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Systems Thinking in 49 Communities Related to Healthy Eating, Active Living, and Childhood Obesity

Brennan, Laura K. PhD, MPH; Sabounchi, Nasim S. PhD; Kemner, Allison L. MPH; Hovmand, Peter PhD

Journal of Public Health Management and Practice: May/June 2015 - Volume 21 - Issue - p S55–S69
doi: 10.1097/PHH.0000000000000248
Original Articles

Background: Community partnerships to promote healthy eating and active living in order to prevent childhood obesity face a number of challenges. Systems science tools combined with group model–building techniques offer promising methods that use transdisciplinary team-based approaches to improve understanding of the complexity of the obesity epidemic. This article presents evaluation methods and findings from 49 Healthy Kids, Healthy Communities sites funded to implement policy, system, and environmental changes from 2008 to 2014.

Methods: Through half-day group model–building sessions conducted as part of evaluation site visits to each community between 2010 and 2013, a total of 50 causal loop diagrams were produced for 49 communities (1 community had 2 causal loop diagrams representing different geographic regions). The analysis focused on the following evaluation questions: (1) What were the most prominent variables in the causal loop diagrams across communities? (2) What were the major feedback structures across communities? (3) What implications from the synthesized causal loop diagram can be translated to policy makers, practitioners, evaluators, funders, and other community representatives?

Results: A total of 590 individuals participated with an average of 12 participants per session. Participants' causal loop diagrams included a total of 227 unique variables in the following major subsystems: healthy eating policies and environments, active living policies and environments, health and health behaviors, partnership and community capacity, and social determinants. In a synthesized causal loop diagram representing variables identified by at least 20% of the communities, many feedback structures emerged and several themes are highlighted with respect to implications for policy and practice as well as assessment and evaluation.

Conclusions: The application of systems thinking tools combined with group model–building techniques creates opportunities to define and characterize complex systems in a manner that draws on the authentic voice of residents and community partners.

Supplemental Digital Content is Available in the Text.This article presents evaluation methods and findings from 49 Healthy Kids, Healthy Communities sites funded to implement policy, system, and environmental changes to promote healthy eating and active living and to prevent childhood obesity.

Transtria LLC, St Louis, Missouri (Dr Brennan and Ms Kemner); and Social Systems Design Lab, Brown School of Social Work and Public Health, Washington University in St Louis, St Louis, Missouri (Drs Sabounchi and Hovmand).

Correspondence: Laura K. Brennan, PhD, Transtria LLC, 6514 Lansdowne Ave, St Louis, MO 63109 (

Support for this evaluation was provided by a grant from the Robert Wood Johnson Foundation (#67099). The authors are grateful for the collaboration with and support from the Robert Wood Johnson Foundation (Laura Leviton, PhD; and Tina Kauh, PhD), the Washington University Institute for Public Health (Ross Brownson, PhD), the Healthy Kids, Healthy Communities (HKHC) National Program Office (Casey Allred; Rich Bell, MCP; Phil Bors, MPH; Mark Dessauer, MA; Fay Gibson, MSW; Joanne Lee, LDN, RD, MPH; Mary Beth Powell, MPH; Tim Schwantes, MPH, MSW; Sarah Strunk, MHA; and Risa Wilkerson, MA), the HKHC Evaluation Advisory Group (Geni Eng, DrPH, MPH; Leah Ersoylu, PhD; Laura Kettel Khan, PhD; Vikki Lassiter, MS; Barbara Leonard, MPH; Amelie Ramirez, DrPH, MPH; James Sallis, PhD; and Mary Story, PhD), the Social System Design Lab at Washington University in St Louis, the University of Memphis (Daniel Gentry, PhD), and participating representatives from all 49 community partnerships. Special thanks to the many individuals who have contributed to these efforts from Transtria LLC, including past and present evaluation officers (Tammy Behlmann, MPH; Kate Donaldson, MPH; Cheryl Carnoske, MPH; Carl Filler, MSW; Peter Holtgrave, MPH, MA; Christy Hoehner, PhD, MPH; and Jessica Stachecki, MSW, MBA), project assistants (James Bernhardt; Rebecca Bradley; Ashley Crain, MPH; Emily Herrington, MPH; Ashley Farell, MPH; Amy Krieg; Brandye Mazdra, MPH; Kathy Mora, PhD; Jason Roche, MPH; Carrie Rogers, MPH; Shaina Sowles, MPH; Muniru Sumbeida, MPH, MSW; Caroline Swift, MPH; Gauri Wadhwa, MPH; and Jocelyn Wagman, MPH), additional staff (Michele Bildner, MPH, CHES; Daedra Lohr, MS; and Melissa Swank, MPH), interns (Christine Beam, MPH; Skye Buckner-Petty, MPH; Maggie Fairchild, MPH; Mackenzie Ray, MPH; and Lauren Spaeth, MS), and transcriptionists (Sheri Joyce; Chad Lyles; Robert Morales; and Vanisa Verma, MPH).

The authors declare no conflicts of interest.

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