Promoting knowledge to policy translation for urban health using community-based system dynamics in Brazil.

BACKGROUND: Effectively bridging the knowledge-policy gap to support the development of evidence-based policies that promote health and well-being remains a challenge for both the research and policy communities. Community-based system dynamics (CBSD) is a participatory modelling approach that aims to build stakeholders' capacity to learn and address complex problems collaboratively. However, limited evidence is available about the contributions of CBSD to knowledge-generating and policy processes across sectors and policy spheres. In the context of a multi-country research project focused on creating an evidence base to inform urban health policies across Latin America, a series of CBSD workshops convened stakeholders from research, policy-making, and other backgrounds working in food and transportation systems. Diverse participants were selected aiming to incorporate multiple perspectives relevant to understanding complex urban systems linked to food and transportation. This study focuses on one of these workshops, whose avenue was São Paulo, Brazil, assembling country-based participants representing local, regional, national, and international institutions with multidisciplinary backgrounds linked to food and transportation systems. OBJECTIVE: The aim of this case study is to explore the perceived influence of one of these workshops on attendees' understandings of food and transportation systems and their relationship to healthy urban environments, with attention to the role of the workshop in supporting knowledge to policy translation for urban health. METHODS: We conducted 18 semi-structured qualitative interviews with attendees one year after their participation in a CBSD workshop held in São Paulo, Brazil. A framework method approach was used to code participants' responses and identify emerging themes. RESULTS: Participants reported that the workshop's group model-building activities influenced their understanding of the knowledge-policy process as it relates to food and transport systems. Workshop contributed to participants' (1) abilities to engage with multisectoral stakeholders, (2) construct a shared language and understanding of urban challenges, (3) improve understanding of the interconnectedness across food and transportation systems, (4) facilitate dialogue across sectors, and (5) apply a systems thinking approach within their sector and professional context. Participants continued to draw on the tools developed during the workshop, and to apply systems thinking to their research and policy-making activities. CONCLUSIONS: CBSD may offer valuable opportunities to connect the research sector to the policy-making process. This possibility may contribute to knowledge to policy translation in the interconnection between the urban context, food and transportation systems, and health.

Integrating complex systems science into road safety research and practice, part 1: review of formative concepts.

Many of our most persistent public health problems are complex problems. They arise from a web of factors that interact and change over time and may exhibit resistance to intervention efforts. The domain of systems science provides several tools to help injury prevention researchers and practitioners examine deep, complex and persistent problems and identify opportunities to intervene. Using the increase in pedestrian death rates as an example, we provide (1) an accessible overview of how complex systems science approaches can augment established injury prevention frameworks and (2) a straightforward example of how specific systems science tools can deepen understanding, with a goal of ultimately informing action.

Integrating complex systems science into road safety research and practice, Part 2: applying systems tools to the problem of increasing pedestrian death rates.

OBJECTIVES: To provide a specific example of how systems dynamics tools can increase understanding of stakeholder 'mental models' and generate robust systems-based hypotheses about the escalating problem of rising pedestrian death rates in the USA. METHODS: We designed and facilitated two group model building (GMB) workshops. Participants generated causal loop diagrams (CLDs) individually and in small groups to explore hypotheses concerning time-dynamic interacting factors underlying the increasing rates of pedestrian deaths. Using a grounded theory approach, research team members synthesised the structures and hypotheses into a single CLD. RESULTS: CLDs from the 41 participants indicated four core factors hypothesised to have a direct impact on pedestrian fatalities: pedestrian-vehicle crashes, vehicle speed at the time of the crash, vehicle size/dimensions and emergency response time. Participants diagrammed how actions and reactions impacted these proximal factors over time and led to ripple effects throughout a larger system to generate an increase in pedestrian deaths. Hypothesised contributing mechanisms fell within the following broad categories: community responses; research, policy and industry influence; potential unintended consequences of responses to pedestrian deaths; and the role of sprawl. CONCLUSIONS: This application of systems science tools suggested several strategies for advancing injury prevention research and practice. The project generated robust hypotheses and advanced stakeholder communication and depth of understanding and engagement in this key issue. The CLD and GMB process detailed in this study provides a concrete example of how systems tools can be adopted and applied to a transportation safety topic.

A systems approach to reducing maternal obesity: The Health in Preconception, Pregnancy and Postbirth (HIPPP) Collaborative.

Obesity in our childbearing population has increased to epidemic proportions in developed countries; efforts to address this issue need to focus on prevention. The Health in Preconception, Pregnancy and Postbirth (HIPPP) Collaborative - a group of researchers, practitioners, policymakers and end-users - was formed to take up the challenge to address this issue as a partnership. Application of systems thinking, participatory systems modelling and group model building was used to establish research questions aiming to optimise periconception lifestyle, weight and health. Our goal was to reduce the burden of maternal obesity through systems change.

Target population involvement in urban ciclovias: a preliminary evaluation of St. Louis open streets.

Ciclovias are active street events when roads are open to walkers, cyclists, and families and closed to automobiles. Over 70 cities in the USA have implemented ciclovias to promote physical activity. The authors evaluated four events during 2010 to determine what activities participants perform and who is attending. For two ciclovia events in St. Louis, Missouri, observation reports of activities, gender, and age of 1,452 participants were collected, and 82 adults were interviewed via direct approach. The survey covered six domains: physical activity, travel to event, sense of community, marketing, economic impact, and demographics. Each event occurred within the city, along multiple streets. Domains were selected from Ciclovia Recreativa developed by Ciclovia Bogota, Pan American Health Organization, and CDC. Additional questions addressed city-specific goals and matched similar evaluations in other cities. Over 50 % of participants met CDC-defined weekly minute thresholds for physical activity. Participants, primarily (>80 %) middle class, college educated, and white, were not representative of the majority minority city population, which has high rates of poverty, and low percentage of college graduates. Cities must work with residents to increase low-income minority population participation in ciclovia-based physical activity.

Means, Intent, Lethality, Behaviors, and Psychiatric Diagnosis in Latina Adolescent Suicide Attempters.

This article describes the means, intent, lethality, behavioral profile, and psychiatric diagnosis of adolescent Latina suicide attempters. From a large mixed-methods project studying the sociocultural processes of Latina suicide attempts, we selected 76 subjects for this report. In addition to quantitative research data, medical records were available for all 76 subjects and qualitative data from in-depth interviews for 34 of them. Using the qualitative and quantitative research data, we explored the intent and behavioral profile of the suicidal adolescents. Medical records provided additional information about the means the adolescents used in their attempts and about their psychiatric diagnosis. The lethality of suicide attempts was coded using the LSARS and the LSARS-II. Findings showed that Latina adolescent suicide attempts are of low lethality. Consistent with the literature, most adolescents reported that they attempted by using means available in their homes (cutting and overdosing with medications were the predominant methods). Interesting discrepancies emerged when comparing adolescents' self-reported behavioral profiles with clinicians' psychiatric diagnoses. This report has implications for diagnosis and treatment approaches for both inpatient and outpatient service providers.

Simulating congestion pricing policy impacts on pedestrian safety using a system dynamics approach.

Research on congestion pricing policy (CPP) impacts has generally focused on the economic and congestion-related benefits of CPPs. Few studies have examined safety effects and the interrelated factors that produce safety outcomes for vulnerable road users. We built a novel system dynamics simulation model to explore the potential mechanisms producing pedestrian injuries over time and the impacts of a CPP (and related interventions) on this trend. We found that pedestrian injury trends varied based on important decisions related to how the CPP is designed, including investments in potential safety-related supports for pedestrians. Infrastructure improvements and speed management interventions could help cities achieve both congestion-relieving goals while also improving safety. Additionally, certain CPP configurations (e.g., additional charges on for-hire vehicles) could further reduce daily vehicle trips and congestion but might lead to unintended negative safety consequences of greater pedestrian injuries. This is the first model to provide a holistic and endogenous look at how interconnected processes affecting congestion and CPP impacts also affect vulnerable road user safety. The use of system dynamics models can facilitate a holistic inspection of potential intended and unintended effects across a range of outcomes, prior to policy implementation.

System Dynamics of Cognitive Vulnerabilities and Family Support Among Latina Children and Adolescents.

The paper describes an approach to developing a data-driven development of a feedback theory of cognitive vulnerabilities and family support focused on understanding the dynamics experienced among Latina children, adolescents, and families. Family support is understood to be a response to avoidant and maladaptive behaviors that may be characteristic of cognitive vulnerabilities commonly associated depression and suicidal ideation. A formal feedback theory is developed, appraised, and analyzed using a combination of secondary analysis of qualitative interviews (N = 30) and quantitative analysis using system dynamics modeling and simulation. Implications for prevention practice, treatment, and future research are discussed.

Family Relationships and Latina Teen Suicide Attempts: Reciprocity, Asymmetry, and Detachment.

Using qualitative data collected from adolescent Latinas and their parents, this article describes ways in which family relationships are organized within low-income Latino families (n = 24) with and without a daughter who attempted suicide. Based on a family-level analysis approach, we present a framework that categorizes relationships as reciprocal, asymmetrical, or detached. Clear differences are identified: Families of non-attempters primarily cluster in reciprocal families, whereas families with an adolescent suicide attempter exhibit characteristics of asymmetrical or detached families. Our results highlight the need for detailed clinical attention to family communication patterns, especially in Latino families. Clinicians may reduce the likelihood of an attempt or repeated attempts by raising mutual, reciprocal exchanges of words and support between parents and daughter.

Familism, parent-adolescent conflict, self-esteem, internalizing behaviors and suicide attempts among adolescent Latinas.

Adolescent Latinas continue to report higher levels of suicide attempts than their African-American and White peers. The phenomenon is still not understood and is theorized to be the result of the confluence of many cultural, familial, and individual level factors. In Latino cultures, belief in the importance of the family, the value known as familism, appears to protect youth's emotional and behavioral health, but parent-adolescent conflict has been found to be a risk factor for suicide attempts. The role of familism in relation to parent-adolescent conflict, self-esteem, internalizing behaviors, and suicide attempts has not been studied extensively. To address this question, we interviewed 226 adolescent Latinas, 50% of whom had histories of suicide attempts. Using path analysis, familism as a cultural asset was associated with lower levels of parent-adolescent conflict, but higher levels of internalizing behaviors, while self-esteem and internalizing behaviors mediated the relationship between parent-adolescent conflict and suicide attempts. Our findings point to the importance of family involvement in culturally competent suicide prevention and intervention programs. Reducing parent-daughter conflict and fostering closer family ties has the added effect of improving self-esteem and shrinking the likelihood of suicide attempts.

Novel participatory methods for co-building an agent-based model of physical activity with youth.

Public health scholarship has increasingly called for the use of system science approaches to understand complex problems, including the use of participatory engagement to inform the modeling process. Some system science traditions, specifically system dynamics modeling, have an established participatory practice tradition. Yet, there remains limited guidance on engagement strategies using other modeling approaches like agent-based models. Our objective is to describe how we engaged adolescent youth in co-building an agent-based model about physical activity. Specifically, we aim to describe how we communicated technical aspects of agent-based models, the participatory activities we developed, and the resulting visual diagrams that were produced. We implemented six sessions with nine adolescent participants. To make technical aspects more accessible, we used an analogy that linked core components of agent-based models to elements of storytelling. We also implemented novel, facilitated activities that engaged youth in the development, annotation, and review of graphs over time, geographical maps, and state charts. The process was well-received by the participants and helped inform the basic structure of an agent-based model. The resulting visual diagrams created space for deeper discussion among participants about patterns of daily activity, important places for physical activity, and interactions between social and built environments. This work lays a foundation to develop and refine engagement strategies, especially for translating qualitative insights into quantitative model specifications such as 'decision rules'.

Using community-based system dynamics modeling to understand the complex systems that influence health in cities: The SALURBAL study.

We discuss the design, implementation, and results of a collaborative process designed to elucidate the complex systems that drive food behaviors, transport, and health in Latin American cities and to build capacity for systems thinking and community-based system dynamics (CBSD) methods among diverse research team members and stakeholders. During three CBSD workshops, 62 stakeholders from 10 Latin American countries identified 98 variables and a series of feedback loops that shape food behaviors, transportation and health, along with 52 policy levers. Our findings suggest that CBSD can engage local stakeholders, help them view problems through the lens of complex systems and use their insights to prioritize research efforts and identify novel solutions that consider mechanisms of complexity.

Understanding a successful obesity prevention initiative in children under 5 from a systems perspective.

INTRODUCTION/BACKGROUND: Systems thinking represents an innovative and logical approach to understanding complexity in community-based obesity prevention interventions. We report on an approach to apply systems thinking to understand the complexity of a successful obesity prevention intervention in early childhood (children aged up to 5 years) conducted in a regional city in Victoria, Australia. METHODS: A causal loop diagram (CLD) was developed to represent system elements related to a successful childhood obesity prevention intervention in early childhood. Key stakeholder interviews (n = 16) were examined retrospectively to generate purposive text data, create microstructures, and form a CLD. RESULTS: A CLD representing key stakeholder perceptions of a successful intervention comprised six key feedback loops explaining changes in project implementation over time. The loops described the dynamics of collaboration, network formation, community awareness, human resources, project clarity, and innovation. CONCLUSION: The CLD developed provides a replicable means to capture, evaluate and disseminate a description of the dynamic elements of a successful obesity prevention intervention in early childhood.

A Community Based Systems Diagram of Obesity Causes.

INTRODUCTION: Application of system thinking to the development, implementation and evaluation of childhood obesity prevention efforts represents the cutting edge of community-based prevention. We report on an approach to developing a system oriented community perspective on the causes of obesity. METHODS: Group model building sessions were conducted in a rural Australian community to address increasing childhood obesity. Stakeholders (n = 12) built a community model that progressed from connection circles to causal loop diagrams using scripts from the system dynamics literature. Participants began this work in identifying change over time in causes and effects of childhood obesity within their community. The initial causal loop diagram was then reviewed and elaborated by 50 community leaders over a full day session. RESULTS: The process created a causal loop diagram representing community perceptions of determinants and causes of obesity. The causal loop diagram can be broken down into four separate domains; social influences; fast food and junk food; participation in sport; and general physical activity. DISCUSSION: This causal loop diagram can provide the basis for community led planning of a prevention response that engages with multiple levels of existing settings and systems.

Mental illness, poverty and stigma in India: a case-control study.

OBJECTIVE: To assess the effect of experienced stigma on depth of multidimensional poverty of persons with severe mental illness (PSMI) in Delhi, India, controlling for gender, age and caste. DESIGN: Matching case (hospital)-control (population) study. SETTING: University Hospital (cases) and National Capital Region (controls), India. PARTICIPANTS: A case-control study was conducted from November 2011 to June 2012. 647 cases diagnosed with schizophrenia or affective disorders were recruited and 647 individuals of same age, sex and location of residence were matched as controls at a ratio of 1:2:1. Individuals who refused consent or provided incomplete interview were excluded. MAIN OUTCOME MEASURES: Higher risk of poverty due to stigma among PSMI. RESULTS: 38.5% of PSMI compared with 22.2% of controls were found poor on six dimensions or more. The difference in multidimensional poverty index was 69% between groups with employment and income of the main contributors. Multidimensional poverty was strongly associated with stigma (OR 2.60, 95% CI 1.27 to 5.31), scheduled castes/scheduled tribes/other backward castes (2.39, 1.39 to 4.08), mental illness (2.07, 1.25 to 3.41) and female gender (1.87, 1.36 to 2.58). A significant interaction between stigma, mental illness and gender or caste indicates female PSMI or PSMI from 'lower castes' were more likely to be poor due to stigma than male controls (p<0.001) or controls from other castes (p<0.001). CONCLUSIONS: Public stigma and multidimensional poverty linked to SMI are pervasive and intertwined. In particular for low caste and women, it is a strong predictor of poverty. Exclusion from employment linked to negative attitudes and lack of income are the highest contributors to multidimensional poverty, increasing the burden for the family. Mental health professionals need to be aware of and address these issues.

Open streets initiatives in the United States: closed to traffic, open to physical activity.

BACKGROUND: The ciclovía, or open streets concept, is a community-level physical activity (PA) promotion strategy where streets are closed to motorized traffic and open for individuals to engage in PA. This paper presents an overview of such initiatives in the United States (US) to understand their potential in PA promotion, comparing event and city characteristics. METHODS: We searched ciclovía and open streets initiatives held in 2011 in the US using internet searches, publication databases, social media, and personal contacts. We extracted data on the each initiative's frequency, route length, attendance, evaluation procedures, and sociodemographic characteristics of host cities. RESULTS: Our search yielded 47 US cities with open streets in 2011. Cities were diverse in sociodemographic characteristics. Route lengths ranged from a few blocks to 51 miles and event frequency ranged from annual to monthly. Reporting number of participants for events was sporadic. Few events conducted formal evaluations. CONCLUSION: The number of US cities hosting open streets is increasing. The sociodemographics of the host cities suggest a potential to increase physical activity in populations at risk for developing chronic diseases through these initiatives. However, further evaluation is required. Identifying successful promotion and evaluation tactics would boost the health promotion potential of these initiatives.

Sacrifice for the sake of the family: expressions of familism by Latina teens in the context of suicide.

Familism is a core value promoted by many individuals of Hispanic or Latino descent that emphasizes the primacy of the family over the individual. This study illuminates some aspects of the relationship between familism and adolescent suicidal behavior. Qualitative data from 24 female Hispanic teens with and without a history of suicidal behaviors and their parents were analyzed to understand the ways in which familism is expressed in their lives. Both suicide attempters and nonattempters demonstrate familism by making material or emotional (or both) sacrifices for the sake of their families. However, for those attempters who expressed a clear intent to die, a third type of sacrifice emerged: Girls expressed a desire to kill themselves in order to make things better for their families, literally sacrificing themselves for the sake of family. Findings point to the complexity of familism in understanding the risks of suicide attempts among teen Latinas and to the value of mixed methods in studying deeply the cultural factors that influence problem behaviors.

Can Better Mother-Daughter Relations Reduce the Chance of a Suicide Attempt among Latinas?

National surveys and other research on adolescent Latinas show that adolescent females have higher rates of suicidal ideation, planning, and attempts than other ethnic and racial minority youth. Internalizing behaviors and family conflicts are commonly associated with suicidality in research on adolescents. In the case of Latinas, we explore the connection between adolescent Hispanic cultural involvement, mother-adolescent mutuality, internalizing behaviors, and suicidality. This paper presents data from a study of 232 Latinas, some with a recent history of suicide attempts (n = 122). The results show that higher adolescent Hispanic cultural involvement was associated with greater mother-daughter mutuality and thus led to reduction in the likelihood of suicide attempts. The relationship between mother-daughter mutuality and suicide attempts among Latinas is mediated by specific internalizing behaviors (withdrawn depressive). Our findings highlight the positive effect that Latino cultural values have in the relationship between Latina adolescent and their mothers and confirm the importance that internalizing behaviors and the mother-daughter relationship have for suicide attempters.

Familism, family environment, and suicide attempts among Latina youth.

In this study, we examined the relationship between familism and family environment type as well as the relationship between family environment type and suicide attempts among Latina youth. Latina teen attempters (n = 109) and nonattempters (n = 107) were recruited from the New York City area. Latent class analysis revealed three family environment types: tight-knit, intermediate-knit, and loose-knit. Tight-knit families (high cohesion and low conflict) were significantly less likely to have teens who attempted suicide as compared with intermediate-knit families or loose-knit families. Moreover, familism increased the odds of being in a tight-knit family versus a loose-knit family and the odds of being in a tight-knit family versus a intermediate-knit. The results suggest that familism may protect against suicide behavior among Latinas via its influence on family environment.