interest in systems modeling and population health. While group model building (GMB) has been effectively applied in developing system dynamics models (SD), few studies have used GMB for developing an agent-based model (ABM). This article explores the use of a GMB approach to develop an ABM focused on food insecurity. In our GMB workshops, we modified a set of the standard GMB scripts to develop and validate an ABM in collaboration with local experts and stakeholders. Based on this experience, we learned that GMB is a useful collaborative modeling platform for modelers and community experts to address local population health issues. We also provide suggestions for increasing the use of the GMB approach to develop rigorous, useful, and validated ABMs.

Implementation framework for chronic disease intervention effectiveness in Māori and other indigenous communities

Background

About 40% of all health burden in New Zealand is due to cancer, cardiovascular disease, and type 2 diabetes/obesity. Outcomes for Māori (indigenous people) are significantly worse than non-Maori; these inequities mirror those found in indigenous communities elsewhere. Evidence-based interventions with established efficacy may not be effective in indigenous communities without addressing specific implementation challenges. We present an implementation framework for interventions to prevent and treat chronic conditions for Māori and other indigenous communities.

Theoretical framework

The He Pikinga Waiora Implementation Framework has indigenous self-determination at its core and consists of four elements: cultural-centeredness, community engagement, systems thinking, and integrated knowledge translation. All elements have conceptual fit with Kaupapa Māori aspirations (i.e., indigenous knowledge creation, theorizing, and methodology) and all have demonstrated evidence of positive implementation outcomes.

Applying the framework

A coding scheme derived from the Framework was applied to 13 studies of diabetes prevention in indigenous communities in Australia, Canada, New Zealand, and the United States from a systematic review. Cross-tabulations demonstrated that culture-centeredness (p = .008) and community engagement (p = .009) explained differences in diabetes outcomes and community engagement (p = .098) explained difference in blood pressure outcomes.

Implications and conclusions

The He Pikinga Waiora Implementation Framework appears to be well suited to advance implementation science for indigenous communities in general and Māori in particular. The framework has promise as a policy and planning tool to evaluate and design effective interventions for chronic disease prevention in indigenous communities.

Development of a Systems Science Curriculum to Engage Rural African American Teens in Understanding and Addressing Childhood Obesity Prevention

Engaging youth from racial and ethnic minority communities as leaders for change is a potential strategy to mobilize support for addressing childhood obesity, but there are limited curricula designed to help youth understand the complex influences on obesity. Our aim was to develop and pilot test a systems science curriculum to elicit rural African American youth perspectives on childhood obesity and enhance their understanding of and support for obesity prevention solutions. The curriculum was designed so it could be integrated with existing positive youth development curricula that help youth advocate for and implement identified solutions. We conducted four workshop sessions with youth that engaged them in systems learning activities such as guided systems diagramming activities. The participants ( n = 21) completed validated surveys presession and postsession that assessed their causal attributions of obesity and support for obesity prevention policies. The youths' perception that environmental factors cause obesity increased ( p < .05), and perceptions that individual behavior and biology cause obesity did not change. Their support for policies that addressed food access and food pricing significantly increased ( p < .05). The youths' system diagrams elucidated links between multilevel factors such as personal attitudes, social influence, and the built environment, which provides important information for designing synergistic solutions. The changes we observed in youths' perceptions of obesity and support for policy changes have important implications for youths' interest and willingness to advocate for social and environmental changes in their community. The strategies have a promising role in supporting community mobilization to address childhood obesity.

Using Systems Science to Inform Population Health Strategies in Local Health Departments: A Case Study in San Antonio, Texas

OBJECTIVES

Because of state and federal health care reform, local health departments play an increasingly prominent role leading and coordinating disease prevention programs in the United States. This case study shows how a local health department working in chronic disease prevention and management can use systems science and evidence-based decision making to inform program selection, implementation, and assessment; enhance engagement with local health systems and organizations; and possibly optimize health care delivery and population health.

METHODS

The authors built a systems-science agent-based simulation model of diabetes progression for the San Antonio Metropolitan Health District, a local health department, to simulate health and cost outcomes for the population of San Antonio for a 20-year period (2015-2034) using 2 scenarios: 1 in which hemoglobin A1c (HbA1c) values for a population were similar to the current distribution of values in San Antonio, and the other with a hypothetical 1-percentage-point reduction in HbA1c values.

RESULTS

They projected that a 1-percentage-point reduction in HbA1c would lead to a decrease in the 20-year prevalence of end-stage renal disease from 1.7% to 0.9%, lower extremity amputation from 4.6% to 2.9%, blindness from 15.1% to 10.7%, myocardial infarction from 23.8% to 17.9%, and stroke from 9.8% to 7.2%. They estimated annual direct medical cost savings (in 2015 US dollars) from reducing HbA1c by 1 percentage point ranging from $6842 (myocardial infarction) to $39 800 (end-stage renal disease) for each averted case of diabetes complications.

CONCLUSIONS

Local health departments could benefit from the use of systems science and evidence-based decision making to estimate public health program effectiveness and costs, calculate return on investment, and develop a business case for adopting programs.

The Development of Health for Hearts United: A Longitudinal Church-based Intervention to Reduce Cardiovascular Risk in Mid-life and Older African Americans

This article describes Health for Hearts United, a longitudinal church-based intervention to reduce cardiovascular disease (CVD) risk in mid-life and older African Americans. Using community-based participatory research (CBPR) approaches and undergirded by both the Socio-ecological Theory and the Transtheoretical Model of Behavior Change, the 18-month intervention was developed in six north Florida churches, randomly assigned as treatment or comparison. The intervention was framed around three conceptual components: awareness building (individual knowledge development); clinical learning (individual and small group educational sessions); and efficacy development (recognition and sustainability). We identified three lessons learned: providing consistency in programming even during participant absences; providing structured activities to assist health ministries in sustainability; and addressing changes at the church level. Recommendations include church-based approaches that reflect multi-level CBPR and the collaborative faith model.

Changing medical relationships after the ACA: Transforming perspectives for population health

American health care has undergone significant organizational change in recent decades. But what is the state of core medical relationships in the wake of these changes? Throughout ACA-era health care reform, the doctor-patient relationship was targeted as a particularly important focus for improving communication and health outcomes. Recent developments however have shifted the focus from individual-level outcomes to the wellbeing of populations. This, we argue, requires a fundamental rethinking of health care reform as an opportunity to renegotiate relationships. For example, the move to population medicine requires that the very concept of a patient be resituated and the scope of relevant relationships expanded. Medical relationships in this era of health care are likely to include partnerships between various types of clinicians and the communities in which patients reside, as well as a host of new actors, from social workers and navigators to scribes and community health workers. To address the upstream determinants of population health, providers must be increasingly willing and trained to collaborate with community stakeholders to address both medical and non-medical issues. These community-based partnerships are critical to providing health care that is both relevant and appropriate for addressing problems, and sustainable. Approaching health care reform, and the focus on population health, as a fundamental reworking of relationships provides scholars with a sharper theoretical lens for understanding 21st century American health care.

Modeling Social Capital as Dynamic Networks to Promote Access to Oral Healthcare

Social capital, as comprised of human connections in social networks and their associated benefits, is closely related to the health of individuals, communities, and societies at large. For disadvantaged population groups such as older adults and racial/ethnic minorities, social capital may play a particularly critical role in mitigating the negative effects and reinforcing the positive effects on health. In this project, we model social capital as both cause and effect by simulating dynamic networks. Informed in part by a community-based health promotion program, an agent-based model is contextualized in a GIS environment to explore the complexity of social disparities in oral and general health as experienced at the individual, interpersonal, and community scales. This study provides the foundation for future work investigating how health and healthcare accessibility may be influenced by social networks.