In February PAPREN was excited to host David Dzewaltowski, PhD, for Comparing Designs for Whole-Community Physical Activity Systems: Wellscapes Randomized Trial. Dr. Dzewaltowski is Professor and Community Chair for Physical Activity, Nutrition, and Obesity in the College of Public Health, University of Nebraska Medical Center. With continuous federal funding since 1999, his research team has made scientific contributions in health behavior theory, setting influences on physical activity and nutrition, and cluster randomized trials examining system interventions to improve school and out-of-school settings. You can access the recording here and his slides here.
Dr. Dzewaltowski graciously agreed to provide responses to questions we couldn’t get to during the Q&A.
Last summer on a bike trip I noticed a big difference between towns in the Midwest with a community pool and without – are there other infrastructure features that influence and reflect community characteristics?
There is considerable literature on how to describe variability in community infrastructure. We have been drawing from the Community Capitals Framework, that has had widespread use in other fields. For example, the World Bank Social Development group uses the Community Capitals Framework for its coalition toolkit on building community resilience for climate change. This Framework categorizes resources into natural, cultural, human, social, political, financial, and built. Cornelia Flora, a developer of the Framework, was a consultant on our project. The principle for our work is to draw on these existing community assets to build solutions. This asset approach to infrastructure contrasts with needs-based methods that require significant unsustainable inputs into communities to deliver some one-size-fits-all program.
How was equity embedded as a lens to explain inequitable structural (policy, practices, resource allocations) and relational/power level implementation factors and potential effects of community system inequities affecting physical activity disparities?
Health promotion has made equity a central goal. We need greater attention to work building on the literature on the social, economic, and political system defining what equity is and what structures and processes lead to inequities. The CDC defines equity as the state in which everyone has a fair and just opportunity to attain their highest level of health. Our whole-community system intervention has three components based on process control theory: (1) a Community hub coalition of stakeholders, (2) a community data and feedback system, and (3) a community development process. Equity is embedded within all of these components.
For the Community Hub, the goal is for the local community to create a system of people who interact with the target audience and are representative of the target audience. The Hub is given the charge to promote physical activity in all kids. We use the term “all” strategically to raise attention to the problem. The Hub also maps the system and the people who make decisions within the system in the delivery of community physical activity services. While this is presented as a method for understanding how to create change, the process illuminates power relations.
For the data system, we disaggregate data by SES, race/ethnicity, and gender and provide that information in a way for people to understand what is happening locally to create disparities.
Finally, one of our innovations is a local rapid cycle improvement process we call Investigate, Design, Practice, Reflect (IDPR). The key difference between IDPR and the typical Plan, Do, Study, Act (PDSA) process is the community begins with investigate. By investigation, an understanding the local system producing disparities is front and center.
I’m struck that both your study conditions include use of data by community coalitions to prioritize action. Can you speak to the readiness of these diverse groups to buy into the concept of role of data in decision-making and to actually understand and utilize data? Did the conditions include any components related to this?
There is a need for health promotion to draw from the existing literature and contribute new knowledge on how to make data more valuable and understandable and how to build the capacity of local coalitions to use data in decision-making. The Collective Impact Model, in its original form, is a community version of an industry quality improvement process where data is used for planning and accountability. Wellscapes is a community-driven development model where data informs local entrepreneurship.
My anecdotal evidence is that people on the coalition are used to data. Everyone uses different data systems to make choices about movies or restaurants. In rural communities, every teacher sees data and is tired of schools being ranked by standardized test scores into categories for quality improvement. Healthcare professionals now see dashboards in their daily work. Youth sport coaches see sports analytics weekly at least in the role as a fan and at best in the role of a coach who is using one of the commercially available youth sport systems like Hudl. So, the problem isn’t getting people to buy into data. The problem is to provide data that has utility to improve decision-making.
We develop community reports and are working on making those reports useful for decision-making rather than just data. Much of the secondary data sources used in community planning are at a scale that is too large to be useful. State data doesn’t drive community decisions well. Also, we don’t use standard system science methods like social networking or agent-based modeling. For example, the Hub maps the social system qualitatively and that is more useful for decision making. Finally, because Wellscapes uses data for building something with local ownership rather than accountability, the process of using data is immediately perceived differently. We are working on including more coalition defined local indicators to build on that premise.