{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T06:09:05Z","timestamp":1789193345418,"version":"build-2803163510"},"reference-count":70,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T00:00:00Z","timestamp":1789084800000},"content-version":"unspecified","delay-in-days":10,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Upstream Research Center","award":["270971"],"award-info":[{"award-number":["270971"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,8,14]]},"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>This study examined social determinants and structural barriers to lung cancer outcomes in Kern and Fresno counties, California, and co-developed a multilevel intervention strategy informed by community perspectives.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Engaging stakeholders through group model building (GMB) to elicit their knowledge to build a system dynamics (SD) simulation model for intervention strategy design.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting and participants<\/jats:title>\n                    <jats:p>We identified and trained four community members from two community-based organisations in Central Valley, California, to help recruit GMB participants. 14 community members representing patient advocacy organisations, cancer survivors, clinicians, caregivers, public health professionals, medical interpreters, housing, agriculture, sanitation, healthcare payer organisations and local policymaking sectors were recruited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Procedures<\/jats:title>\n                    <jats:p>The GMB protocol consisted of two in-person and four virtual workshops from 22 August to 11 November 2024. The SD simulation model was built with iSee System\u2019s Stella Architect SD modelling software (V.4.0).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The 181 variables suggested by the GMB workshop participants were categorised into 3 themes and 13 subthemes, which shaped the system boundary and model structure. 7 of the 16 intervention scenarios tested showed a cumulative reduction in the at-risk population and increases in screening, diagnoses, treatment and cancer-free survival. Participants selected a multilevel strategy focused on expanding public health and insurance education and advocating for air pollution-related screening within existing protocols.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Community engagement is essential for understanding lung cancer disparities and designing practical multilevel interventions. Scenario testing enables informed planning to improve long-term population health outcomes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-120634","type":"journal-article","created":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T05:15:28Z","timestamp":1789190128000},"page":"e120634","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Engaging community to co-design a multilevel intervention to reduce lung cancer disparities in persistent poverty tracts in California through group model building and simulation"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8012-5684","authenticated-orcid":false,"given":"Carmen Y J","family":"Lee","sequence":"first","affiliation":[{"name":"Department of Pediatrics, Stanford University, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arleana","family":"Waller","sequence":"additional","affiliation":[{"name":"MLK Community Initiative in Bakersfield, Bakersfield, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Loretta","family":"Winn","sequence":"additional","affiliation":[{"name":"MLK Community Initiative in Bakersfield, Bakersfield, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charlene","family":"Hill","sequence":"additional","affiliation":[{"name":"MLK Community Initiative in Bakersfield, Bakersfield, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily H","family":"Wood","sequence":"additional","affiliation":[{"name":"Division of Oncology, Stanford University School of Medicine, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Omar Francisco Esteban","family":"Ramos","sequence":"additional","affiliation":[{"name":"Division of Oncology, Stanford University School of Medicine, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathryn C","family":"Conlon","sequence":"additional","affiliation":[{"name":"Public Health Sciences, University of California Davis, Davis, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7522-5824","authenticated-orcid":false,"given":"Gary L","family":"Darmstadt","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Stanford University, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manali I","family":"Patel","sequence":"additional","affiliation":[{"name":"Division of Oncology, Stanford University School of Medicine, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,9,11]]},"reference":[{"key":"2026091122151802000_16.9.e120634.1","unstructured":"NCI . 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Meeting individual social needs falls short of addressing social determinants of health: policy & practice. 2019."},{"key":"2026091122151802000_16.9.e120634.24","doi-asserted-by":"crossref","DOI":"10.17061\/phrp2511404","article-title":"Group model building: a participatory approach to understanding and acting on systems","volume":"25","author":"Siokou","year":"2014","journal-title":"Public Health Research and Practice"},{"key":"2026091122151802000_16.9.e120634.25","doi-asserted-by":"crossref","first-page":"10","DOI":"10.3390\/ijerph17103457","article-title":"Community Group Model Building as a Method for Engaging Participants and Mobilising Action in Public Health","volume":"17","author":"Gerritsen","year":"2020","journal-title":"Int J Environ Res Public Health"},{"key":"2026091122151802000_16.9.e120634.26","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0284765","article-title":"Application of group model building in implementation research: A systematic review of the public health and healthcare literature","volume":"18","author":"Estrada-Magbanua","year":"2023","journal-title":"PLoS One"},{"key":"2026091122151802000_16.9.e120634.27","unstructured":"Sterman J . 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Exploring the link between smoking cessation, socioeconomic status, and quality of life in low-income populations. 2025."},{"key":"2026091122151802000_16.9.e120634.49","doi-asserted-by":"crossref","first-page":"140313","DOI":"10.1016\/j.scitotenv.2020.140313","article-title":"Burden of lung cancer attributable to ambient fine particles and potential benefits from air quality improvements in Beijing, China: A population-based study","volume":"738","author":"Yang","year":"2020","journal-title":"Science of The Total Environment"},{"key":"2026091122151802000_16.9.e120634.50","doi-asserted-by":"crossref","first-page":"101437","DOI":"10.1016\/j.lanwpc.2024.101437","article-title":"National and provincial burden of lung cancer attributable to fine particulate matter air pollution in China, 1990\u20132021: a systematic analysis of the Global Burden of Disease Study 2021","volume":"55","author":"Jiang","year":"2025","journal-title":"The Lancet Regional Health - Western Pacific"},{"key":"2026091122151802000_16.9.e120634.51","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-025-22450-8","article-title":"Global lung cancer burden attributable to air fine particulate matter and tobacco smoke exposure: spatiotemporal patterns, sociodemographic characteristics, and transnational inequalities from 1990 to 2021","volume":"25","author":"Zhang","year":"2025","journal-title":"BMC Public Health"},{"key":"2026091122151802000_16.9.e120634.52","unstructured":"NCI . 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