Table 2. Meeting Themes, Meeting Summaries, and Description of Facilitated Group Model Building^a Activities, Early Ages Healthy Stages Action Building Committee,^b Cuyahoga County, Ohio, May 2018–February 2019.

Meeting theme	Meeting summary and attendance	Description of group model building activity
Project overview and creating a shared vision	• Committee and research team introductions • Project overview (introduction to group model building and systems dynamics) • Hopes and fears (group model building) • Shared vision group discussion • Attendance: 11 of 12	Hopes and fears: Prompted with the question, “What are your hopes and fears for our work together over the next 10 months?” Early Ages Healthy Stages Committee members shared their personal hopes and fears for the project and, with the help of the facilitators, organized responses into themes.
Identifying trends and systems	• Evidence share by research team: Connecting early childhood education and health • Hopes and fears recap • Graphs over time (group model building) • Group discussion • Attendance: 9 of 12	Graphs over time: Given the prompt, “What impacts, or is impacted by, the work of the Early Ages Healthy Stages Coalition?” members identified factors that fit the description then created and shared line graphs showing how they perceived these factors to have changed in recent decades and the potential future trajectories that they hoped and feared might unfold.
Identifying and connecting system variables	• Graphs over time recap • Variable elicitation (group model building) • Connection circles (group model building) • Group share and discussion • Attendance: 9 of 12	Variable elicitation: Guided by the questions, “What are key things that affect the functioning of the Early Ages Healthy Stages Coalition, or the impact that the Coalition has in the community?” members wrote variables that came to mind. Connection circles: Members worked in groups to draw connections between variables around a circle, using arrows to begin seeing how variables can be connected.
Reflecting on the past and sketching a roadmap	• Evidence share by research team: The importance of early learning • Reflection on prior activities (hopes and fears, graphs over time, variable elicitation, connection circles) • Connection circles (focused on connection between coalition’s functioning and impact) • Group share and discussion about defining success moving forward • Attendance: 9 of 12	[See description of Hopes and fears, Graphs over time, Variable elicitation, and Connection circles]
Visualizing systems connections and structures	• Evidence share by research team: Promoting community health improvement through more equitable food systems • Introduction to causal loop diagrams: Purpose and use in Committee • Introduction to causal loop diagrams: Technical aspects and mechanics of drawing (group model building) • Small group drawing of causal loop diagrams • Group share • Causal loop diagram combination by facilitation team (during group lunch break) • Reaction and refinement of combined causal loop diagram as whole group • Attendance: 11 of 12	Causal loop diagrams: Committee members learned how to read and create causal loop diagrams. A causal loop diagram was then developed by the entire group to visualize connections between factors identified in previous group model building activities and identify system structures, such as feedback loops, that drive trends over time. Creating a causal loop diagram helps groups develop shared language and begin to understand the dynamics of a complex problem.
Causal Loop Diagram elaboration and use for action planning as systems map	• Evidence share by research team: Assessment of child health and health care in Ohio • Research team presented integrated causal loop diagram, review of causal loop diagram, progression, summary of key feedback loops (group model building) • Small group discussion: Is there anything missing or that should be changed? • Group share and discussion • Attendance: 10 of 12	Causal loop diagram elaboration: The causal loop diagram was updated between meetings by the research team and then presented back to the group. When presented back, the facilitator explained each loop and reflected on key insights before asking the group for feedback on what is missing. Refining and elaborating the causal loop diagram as a group ensures that all connections are included and that all members feel represented. This causal loop diagram was styled into a systems map to be used primarily as a communication tool moving forward.
Identifying opportunities for systems change	• Evidence share by research team: Overweight/obesity and blood pressure in Cuyahoga County • Review of refined systems map and feedback loop connections • Reflection on the importance of systems change • Individual work to generate action ideas (group model building) • Group share and impact-feasibility grid • Group discussion • Attendance: 7 of 12	Action ideas: Action ideas that targeted specific areas of the systems map were then conceptualized using an impact-feasibility grid, a tool to guide members in formulating actionable solutions, and creating a shared understanding of potential interventions within the system.
Prioritizing activities for action ideas	• Evidence share by research team: Early Ages Healthy Stages engagement in the community • Presentation of top 11 survey results (Committee members voted on top ideas to prioritize from impact-feasibility grid) • Presentation of evidence around top strategies, developed by research team • Group discussion of each idea and what needs to happen to move forward • Attendance: 7 of 12	NA
Action planning and catalyzing future work	• Evidence share by research team: The intersection between health and education in very young children • Action planning continued: more structured discussion around top 4 action items • Introductory discussion to sustainability • Attendance: 9 of 12	NA
Preparing for sustainability of work going forward	• Evidence share by research team: Roundtable discussion on obesity solutions with local early childhood education leaders • Discussion of action strategies moving forward using the systems map • Committee Culmination/Kickoff event with community leaders to showcase work: panel discussion on creating healthier early childhood environments through community • Group discussion on sustainability of work moving forward • Hopes and fears (for future) • Attendance: 3 of 12	NA

Abbreviation: NA, not applicable.

^a Group Model Building is a participatory approach for engaging stakeholders in building system dynamics models that depict how elements within a system interact to produce patterns of behavior over time.

^b Early Ages Healthy Stages is a coalition of 85 agencies that represent various sectors that influence early childhood health in Cuyahoga County, Ohio. Attendance numbers reflect people who attended the regularly scheduled meetings, not those who attended the make-up meetings.