Making the invisible visible: Using a qualitative system dynamics model to map disparities in cumulative environmental stressors and children's neurodevelopment.

BACKGROUND: The combined effects of multiple environmental toxicants and social stressor exposures are widely recognized as important public health problems, likely contributing to health inequities. However, US policy makers at state and federal levels typically focus on one stressor exposure at a time and have failed to develop comprehensive strategies to reduce multiple co-occurring exposures, mitigate cumulative risks and prevent harm. This research aimed to move from considering disparate environmental stressors in isolation to mapping the links between environmental, economic, social and health outcomes as a dynamic complex system using children's exposure to neurodevelopmental toxicants as an illustrative example. Such a model can be used to support a broad range of child developmental and environmental health policy stakeholders in improving their understanding of cumulative effects of multiple chemical, physical, biological and social environmental stressors as a complex system through a collaborative learning process. METHODS: We used system dynamics (SD) group model building to develop a qualitative causal theory linking multiple interacting streams of social stressors and environmental neurotoxicants impacting children's neurodevelopment. A 2 1/2-day interactive system dynamics workshop involving experts across multiple disciplines was convened to develop the model followed by qualitative survey on system insights. RESULTS: The SD causal map covered seven interconnected themes: environmental exposures, social environment, health status, education, employment, housing and advocacy. Potential high leverage intervention points for reducing disparities in children's cumulative neurotoxicant exposures and effects were identified. Workshop participants developed deeper level of understanding about the complexity of cumulative environmental health risks, increased their agreement about underlying causes, and enhanced their capabilities for integrating diverse forms of knowledge about the complex multi-level problem of cumulative chemical and non-chemical exposures. CONCLUSION: Group model building using SD can lead to important insights to into the sociological, policy, and institutional mechanisms through which disparities in cumulative impacts are transmitted, resisted, and understood.

Application of systems dynamics and group model building to identify barriers and facilitators to acute care delivery in a resource limited setting.

BACKGROUND: Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi. METHODS: Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed. RESULTS: Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias. CONCLUSIONS: GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting.

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.

Community-Based System Dynamics for Mobilizing Communities to Advance School Health.

BACKGROUND: Frameworks such as the WSCC model provide evidence-based guidance for addressing school health at the school, district, and regional level. However, frameworks do not implement themselves; they require the mobilization and collaboration of stakeholders within communities and an understanding of the unique resources and barriers within each context. Furthermore, addressing school health presents a complex systems problem. METHODS: Community-based system dynamics (CBSD) is a participatory approach for engaging communities in understanding and changing complex systems. We used a descriptive multiple case study design to evaluate how and why CBSD was used as a tool for stakeholders to engage with the complexity of school health. RESULTS: We analyzed 3 cases to understand how these methods were used to enhance collaboration, analysis, and community action at multiple levels, including in 2 school districts, with a city-wide stakeholder committee, and with a group of high school students. CONCLUSIONS: Community-based system dynamics presents a promising approach for building shared language and ownership among stakeholders, tailoring to local community contexts, and mobilizing stakeholders for action based on new system insights. We close with a discussion of unique opportunities and challenges of expanding the use of CBSD in the field of school health.

Developing a Socioculturally Nuanced Systems Model of Childhood Obesity in Manhattan's Chinese American Community via Group Model Building.

The purpose of this study was to develop a qualitative and socioculturally tailored systems model of childhood obesity in the Chinese American community in Manhattan's Chinatown. We utilized group model building (GMB) methodology as a form of participatory systems modeling. The study was conducted in Manhattan's Chinatown community. We recruited 16 Chinese American adults from the community. GMB workshops engendered a causal loop diagram (CLD), the visualization of a complex systems model illustrating the structures, feedbacks, and interdependencies among socioculturally specific pathways underlying childhood obesity, in Manhattan's Chinatown community. The analysis of CLD revealed that participants considered the following factors to influence childhood obesity: (1) traditional social norms affecting body image, how children are raised, parental pressure to study, and trust in health of traditional foods; (2) grandparents' responsibility for children; (3) limited time availability of parents at home; and (4) a significant amount of children's time spent indoors. GMB represents a novel method to understand the complexity of childhood obesity in culturally specific populations and contexts. The study identified sociocultural subsystems that may underlie the development and perpetuation of childhood obesity among Chinese American children. Insights from the study can be useful in the design of future empirical studies and interventions.

Research to Translation: The Healthy Schools Toolkit and New Approaches to the Whole School, Whole Community, Whole Child Model.

BACKGROUND: The Whole School, Whole Community, Whole Child (WSCC) model is an evidence-based comprehensive framework to address health in schools. WSCC model use improves health and educational outcomes, but implementation remains a challenge. METHODS: Working with 6 schools in 2 districts in the Midwest, we used a mixed-methods approach to determine the people, systems, and messages needed to activate WSCC implementation. We report on social network analysis and message testing findings and research translation to develop the Healthy Schools Toolkit. RESULTS: Social networks for both districts included more than 150 individuals. Both demonstrated network densities less than half of the desirable threshold, with evidence of clustering by role and minimal cross-school relationships, posing challenges for WSCC implementation. Across stakeholder groups, messages that emphasize empathy, teamwork, and action were well-received, especially when shared by trusted individuals through communication channels that align with stakeholder needs. CONCLUSIONS: The Healthy Schools Toolkit provides an example of a translational product that helps to bridge research with practice. With features that highlight 6 design principles, the toolkit provides complementary activities that schools and districts can use as they plan for integration of the WSCC model.

Capability Traps Impeding Homeless Services: A Community-Based System Dynamics Evaluation.

Continuums of Care (CoCs) are the primary coordinating bodies for homeless services in the United States. However, the complexities involved in delivering homeless services across interagency networks challenges coordination and system improvement. CoC governance, planning, and service provision have received little attention in academic literature, and thus, Continuums attempt to manage complex systems with little guidance. This evaluation applied community-based system dynamics with homeless consumers and service providers to (1) identify capability traps that impede services delivery and to (2) engage stakeholders in a structured system improvement process. Results revealed organizational structures for governance and planning that inhibit system outcomes. Insights led to policy and practice recommendations for the homeless system.

Leverage points to improve smoking cessation treatment in a large tertiary care hospital: a systems-based mixed methods study.

OBJECTIVES: To generate system insights on patient and provider levers and strategies that must be activated to improve hospital-based smoking cessation treatment. DESIGN: Mixed methods study including a series of in-depth group model building sessions, which informed the design of an online survey completed by healthcare providers and a structured interview protocol administered at the bedside to patients who smoke. SETTING: Large, tertiary care hospital in the Midwestern United States. PARTICIPANTS: Group model building: 28 healthcare providers and 22 previously-hospitalised patients; Online survey: 308 healthcare providers; Bedside interviews: 205 hospitalised patients. PRIMARY AND SECONDARY OUTCOME MEASURES: Hypothesis-generating, participatory qualitative methods informed the examination of the following quantitative outcomes: patient interest versus provider perception of patient interest in smoking cessation and treatment; patient-reported receipt versus provider-reported offering of inpatient smoking cessation interventions; and priority ratings of importance and feasibility of strategies to improve treatment. RESULTS: System insights included patients frequently leaving the floor to smoke, which created major workflow disruption. Leverage points included interventions to reduce withdrawal symptoms, and action ideas included nurse-driven protocols for timely administration of nicotine replacement therapy. Quantitative data corroborated system insights; for instance, 80% of providers reported that patients frequently leave the floor to smoke, leading to safety risks, missed assessments and inefficient use of staff time. Patients reported significantly lower rates of receiving any smoking cessation interventions, compared with provider reports (mean difference=17.4%-33.7%, p<0.001). Although 92% of providers cited patient interest as a key barrier, only 4% of patients indicated no interest in quitting or reducing smoking. CONCLUSIONS: Engaging hospital providers and patients in participatory approaches to develop an implementation strategy revealed discrepant perceptions of patient interest and frequency of hospital-based treatment for smoking. These findings spurred adoption of standardised point-of-care treatment for cigarette smoking, which remains highly prevalent yet undertreated among hospitalised patients.

A community-based system dynamics approach suggests solutions for improving healthy food access in a low-income urban environment.

Little is known about the mechanisms through which neighborhood-level factors (e.g., social support, economic opportunity) relate to suboptimal availability of healthy foods in low-income urban communities. We engaged a diverse group of chain and local food outlet owners, residents, neighborhood organizations, and city agencies based in Baltimore, MD. Eighteen participants completed a series of exercises based on a set of pre-defined scripts through an interactive, iterative group model building process over a two-day community-based workshop. This process culminated in the development of causal loop diagrams, based on participants' perspectives, illustrating the dynamic factors in an urban neighborhood food system. Synthesis of diagrams yielded 21 factors and their embedded feedback loops. Crime played a prominent role in several feedback loops within the neighborhood food system: contributing to healthy food being "risky food," supporting unhealthy food stores, and severing social ties important for learning about healthy food. Findings shed light on a new framework for thinking about barriers related to healthy food access and pointed to potential new avenues for intervention, such as reducing neighborhood crime.

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.

Assessment of progress towards universal health coverage for people with disabilities in Afghanistan: a multilevel analysis of repeated cross-sectional surveys.

BACKGROUND: Since 2002, Afghanistan has made much effort to achieve universal health coverage. According to the UN Sustainable Development Goal 3, target eight, the provision of quality care to all must include usually underserved groups, including people with disabilities. We investigated whether a decade of international investment in the Afghan health system has brought quality health care to this group. METHODS: We used data from two representative household surveys, one done in 2005 and one in 2013, in 13 provinces of Afghanistan, that included questions about activity limitations and functioning difficulties, socioeconomic factors, perceived availability of health care, and experience with coverage of health-care needs. We used multilevel modelling and tests for interaction to investigate factors associated with differences in perception between timepoints and whether village remoteness affected changes in perception. FINDINGS: The 2005 survey included 334 people, and the 2013 survey included 961 people. Mean age, employment, and asset levels of participants with disabilities increased slightly between 2005 and 2013, but the level of education decreased. Formal education and higher asset level were associated with improved availability of health care and positive experience with coverage of health-care needs, whereas being employed was only associated with the latter. Perceived availability of health care and positive experience with coverage of health-care needs significantly worsened in 2013 compared with in 2005 (227 [69%] perceived that services were available in 2005 vs 405 [44%] in 2013, p<0·0001; 255 [78%] perceived a positive experience in 2005 vs 410 [45%] in 2013, p<0·0001). Village remoteness increased in 2013 (no connectivity by paved road 186 [57%] in 2005 vs 797 [87%] in 2013, p<0·0001; mean time to reach health-care facility 64·3 min [SD 167·7] vs 84·4 min [107·7], p<0·0001) and negatively affected perception of health-care availability. INTERPRETATION: Perceived availability of health care and experience with health-care coverage have not greatly improved for people with disabilities in Afghanistan, particularly in remote areas. Health policy in Afghanistan will need to address attitudinal, social, and accessibility barriers to health care. FUNDING: Swedish International Development Agency.

Conceptualizing Productive Engagement in a System Dynamics Framework.

Gerontologists have argued that the growing human capital of the aging population can be better marshaled as a resource for families, communities, and society at large. Additionally, this active, purposeful engagement can produce positive outcomes for older adults themselves. In this manuscript, we propose that existing conceptual frameworks articulating antecedents and outcomes of productive engagement, including working, volunteering, and caregiving can be improved using a system dynamics (SD) approach. Through a series of five unstructured group model-building sessions, experts from gerontology and systems science developed a qualitative SD model of the productive engagement of older adults. The model illustrates the reciprocal and dynamic nature of the stocks of human capital of older adults, social capital of older adults, and family resources; the engagement of older adults in productive activities; and the social and organizational variables that affect the flow and depletion of these stocks. Given this is the first attempt to develop a SD model for productive engagement in later life, the model is preliminary and heuristic. However, it offers a new approach to advancing theory and research on productive engagement in later life. Further, it can guide the development of mathematical models to estimate the effects of changes in any part of this system.

Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan.

BACKGROUND: Afghanistan lacks suitable specialized mental healthcare services despite high prevalence of severe mental health disorders which are aggravated by the conflict and numerous daily stressors. Recent studies have shown that Afghans with mental illness are not only deprived of care but are vulnerable in many other ways. Innovative participatory approaches to the design of mental healthcare policies and programs are needed in such challenging context. METHODS: We employed community based system dynamics to examine interactions between multiple factors and actors to examine the problem of persistently low service utilization for people with mental illness. Group model building sessions, designed based on a series of scripts and led by three facilitators, took place with NGO staff members in Mazar-I-Sharif in July 2014 and in Kabul in February 2015. RESULTS: We identified major feedback loops that constitute a hypothesis of how system components interact to generate a persistently low rate of service utilization by people with mental illness. In particular, we found that the interaction of the combined burdens of poverty and cost of treatment interact with cultural and social stigmatizing beliefs, in the context of limited clinical or other treatment support, to perpetuate low access to care for people with mental disorders. These findings indicate that the introduction of mental healthcare services alone will not be sufficient to meaningfully improve the condition of individuals with mental illness if community stigma and poverty are not addressed concurrently. CONCLUSIONS: Our model highlights important factors that prevent persons with mental illness from accessing services. Our study demonstrates that group model building methods using community based system dynamics can provide an effective tool to elicit a common vision on a complex problem and identify shared potential strategies for intervention in a development and global health context. Its strength and originality is the leadership role played by the actors embedded within the system in describing the complex problem and suggesting interventions.

Stigma of persons with disabilities in Afghanistan: Examining the pathways from stereotyping to mental distress.

Despite evidence that stigma of disability is frequently reflected through stereotyping and often results in mental distress, very limited literature demonstrates the pathways through which stereotyping has an impact on mental health. Drawing from a large sample of 1449 participants interviewed between December 2012 and September 2013 from an Afghan community-based rehabilitation program, we examined the structure of stigma associated with disability in Afghanistan. Labeling and negative stereotypes, associated with a specific cause of disability, result in social exclusion that in turn impacts mental health. Using structural equation modeling with latent variables, we examined the mediation effect of stereotypes associated with disability on mental distress and anxiety. We found a mediating role of social exclusion between stereotypes and mental distress but only in the case of persons with disabilities from birth. Comparing the total effect of 'disabled at birth' and mental distress 0.195 (95% CI: 0.018-0.367) the effect size of this mediation effect was 0.293 (95% CI: 0.173-0.415). There was no significant direct effect between 'disabled at birth' and mental distress once mediation effect was accounted for in our model. These findings suggest that a multipronged policy approach that recognizes the driving forces of stigma and promotes social participation directly alongside psychosocial interventions on mental distress of persons with disabilities is necessary to achieve wellbeing for a group that has been historically and systematically excluded from development interventions.