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The Maternal and Child Health workforce, public health practitioners, researchers, and other groups need clear, practical guidance on how to promote health equity in the communities they serve. The National Maternal and Child Health Workforce Development Center’s Health Equity Team synthesized eight approaches for promoting health equity that drew on their experience working with public health practitioners and communities. The approaches are to: Expand the understanding of the drivers of health and work across sectors; Take a systems approach; Reflect on your own organization; Follow the lead of communities who experience injustices; Work with community members, decision-makers, and other stakeholders to prioritize action; Foster agency within individuals and collective action within groups; Identify and collect data to show where health inequities currently exist to inform equitable investment of resources; and Be accountable to outcomes that reflect real improvements in people’s lives. The fields of maternal and child health and public health more broadly is already engaged in the complex work of promoting equity and social justice, and in doing so, should refine, challenge, add to, and build upon these approaches.

Purpose and Objectives The purpose of this article is to demonstrate and evaluate aspects of a Stakeholder-Driven Community Diffusion (SDCD)–informed intervention with a group of stakeholders drawn from a large coalition seeking a novel approach for promoting policy, systems, and environmental-level change. The objectives were to implement an SDCD intervention, assess changes in participants’ perspectives, and evaluate where the group’s actions fit within the context of a systems map that the group created during the intervention. Intervention Approach An SDCD-informed intervention convened 12 multisector stakeholders from the Early Ages Healthy Stages coalition in Cuyahoga County, Ohio. They participated in group model building activities to promote systems thinking related to childhood obesity prevention, reviewed evidence about topics of interest to the group, and were provided with technical assistance and seed funding to guide the selection and implementation of actions prioritized by the group. Evaluation Methods Data were collected via meeting notes and group model building outputs to demonstrate implementation and action prioritization; online surveys and qualitative interviews to measure perspective change among stakeholders; and a follow-up survey to the broader coalition assessing actions coalition members were taking. Results An SDCD-informed intervention guided the development of a systems map and the selection of 4 actions: 1) develop a better understanding of the local early childcare environment; 2) assess the effectiveness and impact of Ohio Healthy Programs (OHP); 3) advocate for OHP and improved early childhood education quality; and 4) hold OHP designees accountable to high-quality programming. Data collected from surveys and interviews showed increased awareness of programs, resources, and collaboration opportunities among stakeholders. Follow-up survey results showed ongoing coalition action throughout the systems map. Implications for Public Health Using an SDCD-informed intervention among a coalition of community stakeholders provided a unique approach for implementing, assessing, and analyzing collaborative efforts to prevent childhood obesity in Cuyahoga County. Our approach can be applied to help researchers and stakeholders improve efforts to address childhood obesity in their communities.

Objective This study aimed to (1) identify mechanistic model structures that produced quality fit to historic obesity prevalence trends and (2) evaluate the sensitivity of future obesity prevalence to social transmission and nonsocial parameters. Methods An age- and gender-structured compartmental model was used to describe transitions between weight status groups. Four model structures with different combinations of social transmission and nonsocial mechanisms were calibrated to match historic time series and assessed for quality of fit. Projections of overall obesity prevalence to 2052 were simulated, and sensitivity analyses were conducted. Results The model structure that included only nonsocial mechanisms indicated that the overall obesity prevalence in the United States has already stabilized and will increase little more; however, it underestimated observed obesity prevalence since 2013. If social transmission mechanisms influence obesity, the model estimated continued increases in obesity prevalence, reaching 48.0% to 55.1% by 2050. Obesity prevalence was most sensitive to changes in the adult social transmission parameters, especially among women. Conclusions The model projected that US obesity prevalence in the overall population will likely continue to increase for decades. The findings that obesity prevalence was most sensitive to adult parameters can be used to inform conversations about priorities for public health and health care programs and policies.

Objective To describe our process of using group model building (GMB) with the Shape Up Under 5 Committee; measure the effects on Committee members; and describe the community-wide health messaging campaign that resulted from the process. Design Pilot study. Setting Somerville, Massachusetts. Participants Members of the Shape Up Under 5 Committee, a multisector group of professionals. Intervention Research team convened the Committee and facilitated GMB from October 2015 to June 2017. Main outcome measures Boundary objects produced during GMB activities; committee members' perspectives on early childhood obesity in their community; and Committee members' knowledge, engagement, and trust at the conclusion of each meeting. Results Working together using GMB activities and with support from the research team, the Committee created a community-wide campaign that provided evidence-based messages to reach an entire city that emphasized diversity and reaching immigrants and community members who spoke languages other than English. More than 80% of Committee members reported changes in their perspectives related to early childhood obesity at the conclusion of the pilot test. Six perspective shift themes emerged from interviews and open-ended survey items: exposure to new perspectives about challenges community members face; increased awareness of others working on similar issues; increased knowledge about early childhood obesity; seeing value in creating a space to work across sectors; appreciating complexity and linkages between early childhood obesity prevention and other community issues; and how participation in committee influences members' priorities in their own work. Knowledge of and engagement with early childhood obesity prevention varied at the conclusion of each meeting, as did increases in trust among Committee members. Conclusion Group model building is a promising approach to support multisector groups working to address early childhood obesity in their community. Meeting activities may have had differential impacts on members' knowledge of and engagement with early childhood obesity.

The sustained multi-decade increase in the prevalence of obesity calls for a new approach on addressing this public health concern. The Roundtable on Obesity Solutions (ROOS) (of the National Academies of Sciences, Engineering, and Medicine NASEM), a multisector group comprised of members from a variety of organizations and institutions, initiated a year-long effort to build a strategic plan and roadmap for action that would drive a paradigm shift for the ROOS in pursuing obesity solutions. Following a review of obesity prevention and treatment recommendations with sufficient actionable-evidence by authoritative organizations, the ROOS deployed systems science methods. Members engaged in group model building (GMB) exercises to develop an obesity systems map based on determinants and drivers from a multi-sector perspective and overlaid with aligned solutions. To expand the understanding of systems science approaches and methods, 3 public workshops were held in tandem with the development of the map. The causal map was refined, and solutions were ranked using a leverage-point framework to inform a strategic plan and narrative roadmap for action. For the ROOS, structural racism and social justice, biased mental models and social norms, and effective health communications were prioritized as the leverage points most likely to have a significant impact in addressing obesity. Complementary to the mission, vision, and guiding principles of the ROOS, the obesity systems map, and narrative roadmap will drive the ROOS activities over the next 3-6 years and serve as a resource for researchers, organizations, and institutions involved with policy, prevention, and treatment of obesity.

Evidence of the effectiveness of community-based lifestyle behavior change interventions among African-American adults is mixed. We implemented a behavioral lifestyle change intervention, Heart Matters, in two rural counties in North Carolina with African-American adults. Our aim was to evaluate the effect of Heart Matters on dietary and physical activity behaviors, self-efficacy, and social support. We used a cluster randomized controlled trial to compare Heart Matters to a delayed intervention control group after 6 months. A total of 143 African-American participants were recruited and 108 completed 6-month follow-up assessments (75.5%). We used mixed regression models to evaluate changes in outcomes from baseline to 6-month follow-up. The intervention had a significant positive effect on self-reported scores of encouragement of healthy eating, resulting in an increase in social support from family of 6.11 units (95% CI [1.99, 10.22]) (p < .01). However, intervention participants also had an increase in discouragement of healthy eating compared to controls of 5.59 units (95% CI [1.46, 9.73]) among family (p < .01). There were no significant differences in changes in dietary behaviors. Intervention participants had increased odds (OR = 2.86, 95% CI [1.18, 6.93]) of increased frequency of vigorous activity for at least 20 min per week compared to control participants (p < .05). Individual and group lifestyle behavior counseling can have a role in promoting physical activity levels among rural African-American adults, but more research is needed to identify the best strategies to bolster effectiveness and influence dietary change. Trial Registration: Clinical Trials, NCT02707432. Registered 13 March 2016.

OBJECTIVES: Community efforts to improve access to nutritious foods are one strategy to reduce food insecurity, promote healthy eating, and prevent diet-related chronic diseases. Food policy councils (FPCs) can facilitate relationships between food systems players and implementation of local policy efforts to increase access to healthier foods. This study examined associations between FPCs with local policy supports for healthy food access. METHODS: We used data from CDC's 2014 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living, a nationally representative survey of U.S. municipalities with population ≥1000 (n = 2029). We calculated the prevalence of FPCs, overall and by municipal characteristics including population size, census region, rural/urban status, poverty prevalence, median education level, and racial/ethnic composition. We used multivariable logistic regression to examine cross-sectional associations between FPCs and four types of supports for healthy food access (approaches to help open or improve food stores; practices to support farmers markets; transportation-related supports; and community planning documents). RESULTS: Overall, 7.6% of municipalities reported having a local or regional FPC. FPCs were reported more frequently among larger municipalities with ≥50,000 people (29.2%, 95% confidence interval (CI): 21.6–36.8) compared to smaller municipalities (4.3% for

Context The Maternal and Child Health (MCH) workforce aims to improve health outcomes for women, children, and families. The work requires coordination and partnerships that span disciplines and service systems. As such, workforce needs assessment requires an approach that is broad, flexible, and "systems-aware." Objective To illustrate the use of System Support Mapping, a novel systems thinking tool that was used to guide participants through a structured assessment of their discrete responsibilities, key needs, and specific resources required for each. Participants Thirty-four Title V MCH professionals and partners from 15 states or jurisdictions. Main outcome measure(s) Description and frequency of Title V MCH professionals' coded roles, responsibilities, needs, resources, and wishes. An aggregated map illustrating interconnections between identified codes is presented. Results State- and local-level MCH professionals reported a range of roles, responsibilities, needs, resources, and wishes. The most and least frequently reported roles, responsibilities, needs, resources, and wishes by state- and local-level MCH professionals are listed, as well as the most frequent connections between those responses. The most frequent responsibility reported in local maps was "link to or provide care or resources" (82%), whereas the most frequent responsibility reported in state maps was "system management" (65%). System management was indirectly connected to 3 wishes: "access to data or information," "funding or resources," and "collaboration, coordination, or support from community or other external organizations." Conclusions System Support Mapping can be used to support needs assessment with MCH professionals. System Support Maps show not only the most and least frequently reported roles, responsibilities, needs, resources, and wishes of participants but also how those responses are connected and potentially interdependent. System Support Maps may be useful for MCH leaders determining how best to organize their teams to take on complex public health challenges and prioritize improvements that will better support their work.

Background School meals have the potential to improve diet quality for millions of students across the United States. Objectives Evaluate the feasibility of the FAV5 program, which aims to strengthen school meals by increasing appeal of school meals and improving relationships within the team of child nutrition staff and with other staff/teachers at their schools. Methods Nutrition researchers facilitated partnerships between the following groups to develop and implement the FAV5 program: the child nutrition director (CND) and managers at seven elementary schools in a North Carolina county, teachers and principals at those schools, a chef, the North Carolina Department of Agriculture, and volunteers. Results The partnerships developed through the FAV5 program produced successful taste test events in seven elementary schools that generated enthusiasm around the school meals program and strengthened relationships. Conclusions Engaging child nutrition staff and other community partners to plan and implement the FAV5 program in schools is feasible.

Food policy councils (FPCs) are collaboratives that work to strengthen food systems. Over 300 FPCs exist in the United States, Canada, and Tribal Nations. In 2015, we surveyed the types of initia­tives FPCs undertook and identified food sector targets and domains of potential impact in an effort to inform comprehensive FPC impact assessments. FPCs (N=66) reported 317 policy, systems, and environmental initiatives. At least half of these were focused on food production, and many were focused on institutional food service and the food assistance sectors. Commercial food service, food processing, and food waste were less often the focus. Potential impacts of their initia­tives were classified into six domains: supporting resilient food systems (235, 74%); increasing access to healthy foods (171, 54%); supporting economic development (115, 36%); promoting equity in the food system (94, 30%); promoting environmental sustainability (82, 26%); and increasing knowledge of or demand for healthy foods (27, 9%). Many initiatives were likely to impact multiple domains.

In recent years, social entrepreneurship has emerged as a new field to address social and public health challenges. Social entrepreneurship, which harnesses traditional business practices and market forces to address social challenges, may produce solutions that are more cost-effective and sustainable than those produced by governmental and nonprofit sectors. In this paper, we discuss whether and how social entrepreneurship can be harnessed for obesity prevention by defining and briefly reviewing the rise of social entrepreneurship in the USA, outlining the threat that obesity poses to US society and offering some examples of how social ventures are addressing the problem of obesity. Additional untapped opportunities are also discussed and recommendations given for how social entrepreneurship might impact obesity prevention in the future.

Public health practitioners can use Behavior Over Time (BOT) graphs to spur discussion and systems thinking around complex challenges. Multiple large systems, such as health care, the economy, and education, affect chronic disease rates in the United States. System thinking tools can build public health practitioners' capacity to understand these systems and collaborate within and across sectors to improve population health. BOT graphs show a variable, or variables (y axis) over time (x axis). Although analyzing trends is not new to public health, drawing BOT graphs, annotating the events and systemic forces that are likely to influence the depicted trends, and then discussing the graphs in a diverse group provides an opportunity for public health practitioners to hear each other's perspectives and creates a more holistic understanding of the key factors that contribute to a trend. We describe how BOT graphs are used in public health, how they can be used to generate group discussion, and how this process can advance systems-level thinking. Then we describe how BOT graphs were used with groups of maternal and child health (MCH) practitioners and partners (N = 101) during a training session to advance their thinking about MCH challenges. Eighty-six percent of the 84 participants who completed an evaluation agreed or strongly agreed that they would use this BOT graph process to engage stakeholders in their home states and jurisdictions. The BOT graph process we describe can be applied to a variety of public health issues and used by practitioners, stakeholders, and researchers.

Problem Food Policy Councils (FPCs) are cross-sector collaborations that bring representatives from across the food system together to identify issues, coordinate programs, and inform policy. Little is known about how rural FPCs operate to influence food access in their communities. Purpose To explore how a rural FPC facilitates cross-sector partnerships and influences food system change through interviews with eight members of the Adam's County FPC. Results Connections developed through the FPC helped council members work more effectively in their home organizations. Four themes were discussed: council dynamics and structure; sharing resources, expertise, and information; promoting healthy food access through programs; and food policy opportunities and challenges. Conclusions This case study illustrates connections between FPC members in a rural county and identifies how FPCs can facilitate food system change in their communities. Improving our understanding of how rural FPCs function can help to advance the potential public health impact of councils.

At least 282 Food Policy Councils (FPCs) are currently working to improve access to healthy foods in their communities by connecting food system sectors, gathering community input, and advising food policy. Empirical research on FPCs is limited. This study empirically evaluates FPCs to better understand the relationships between Organizational Capacity, Social Capital, and Council Effectiveness by testing a FPC Framework adapted from Allen and colleagues (2012). Members of all FPCs in the U.S., Canada, and Native American Tribes and First Nations were invited to complete the Food Policy Council Self-Assessment Tool (FPC-SAT). Structural equation modeling was used to test the FPC Framework. Three hundred and fifty-four FPC members from 95 councils completed the FPC-SAT. After slight modification, a revised FPC Framework was a good fit with the data (χ2 = 40.085, df = 24, p-value = .021, comparative fit index = 0.988, Tucker Lewis index = 0.982, root mean squared error of approximation = 0.044, p-close = .650). A moderation analysis revealed that community context influences the relationship between Social Capital and Council Effectiveness within the FPC Framework. The FPC Framework can guide capacity building interventions and FPC evaluations. The empirically tested framework can help FPCs efficiently work toward achieving their missions and improving their local food system.

Food policy councils (FPCs) are a useful way for interested groups to work together to create mutually beneficial change within the food system. Often formed through grassroots organizing or commissioned by governmental entities, FPCs have been successful at tackling challenges within food systems by creating forums to address issues whose roots ordinarily are in disparate parts of these systems. Little peer-reviewed research exists, however, examining the formation of state-level FPCs, particularly among states known for their conventional production practices. In this case study, we explored the process of forming a statewide FPC in North Carolina from 2007 to 2009. The objectives were to (a) qualitatively exam­ine the two-year process of forming a statewide FPC in a traditional agriculture state, and (b) iden­tify the factors that led to its formation. To do so, we developed an in-depth interview guide for inter­viewing eight individuals, including government stakeholders, conventional agricultural producers, sustainable agricultural producers, philanthropists, and legal representatives. We used qualitative analy­sis methods to analyze the transcripts, drawing on John Kingdon’s agenda-setting and policy-formation theory to guide analysis. Results indi­cated that four factors drove the formation of the North Carolina state-level FPC: (1) stakeholder involvement, (2) diverse partnerships, (3) stake­holder ability to compromise, and (4) a conducive political setting. While the small sample size pre­vents us from causally interpreting our results and generalizing our findings, this preliminary research may provide insight for other states, especially those with a predominately traditional agriculture system, that are interested in forming state-level FPCs.

A large number of food policy councils (FPCs) exist in the United States, Canada, and Tribal Nations (N = 278), yet there are no tools designed to measure their members' perceptions of organizational capacity, social capital, and council effectiveness. Without such tools, it is challenging to determine best practices for FPCs and to measure change within and across councils over time. This study describes the development, testing, and findings from the Food Policy Council Self-Assessment Tool (FPC-SAT). The assessment measures council practices and council members' perceptions of the following concepts: leadership, breadth of active membership, council climate, formality of council structure, knowledge sharing, relationships, member empowerment, community context, synergy, and impacts on the food system. All 278 FPCs listed on the Food Policy Network's Online Directory were recruited to complete the FPC-SAT. Internal reliability (Cronbach's α) and inter-rater reliability (AD, rWG(J), ICC [intraclass correlations][1], ICC[2]) were calculated, and exploratory and a confirmatory factor analyses were conducted. Responses from 354 FPC members from 94 councils were used to test the assessment. Cronbach's α ranged from 0.79 to 0.93 for the scales. FPC members reported the lowest mean scores on the breadth of active membership scale (2.49; standard deviation [SD], 0.62), indicating room for improvement, and highest on the leadership scale (3.45; SD, 0.45). The valid FPC-SAT can be used to identify FPC strengths and areas for improvement, measure differences across FPCs, and measure change in FPCs over time.

The most threatening public health challenges today are chronic and complex and require joint effort from academic researchers in partnership with clinical and public health practitioners to identify and implement sustainable solutions that work in the real world. Practice-based research offers researchers and practitioners an underutilized way forward, an opportunity to work together to design and test feasible, evidence-based programs to address our greatest challenges. In this article, we outline the need for practice-based evidence, tools, and strategies that investigators can use to generate practice-based evidence, describe approaches to translating practice-based evidence into practice, and offer recommendations for making practice-based research the norm in public health.

Public health and other community-based practitioners have access to a growing number of evidence-based interventions (EBIs), and yet EBIs continue to be underused. One reason for this underuse is that practitioners often lack the capacity (knowledge, skills, and motivation) to select, adapt, and implement EBIs. Training, technical assistance, and other capacity-building strategies can be effective at increasing EBI adoption and implementation. However, little is known about how to design capacity-building strategies or tailor them to differences in capacity required across varying EBIs and practice contexts. To address this need, we conducted a scoping study of frameworks and theories detailing variations in EBIs or practice contexts and how to tailor capacity-building to address those variations. Using an iterative process, we consolidated constructs and propositions across 24 frameworks and developed a beginning theory to describe salient variations in EBIs (complexity and uncertainty) and practice contexts (decision-making structure, general capacity to innovate, resource and values fit with EBI, and unity vs. polarization of stakeholder support). The theory also includes propositions for tailoring capacity-building strategies to address salient variations. To have wide-reaching and lasting impact, the dissemination of EBIs needs to be coupled with strategies that build practitioners’ capacity to adopt and implement a variety of EBIs across diverse practice contexts.

Background Numerous agencies are providing training, technical assistance, and other support to build community-based practitioners’ capacity to adopt and implement evidence-based prevention interventions. Yet, little is known about how best to design capacity-building interventions to optimize their effectiveness. Wandersman et al. (Am J Community Psychol.50:445–59, 2102) proposed the Evidence-Based System of Innovation Support (EBSIS) as a framework to guide research and thereby strengthen the evidence base for building practitioners’ capacity. The purpose of this review was to contribute to further development of the EBSIS by systematically reviewing empirical studies of capacity-building interventions to identify (1) the range of strategies used, (2) variations in the way they were structured, and (3) evidence for their effectiveness at increasing practitioners’ capacity to use evidence-based prevention interventions. Methods PubMed, EMBASE, and CINAHL were searched for English-language articles reporting findings of empirical studies of capacity-building interventions that were published between January 2000 and January 2014 and were intended to increase use of evidence-based prevention interventions in non-clinical settings. To maximize review data, studies were not excluded a priori based on design or methodological quality. Using the EBSIS as a guide, two researchers independently extracted data from included studies. Vote counting and meta-summary methods were used to summarize findings. Results The review included 42 publications reporting findings from 29 studies. In addition to confirming the strategies and structures described in the EBSIS, the review identified two new strategies and two variations in structure. Capacity-building interventions were found to be effective at increasing practitioners’ adoption (n = 10 of 12 studies) and implementation (n = 9 of 10 studies) of evidence-based interventions. Findings were mixed for interventions’ effects on practitioners’ capacity or intervention planning behaviors. Both the type and structure of capacity-building strategies may have influenced effectiveness. The review also identified contextual factors that may require variations in the ways capacity-building interventions are designed. Conclusions Based on review findings, refinements are suggested to the EBSIS. The refined framework moves the field towards a more comprehensive and standardized approach to conceptualizing the types and structures of capacity-building strategies. This standardization will assist with synthesizing findings across studies and guide capacity-building practice and research. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0272-7) contains supplementary material, which is available to authorized users.

Introduction Residents of rural communities in the United States are at higher risk for obesity than their urban and suburban counterparts. Policy and environmental-change strategies supporting healthier dietary intake can prevent obesity and promote health equity. Evidence in support of these strategies is based largely on urban and suburban studies; little is known about use of these strategies in rural communities. The purpose of this review was to synthesize available evidence on the adaptation, implementation, and effectiveness of policy and environmental obesity-prevention strategies in rural settings. Methods The review was guided by a list of Centers for Disease Control and Prevention Recommended Community Strategies and Measurements to Prevent Obesity in the United States, commonly known as the “COCOMO” strategies. We searched PubMed, Cumulative Index of Nursing and Allied Health Literature, Public Affairs Information Service, and Cochrane databases for articles published from 2002 through 2013 that reported findings from research on nutrition-related policy and environmental strategies in rural communities in the United States and Canada. Two researchers independently abstracted data from each article, and resolved discrepancies by consensus. Results Of the 663 articles retrieved, 33 met inclusion criteria. The interventions most commonly focused on increasing access to more nutritious foods and beverages or decreasing access to less nutritious options. Rural adaptations included accommodating distance to food sources, tailoring to local food cultures, and building community partnerships. Conclusions Findings from this literature review provide guidance on adapting and implementing policy and environmental strategies in rural communities.

Background Heart Healthy Lenoir is a transdisciplinary project aimed at creating long-term, sustainable approaches to reduce cardiovascular disease risk disparities in Lenoir County, North Carolina using a design spanning genomic analysis and clinical intervention. We hypothesized that residents of Lenoir County would be unfamiliar and mistrustful of genomic research, and therefore reluctant to participate; additionally, these feelings would be higher in African-Americans. Methodology To test our hypothesis, we conducted qualitative research using community-based participatory research principles to ensure our genomic research strategies addressed the needs, priorities, and concerns of the community. African-American (n = 19) and White (n = 16) adults in Lenoir County participated in four focus groups exploring perceptions about genomics and cardiovascular disease. Demographic surveys were administered and a semi-structured interview guide was used to facilitate discussions. The discussions were digitally recorded, transcribed verbatim, and analyzed in ATLAS.ti. Results and Significance From our analysis, key themes emerged: transparent communication, privacy, participation incentives and barriers, knowledge, and the impact of knowing. African-Americans were more concerned about privacy and community impact compared to Whites, however, African-Americans were still eager to participate in our genomic research project. The results from our formative study were used to improve the informed consent and recruitment processes by: 1) reducing misconceptions of genomic studies; and 2) helping to foster participant understanding and trust with the researchers. Our study demonstrates how community-based participatory research principles can be used to gain deeper insight into the community and increase participation in genomic research studies. Due in part to these efforts 80.3% of eligible African-American participants and 86.9% of eligible White participants enrolled in the Heart Healthy Lenoir Genomics study making our overall enrollment 57.8% African-American. Future research will investigate return of genomic results in the Lenoir community.