Denver Public Health facilitated 1 of 49 community partnerships participating in the national Healthy Kids, Healthy Communities (HKHC) program of the Robert Wood Johnson Foundation (www.healthykidshealthycommunities.org) during 2009-2013. The purpose of the HKHC national program was to implement active living and healthy eating policy, system, and environmental change strategies to support healthier communities for children and families, with special emphasis on reaching children at greatest risk for obesity based on race, ethnicity, income, or geographic location. Active Living By Design served as the HKHC National Program Office, which provided overall direction and technical assistance for the initiative. As part of the Evaluation of Healthy Kids, Healthy Communities funded by the Robert Wood Johnson Foundation, one method of evaluation was to introduce systems thinking at the community level by identifying the essential parts of the Denver partnership system and how the system influences policy and environmental changes to promote active living, healthy eating and to prevent childhood obesity. Ten community partners and residents participated in a group model-building (GMB) session designed by staff from Transtria LLC and the Social System Design Lab at Washington University in St Louis, Missouri.1
Outcomes of the Denver partnership included increased access to healthy food through implementation of a community garden, urban farm, and grocery store. Increased access to active living was achieved through support of the Denver Bike Share program to reach low-income residents, renovated and developed park space, and implementation of walking and biking amenities. Economic, language, culture, limited access to affordable fresh fruit and vegetables, safe parks and recreation facilities, and reliable, consistent transportation are some of the challenges faced by residents. Partners contributed a focus on ensuring resident engagement in planning and decision making.
This article explains systems-thinking approaches that were applied specifically to improving park space access in West Denver. Its intent is to familiarize readers with the benefits of using such approaches to improve outcomes of increasing physical activity behavior through access to park space.
Design and recruitment
Key members were invited to participate in a half-day GMB workshop to create behavior-over-time graphs and a causal loop diagram. A behavior-over-time graph is a workshop participant–designed graph identifying an influence affecting policy system and environmental changes in Denver related to active living, healthy eating and childhood obesity and illustrates how the influences have changed over time (past, present, and future). A causal loop diagram examines the relationships among the variables from the behavior-over-time graphs. Workshop facilitators work together with participants to create the causal loop diagram.2 These activities were meant to build on the Denver partnership's work by identifying factors that affect or are affected by policy, system, and environmental changes that influence active living, healthy eating or childhood obesity.
Partnership members were recruited by the Project Coordinator to participate in the Workshop Organization representatives and residents participated. Organizations representing residents, especially the disparate populations, fully participated. Organization and agency type included community, urban agriculture, sustainable food policy council, government, and housing. The session was held at a local recreation center located in 1 of the 7 focus neighborhoods.
Group model-building methods
The facilitators explained 2 activities of the GMB process: the behavior-over-time graphs designed to gather participants perspectives of how the community has changed over time related to active living and healthy eating (eg, the number of farms and gardens has increased over the last 5 years), and the causal loop diagram exercise that identified themes from the behavior-over-time graph exercise and participants discussed the causal connections and relationships between the themes. Participants identified a range of things that affect or are affected by policy, system, and environmental changes in Denver related to active living, healthy eating and childhood obesity. Examples included amount of gulch (a ravine marking the course of water drainage) park space renovated; number of farms and gardens; city budget allocation for active living and healthy eating activities/organizations; number of kids walking and biking; childhood obesity; equitable, sustainable, and practical development in Denver; partnership collaboration; median household income in Southwest Denver; and zoning allowing urban agriculture. Discussion occurred about the diagram and participants provided feedback on how it reflected barriers and facilitators to the environmental change goals to increase access to active living and healthy eating of the partnership. Participants also provided feedback on how GMB can inform planning, strategy, and work plan development (Figure).
The behavior-over-time graphs reflected many of the environmental change goals of the partnership to increase access to healthy food and safe places to be active in West Denver. Participants also captured safety concerns related to being active on streets and in park spaces, especially those with gulch park space. Insights gained through the GMB process included that the gulch park space in West Denver is an opportunity to increase physical activity and recreation space. The gulch park spaces are underutilized because of the perception they are unsafe, water quality and flooding issues, lack of visibility in some areas, poor maintenance, and lack of amenities. Leveraging funds and prioritizing West Denver gulch park space were a focus of the Denver work. The problem of underutilization is anticipated to persist if the perception of lack of safety is not addressed.
As a result of GMB, the partnership acknowledged these issues and involved residents and organizations in 3 ways to begin to dialogue about the potential for Weir Gulch park space to be a safe, attractive, and popular place for families to recreate. The development of safe parks will increase environments for kids to be physically active (outside) and support opportunities for youth to meet the recommended physical activity standards.
The GMB process created a visual diagram representing the multiple and complex variables that impact their active living and healthy eating. Using gulch park space as an example, participants captured the relationship social determinants have with determining health outcomes. Participants gained greater awareness of the complex factors involved with changing behavior. Participants considered how efforts can be tailored to address aspects not previously considered. In addition, residents saw a high-level view of the goal to reduce childhood obesity, with all the efforts being interrelated and each small effort or behavior linked in some way to each other and the larger goal. For example, the perception of safety was very significant to the relationship of renovating gulch park space that has potential to increase the behavior of the number of kids walking and biking. Participants were more aware of the influence of safety and had to consider how to be sensitive to the perception of safety in gulch park spaces. Processes to address community safety concerns and include community input within West Denver gulch park space renovations were piloted. Three important relationship insights were gained through this experience. First, the expansion of well-maintained and developed parks increases physical activity; second, perceptions of parks and gulch park spaces strongly influence the use for walking, bicycling, and playing; third, enhanced perception of gulch park space as routes to destinations can decrease driving trips. Recognition and discussion of the relationship insights earlier in the planning process may have triggered different approaches earlier in the work. Partners recommend using these systems approaches early in the planning process to shape the goals and strategies of a community-driven work plan.
Group model building assisted the partnership in elevating and addressing relationships and dynamics within the parks efforts. In addition, it was able to increase the attention of high-level leadership to social determinants and conditions not typically considered barriers to health. Community initiatives that utilize GMB can probe these causal relationships further to address root issues that may be unforeseen barriers or limitations to active living and healthy eating policy, system, and environment works. Finally, the GMB process reinforced that the community must be meaningfully involved. A few challenges occurred with the GMB workshop. The session occurred more than 3 years into the grant cycle. Also, because of being held during the middle of the day, it did not allow for participation from working family residents or those requiring childcare. The workshop had 10 participants. Without increased participation, the causal relationships are only assumptions and these assumptions need to be confirmed, checked, and rechecked within the community.
Next steps include integration of GMB with ongoing efforts to engage community partners. As a result of the 2008 Public Health Act, SB08-194, Denver Public Health and Environmental Health has launched a 5-year plan to reduce childhood obesity. The causal loop diagram specific to West Denver can be considered and reflected on for the 5-year plan to ensure consideration of these variables.