Informing the Process of the Collective-Efficacy-Mechanism-to-Action Model through Analysis of a Multilevel, Multisite Intervention: The Children's Healthy Living Program

Abstract

Interventions to reduce health disparities should target organizations, communities, and policy, plus individuals and families. Community collective efficacy (CE), defined as social cohesion combined with willingness to act/intervene, has potential to affect health outcomes. Place-based relationships are central to CE, as social cohesion is built through social bonding, social bridging, and social leveraging. CE involves citizen empowerment and civic engagement, preparing citizens to act to address organizational, community, and policy issues. However, there is a lack of pathway clarity by which CE is strengthened in community interventions aiming for multilevel change. In this dissertation, the Collective Efficacy Mechanism to Action Model (CE MAM) is proposed to fill this gap. The model is tested using Children’s Healthy Living (CHL) program data, which aimed to prevent young child obesity through 19 activities in four areas: (1) assessing/strengthening school wellness policies and the community’s physical environment; (2) partnering/advocating for environmental change; (3) promoting CHL messages; and (4) building capacity to promote six CHL behavioral objectives (increasing children’s physical activity, fruit/vegetable consumption, water consumption, and sleep, and decreasing sugar-sweetened beverage consumption and recreational screen time). Intervention effect was tested through a cluster randomized controlled trial in Alaska, American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, and Hawai’i, where nine communities received the intervention, and nine matched communities served as controls. Chapters one, two, and three provide background. Chapter four presents results on CE intervention dose obtained across the nine communities, suggesting a critical CE dose for affecting community outcomes. Chapter five presents results from social network analyses in each intervention community, suggesting strong linkages between community groups, local schools, and large organizations are needed to affect change in children’s behaviors. Chapter six explored strategies and barriers in intervention implementation across the nine communities, finding that multiple CE building blocks need to be strengthened simultaneously to affect change, and that time for tailoring the intervention to local conditions was a barrier. Multilevel community interventions could use the CE MAM to develop, implement, and track interventions. The actualization of the CE MAM may prove beneficial in reducing health inequality and improving community outcomes.