Disseminating policy and environmental change interventions: insights from obesity prevention and tobacco control

A streamlined approach to classifying and tailoring implementation strategies: recommendations to speed the translation of research to practice

BACKGROUND

Implementation science emerged from the recognized need to speed the translation of effective interventions into practice. In the US, the science has evolved to place an ever-increasing focus on implementation strategies. The long list of implementation strategies, terminology used to name strategies, and time required to tailor strategies all may contribute to delays in translating evidence-based interventions (EBIs) into practice. To speed EBI translation, we propose a streamlined approach to classifying and tailoring implementation strategies.

MAIN TEXT

A multidisciplinary team of eight scholars conducted an exercise to sort the Expert Recommendations for Implementing Change (ERIC) strategies into three classes: implementation processes (n = 25), capacity-building strategies (n = 20), and integration strategies (n = 28). Implementation processes comprise best practices that apply across EBIs and throughout the phases of implementation from exploration through sustainment (e.g., conduct local needs assessment). Capacity-building strategies target either general or EBI-specific knowledge and skills (e.g., conduct educational meetings). Integration strategies include "methods and techniques" that target barriers or facilitators to implementation of a specific EBI beyond those targeted by capacity building. Building on these three classes, the team collaboratively developed recommendations for a pragmatic, five-step approach that begins with the implementation processes and capacity-building strategies practice-settings are already using prior to tailoring integration strategies. A case study is provided to illustrate use of the five-step approach to tailor the strategies needed to implement a transitional care intervention in skilled nursing facilities.

CONCLUSIONS

Our proposed approach streamlines the formative work required prior to implementing an EBI by building on practice partner preferences, expertise, and infrastructure while also making the most of prior research findings.

The Role of Cooperative Extension in Delivering Training and Technical Assistance to Support Evidence-Based Behavioral Health Practices in Rural Communities

The opioid epidemic in the United States continues to disproportionately affect those in rural, compared to urban, areas due to a variety of treatment and recovery barriers. One mechanism to increase capacity of rural-serving providers is through delivery of training and technical assistance (TTA) for evidence-based programs by leveraging the Cooperative Extension System. Guided by the Interactive Systems Framework, the current study evaluates TTA delivered by the Northwest Rural Opioid Technical Assistance Collabroative to opioid prevention, treatment, and recovery providers on short- (satisfaction, anticipated benefit), medium-, (behavioral intention to change current practice), and long-term goals (changes toward adoption of evidence-based practices). We also evaluated differences in short- and medium-term goals by intensity of TTA event and rurality of provider. Surveys of 351 providers who received TTA indicated high levels of satisfaction with TTA events attended, expressed strong agreement that they would benefit from the event, intended to make a professional practice change, and preparation toward implementing changes. Compared to urban-based providers, rural providers reported higher intention to use TTA information to change current practice. We conclude with a review of remaining gaps in the research to practice pipeline and recommendations for moving forward.

Increasing use of systems science in cardiovascular disease prevention to understand how to address geographic health disparities in communities with a disproportionate burden of risk

Objective

Marginalized communities shoulder a disproportionate burden of cardiovascular disease (CVD) driven by concentrated neighborhood social risk factors. We provide a case study of systems science application to address geographic CVD health disparities at the community level - informing the science of CVD health disparities research.

Methods

We conducted a two-phased, multi-methods needs assessment in the Denver, Colorado area. Phase I consisted of a social network analysis to map a two-mode network of existing CVD prevention interventions and their implementing organizations. In Phase II, group model building (GMB) sessions with key community, public health, and healthcare provider stakeholders, were utilized to identify and visualize community factors contributing to disparities in CVD risk, producing a consensus-based causal loop diagram.

Results

Between May 2021 and June 2022, we conducted 24 virtual, semi-structured interviews in Phase I to describe CVD prevention interventions, and 7 virtual GMB sessions in Phase II to describe experiences of disparities in CVD risk. For the purposes of this paper, we focus on a subset of results for both phases. In Phase I we identified 89 active CVD prevention interventions, 29 of which addressed tobacco use. In Phase II, causal loop diagrams revealed root causes of disparities in CVD risk. We provide an example of a causal loop diagram that focuses on the community prevalence of tobacco use, identifying stress as a key underlying factor driving disparities. The integration of findings from both phases highlighted the alignment and misalignment between quit tobacco intervention goals and how they are being experienced in marginalized communities.

Conclusion

Systems science methods were useful to organize a large number of CVD prevention efforts, and evaluate the root causes of CVD health disparities in a high risk community. By integrating these two aspects, interventions may be reoriented to more effectively address the root causes of CVD health disparities.

Applying Theory to Explain the Influence of Factors External to an Organization on the Implementation of an Evidence-Based Intervention

Despite its widely acknowledged influence on implementation, limited research has been done on how the external environment (i.e., outer setting) determines when organizations adopt and implement new interventions. Determinant frameworks identify several outer setting-level factors such as funding streams, inter-organizational relationships, and peer pressure. However, these frameworks do not explain how or why outer-setting factors influence implementation. To advance research in this area, we argue for the importance of deriving theory-based propositions from organization theory to explain how outer setting factors influence organizations. Drawing on the work of the Organization Theory in Implementation Science (OTIS) project, we identified 20 propositions from five classic organization theories-Complexity Theory, Contingency Theory, Institutional Theory, Resource Dependence Theory, and Transaction Cost Economics. We then applied those propositions to hypothesize relationships among outer setting factors, implementation strategies, and implementation outcomes in five case studies of evidenced-based tobacco control interventions. The five case studies address the implementation of smoke-free policies, community health worker-led tobacco education and cessation programs, 5 A's (Ask, Advise, Assess, Assist, and Arrange), point-of-sale tobacco marketing policy interventions, and quitlines. The case studies illustrate how propositions may be used to guide the selection and testing of implementation strategies. Organization theories provide a menu of propositions that offer guidance for selecting and optimizing high-leverage implementation strategies that target factors at the level of outer setting. Furthermore, these propositions suggest testable hypotheses regarding the mechanisms underlying the influence of outer-setting factors on how and why organizations adopt and implement interventions.

Scaling Up Public Health Interventions: Engaging Partners Across Multiple Levels

Advancing the science of intervention scale-up is essential to increasing the impact of effective interventions at the regional and national levels. In contrast with work in high-income countries (HICs), where scale-up research has been limited, researchers in low- and middle-income countries (LMICs) have conducted numerous studies on the regional and national scale-up of interventions. In this article, we review the state of the science on intervention scale-up in both HICs and LMICs. We provide an introduction to the elements of scale-up followed by a description of the scale-up process, with an illustrative case study from our own research. We then present findings from a scoping review comparing scale-up studies in LMIC and HIC settings. We conclude with lessons learned and recommendations for improving scale-up research. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Maximizing the Potential of Mini-Grants to Promote Policy, Systems, and Environmental Changes: Outcomes and Challenges

PURPOSE AND OBJECTIVES

This article describes the implementation and evaluation of a chronic disease mini-grant initiative, coordinated by a state health department in collaboration with multiple stakeholders. Braided funding from federal and state sources was used to build and implement the initiative.

INTERVENTION APPROACH

Mini-grants, facilitated by five different facilitating organizations, were funded to promote implementation of policy, systems, and environmental (PSE) changes at the local level. Grant recipients represented a variety of sectors, including education, government, and nonprofit organizations.

EVALUATION METHODS

Primary (surveys) and secondary (final reports) data documented achievement of PSE changes.

RESULTS

A total of $196,369 was dispersed to 65 organizations; 126 PSE changes in the areas of physical activity, nutrition, and tobacco were reported. Challenges in implementing and evaluating mini-grants were identified, including the heterogeneity of the sectors/settings involved and associated variability of proposed activities, time lines, measurement, and evaluation activities. COVID-19 (coronavirus disease 2019) also disrupted the plans for many projects.

IMPLICATIONS FOR PUBLIC HEALTH

The success of this initiative can be attributed to four main elements: (1) the use of intermediary organizations to facilitate the mini-grants; (2) a participatory evaluation process, combined with early and ongoing communication among all stakeholders; (3) a braided funding strategy; and (4) a multisector approach that engaged both traditional and nontraditional public health organizations. The processes and outcomes, including challenges, can inform other state health departments' efforts in braiding funding and engaging intermediary organizations to expand the reach of PSE changes at the local level.

Promoting Responsive Bottle-Feeding Within WIC: Evaluation of a Policy, Systems, and Environmental Change Approach

BACKGROUND

Bottle-fed infants are at greater risk for overfeeding and rapid weight gain (RWG); evidence-based strategies for promoting healthy bottle-feeding practices are needed.

OBJECTIVE

Our aim was to assess whether policy, systems, and environmental (PSE) strategies for promoting responsive bottle-feeding practices within the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were associated with lower risk for RWG.

DESIGN

We conducted a matched-pair cluster randomized trial. PSE strategies were implemented at 3 WIC clinics in Los Angeles County. PSE clinics were compared with 3 matched control clinics. Mothers and infants were assessed when infants were newborn and 3 months and 6 months of age.

PARTICIPANTS/SETTING

Participants were mothers (n = 246) who enrolled their newborn infants (younger than 60 days) into WIC between May and August 2019.

MAIN OUTCOME MEASURES

Infant weight was assessed and standardized to sex- and age-specific z scores. RWG was defined as weight-for-age z score change > 0.67. Mothers completed questionnaires assessing responsive and pressuring feeding styles, breast- and bottle-feeding patterns, and perceptions of WIC experiences.

STATISTICAL ANALYSES PERFORMED

Logistic regression with estimation via generalized estimating equations and linear mixed models with repeated measures assessed effects of PSE strategies on categorical and continuous outcomes, respectively.

RESULTS

Infants in PSE clinics had significantly lower likelihood of exhibiting RWG (P = .014) than infants in control clinics. Mothers in PSE and control clinics reported similar levels of responsive and pressuring feeding style and similar prevalence of breastfeeding and bottle-feeding. Mothers in PSE clinics trended toward feeling better supported with respect to their decision to bottle-feed (P = .098) and had more stable intentions to stay in the WIC program (P = .002) compared with mothers in control clinics.

CONCLUSIONS

PSE strategies focused on promoting more inclusive assessment of infant feeding, tailored bottle-feeding counseling, and increased education and support for responsive bottle-feeding were associated with lower risk for RWG among WIC infants.

Evaluation of the Reaching People with Disabilities through Healthy Communities Project

BACKGROUND

People with disabilities experience disparities in chronic diseases, such as obesity, heart disease, and diabetes, in disproportionate numbers. Research suggests that healthy communities initiatives that work to implement policy, systems and environmental (PSE) changes can help reduce these disparities by improving access to healthy choices for community residents with disabilities. However, healthy communities efforts to implement PSE changes are often not inclusive of people with disabilities.

OBJECTIVE

The purpose of this paper is to evaluate the implementation of an Inclusive Healthy Communities Model that was designed to reach people with disabilities through inclusive PSE changes.

METHODS

Professionals from local public health agencies and disability organizations in 10 diverse communities worked to infuse disability inclusion into PSE changes promoting healthy living. Data on PSE implementation was collected and coded into categories to describe the nature of the inclusive PSEs.

RESULTS

Communities implemented 507 inclusive PSEs, 466 of which were environmental changes, 25 systems changes, and 16 policy changes. A large majority of PSEs were related to improving the built environment to facilitate access to public spaces, such as parks, playgrounds, and community gardens. Many communities also implemented policy and systems changes related to the addition of inclusion into existing policies, community plans, and ongoing training of staff.

CONCLUSION

Integrating disability inclusion into traditional healthy communities efforts can facilitate improved access and opportunity for healthy living among people with disabilities. This pilot project has implications for public health workforce training, current practices, and PSE development with interdisciplinary teams and multisectoral coalitions.

Improving the Health of Alaska Native People Through Use of a Policy Change Model and Capacity Building

Public health training often includes program and education development but not policy, systems, and environmental (PSE) strategies. The Alaska Native Tribal Health Consortium's Good Health and Wellness in Indian Country program works to build tribal PSE change capacity. Trainings included community health assessment, facilitation and leadership engagement, policy and systems, and digital storytelling. From 2014 to 2017, 30 PSE changes were made: 3 tobacco-free healthcare organization policies; 2 tobacco-free tribal resolutions; 1 tobacco-free school district policy; 3 healthy food policies and environmental changes; 4 improvements in patient-provider communication; 13 prediabetes, obesity, and/or tobacco screening and referral policies; 3 improvements to health care facility signage; and 1 Baby-friendly Hospital application, protecting the health of 46,000 tribal community members. Targeted training and technical assistance moved tribal staff from a focus on direct services to population-based improvements. This increased self-efficacy may increase the sustainability of chronic disease public health efforts and improve tribal health.

Tapping Into Multiple Data "Springs" to Strengthen Policy Streams: A Guide to the Types of Data Needed to Formulate Local Retail Tobacco Control Policy

In 2015, the tobacco industry spent $8.24 billion to market tobacco products in convenience stores, supermarkets, pharmacies, and other retail or point-of-sale settings. Community tobacco control partnerships have numerous evidence-based policies (eg, tobacco retailer licensing and compliance, tobacco-free–school buffer zones, eliminating price discounts) to counter point-of-sale tobacco marketing. However, deciding which point-of-sale policies to implement — and when and in what order to implement them — is challenging. The objective of this article was to describe tools and other resources that local-level tobacco use prevention and control leaders can use to assemble the data they need to formulate point-of-sale tobacco policies that fit the needs of their communities, have potential for public health impact, and are feasible in the local policy environment. We were guided by Kingdon’s theory of policy change, which contends that windows of policy opportunity open when 3 streams align: a clear problem, a solution to the problem, and the political will to work for change. Community partnerships can draw on 7 data “springs” to activate Kingdon’s streams: 1) epidemiologic and surveillance data, 2) macro retail environment data, 3) micro retail environment data, 4) the current policy context, 5) local legal feasibility of policy options, 6) the potential for public health impact, and 7) political will.

Data-Powered Participatory Decision Making: Leveraging Systems Thinking and Simulation to Guide Selection and Implementation of Evidence-Based Colorectal Cancer Screening Interventions

A robust evidence base supports the effectiveness of timely colorectal cancer (CRC) screening, follow-up of abnormal results, and referral to care in reducing CRC morbidity and mortality. However, only two-thirds of the US population is current with recommended screening, and rates are much lower for those who are vulnerable because of their race/ethnicity, insurance status, or rural location. Multiple, multilevel factors contribute to observed disparities, and these factors vary across different populations and contexts. As highlighted by the Cancer Moonshot Blue Ribbon Panel working groups focused on Prevention and Early Detection and Implementation Science inadequate CRC screening and follow-up represent an enormous missed opportunity in cancer prevention and control. To measurably reduce CRC morbidity and mortality, the evidence base must be strengthened to guide the identification of (1) multilevel factors that influence screening across different populations and contexts, (2) multilevel interventions and implementation strategies that will be most effective at targeting those factors, and (3) combinations of strategies that interact synergistically to improve outcomes. Systems thinking and simulation modeling (systems science) provide a set of approaches and techniques to aid decision makers in using the best available data and research evidence to guide implementation planning in the context of such complexity. This commentary summarizes current challenges in CRC prevention and control, discusses the status of the evidence base to guide the selection and implementation of multilevel CRC screening interventions, and describes a multi-institution project to showcase how systems science can be leveraged to optimize selection and implementation of CRC screening interventions in diverse populations and contexts.

Communication and comprehensive cancer control coalitions: lessons from two decades of campaigns, outreach, and training

PURPOSE

Comprehensive cancer control (CCC) coalitions and programs have delivered effective models and approaches to reducing cancer burden across the United States over the last two decades. Communication plays an essential role in diverse coalition activities from prevention to survivorship, including organizational and community capacity-building and as cancer control intervention strategies.

METHODS

Based upon a review of published CCC research as well as public health communication best practices, this article describes lessons learned to assist CCC coalitions and programs with systematic implementation of communication efforts as key strategies in cancer control.

RESULTS

Communication-oriented lessons include (1) effective communication work requires listening and ongoing engagement with key stakeholders, (2) communication interventions should target multiple levels from interpersonal to mediated channels, (3) educational outreach can be a valuable opportunity to bolster coalition effectiveness and cancer control outcomes, and (4) dedicated support is necessary to ensure consistent communication efforts.

CONCLUSIONS

External and internal communication strategies can optimize coalition efforts and resources to ultimately help produce meaningful improvement in cancer control outcomes.

Local Organizations Supporting Implementation of Graphic Health Warnings for Tobacco in Underserved Communities: A Qualitative Inquiry

Background: Graphic health warnings (GHWs) on cigarette packages offer the potential to support tobacco cessation and prevention of initiation. Guidance for supporting implementation at the local level is limited, which can lead to missed opportunities to amplify the health impact of GHWs. This study examines the potential for local organizations engaged in tobacco control in underserved communities to support GHW implementation. Materials and Methods: Key informant interviews were conducted with 20 leaders in the three partner communities of Boston, Lawrence, and Worcester, Massachusetts. Data were analyzed using a combination of inductive and deductive methods, grounded in a framework analysis approach. Results: First, participants expected local organizations to play a diverse range of roles to support GHW policy implementation, ranging from convening local actors to offering complementary health education activities. Second, there is a need for external agencies to actively support local organizations during the pre-implementation and implementation phases, e.g., by engaging local organizations and providing resources and technical assistance. Finally, participants noted concerns about potential disconnects between the GHWs and the needs of underserved populations. Discussion: With the necessary supports, local community organizations can be important implementation partners to maximize the impact of GHWs and ensure that benefits accrue to members of underserved communities.

Networks for prevention in 19 communities at the start of a large-scale community-based obesity prevention initiative

Community-based obesity prevention efforts are dependent on the strength and function of collaborative networks across multiple community members and organizations. There is little empirical work on understanding how community network structure influences obesity prevention capacity. We describe network structures within 19 local government communities prior to a large-scale community-based obesity prevention intervention, Healthy Together Victoria, Australia (2012-2015). Participants were from a large, multi-site, cluster randomized trial (cRCT) of a whole-of-systems chronic disease prevention initiative. Community leaders from 12 intervention and seven comparison (non-intervention) regions identified and described their professional networks in relation to dietary, physical activity, and weight status among young children (<5 years of age). Social network measures of density, modularity, clustering, and centrality were calculated for each community. Comparison of means and tests of association were conducted for each network relationship. One-hundred and seven respondents (78 intervention; 29 comparison) reported on 996 professional network relationships (respondent average per region: 10 intervention; 8 comparison). Networks were typically sparse and highly modular. Networks were heterogeneous in size and relationship composition. Frequency of interaction, close and influential relationships were inversely associated with network density. At baseline in this cRCT there were no significant differences between community network structures of key actors with influence over environments affecting children's diet and physical activity. Tracking heterogeneity in both networks and measured outcomes over time may help explain the interaction between professional networks and intervention effectiveness of community-based obesity prevention.

Creating Environments to Support Breastfeeding: The Challenges and Facilitators of Policy Development in Hospitals, Clinics, Early Care and Education, and Worksites

Objectives Supportive organizational breastfeeding policies can establish enabling environments for breastfeeding. In this qualitative study we identify facilitators and barriers to the development, adoption, and implementation of supportive breastfeeding policies and practices in four influential sectors for breastfeeding women: hospitals, clinics, early care and education settings, and worksites. Methods We interviewed 125 individuals representing 110 organizations in Washington State about their breastfeeding policy development and implementation process between August 2014 and February 2015. Greenhalgh's diffusion of innovations framework guided the interviews and qualitative analysis. Results Breastfeeding policy facilitators across the sectors include national and state laws and regulations, performance tracking requirements, and an increasingly supportive sociopolitical climate; barriers include limited resources and appreciation about the need for breastfeeding policies, and certain organizational characteristics such as workforce age. Despite broad support for breastfeeding, organizations differed on perceptions about the usefulness of written breastfeeding policies. Personal breastfeeding experiences of policy makers and staff affect organizational breastfeeding policies and practices. Conclusions for Practice Supportive organizational systems and environments are built through effective policy development processes; public health can support breastfeeding policy development and assure a coordinated continuum of care by leveraging federal health care policy requirements, building networks to support training and collaboration, and disseminating strategies that reflect the personal nature of breastfeeding.

Implementation strategies to promote community-engaged efforts to counter tobacco marketing at the point of sale

The US tobacco industry spends $8.2 billion annually on marketing at the point of sale (POS), a practice known to increase tobacco use. Evidence-based policy interventions (EBPIs) are available to reduce exposure to POS marketing, and nationwide, states are funding community-based tobacco control partnerships to promote local enactment of these EBPIs. Little is known, however, about what implementation strategies best support community partnerships' success enacting EBPI. Guided by Kingdon's theory of policy change, Counter Tools provides tools, training, and other implementation strategies to support community partnerships' performance of five core policy change processes: document local problem, formulate policy solutions, engage partners, raise awareness of problems and solutions, and persuade decision makers to enact new policy. We assessed Counter Tools' impact at 1 year on (1) partnership coordinators' self-efficacy, (2) partnerships' performance of core policy change processes, (3) community progress toward EBPI enactment, and (4) salient contextual factors. Counter Tools provided implementation strategies to 30 partnerships. Data on self-efficacy were collected using a pre-post survey. Structured interviews assessed performance of core policy change processes. Data also were collected on progress toward EBPI enactment and contextual factors. Analysis included descriptive and bivariate statistics and content analysis. Following 1-year exposure to implementation strategies, coordinators' self-efficacy increased significantly. Partnerships completed the greatest proportion of activities within the "engage partners" and "document local problem" core processes. Communities made only limited progress toward policy enactment. Findings can inform delivery of implementation strategies and tests of their effects on community-level efforts to enact EBPIs.

The impact of tobacco-free pharmacy policies on smoking prevalence

OBJECTIVES

California and Massachusetts are the only 2 states in the United States with municipalities that have local laws prohibiting the sale of tobacco products by pharmacies. The impacts of the tobacco-free pharmacy laws remain understudied. This study aims to fill this gap by examining the association between tobacco-free pharmacy laws and smoking prevalence among adults over time in California and Massachusetts.

DESIGN

This study used a series of cross-sectional surveys. The data source for this study was the Behavioral Risk Factor Surveillance Survey for each year from 2005 to 2013.

SETTING

The longitudinal changes in smoking prevalence at the city or county level were estimated and comparisons were made between cities or counties with tobacco-free pharmacy laws and those without the laws.

PARTICIPANTS

The participants used to estimate smoking prevalence were representative of adults within California and Massachusetts.

INTERVENTION

The implementation of tobacco-free pharmacy laws was considered to be the intervention in this study.

MAIN OUTCOME MEASURES

The outcome measures were smoking prevalence among adults. Mixed-effects negative binomial models were performed primarily to examine longitudinal changes in outcome measures.

RESULTS

The prevalence of smoking decreased in both states over time. In Massachusetts, there was a statistically significant decrease in smoking prevalence among cities with tobacco-free pharmacy laws compared with those without such laws. Despite the presence of an 8.6% decrease in prevalence after the implementation of tobacco-free pharmacy laws, this reduction was not statistically significant after controlling for the negative trend in smoking rates overall and other factors.

CONCLUSION

This study evaluated tobacco-free pharmacy laws with regard to the real-world impacts. Our findings highlight the need for future research on the effects of tobacco-free pharmacy laws with a prolonged time span and a comprehensive understanding of the law's implementation and enforcement.

Developing Theory to Guide Building Practitioners' Capacity to Implement Evidence-Based Interventions

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.

Advancing the science of dissemination and implementation in behavioral medicine: evidence and progress

The enormous time lag between the discovery of new knowledge and its implementation poses a significant challenge to improving public health because of the very slow uptake into policy and practice. The field of dissemination and implementation research in behavioral medicine is receiving increased attention because of the keen interest in accelerating knowledge transfer from relevant research to improve the health and wellbeing of populations in many different settings, contexts, and countries around the world. This is particularly important in high-risk populations, resource-poor and developing regions of the world where the difference in health systems, languages, and cultures very significantly influences the translation of evidence into policy and practice. Moreover, demonstrating the broader societal and economic value of behavioral interventions in settings where they are implemented can further support the sustainability, uptake, and implementation of these findings in other settings and contexts. This special issue presents a series of empirical studies, reviews, and case studies that address dissemination, implementation, and translation issues in both developed and developing countries. Specifically, the learnings from the application of many and varied theories and research methodologies are very relevant for bridging the current division between research findings and their translation and uptake into policy and practice.

Policy, Systems, and Environmental Approaches to Obesity Prevention: Translating and Disseminating Evidence from Practice

To reduce obesity prevalence, public health practitioners are intervening to change health behaviors as well as the policies, systems, and environments (PSEs) that support healthy behaviors. Although the number of recommended PSE intervention strategies continues to grow, limited guidance is available on how to implement those strategies in practice. This article describes the University of North Carolina at Chapel Hill, Center for Training and Research Translation's (Center TRT's) approach to reviewing, translating, and disseminating practitioner-developed interventions, with the goal of providing more practical guidance on how to implement PSE intervention strategies in real-world practice. As of August 2014, Center TRT had disseminated 30 practice-based PSE interventions. This article provides an overview of Center TRT's process for reviewing, translating, and disseminating practice-based interventions and offers key lessons learned during the nine years that Center TRT has engaged in this work.

Evaluating Policy, Systems, and Environmental Change Interventions: Lessons Learned From CDC's Prevention Research Centers

Introduction

The field of public health is increasingly implementing initiatives intended to make policies, systems, and environments (PSEs) more supportive of healthy behaviors, even though the evidence for many of these strategies is only emerging. Our objective was 3-fold: 1) to describe evaluations of PSE-change programs in which the evaluators followed the steps of the Centers for Disease Control and Prevention’s (CDC’s) Framework for Program Evaluation in Public Health, 2) to share the resulting lessons learned, and 3) to assist future evaluators of PSE-change programs with their evaluation design decisions.

Methods

Seven Prevention Research Centers (PRCs) applied CDC’s framework to evaluate their own PSE-change initiatives. The PRCs followed each step of the framework: 1) engage stakeholders, 2) describe program, 3) focus evaluation design, 4) gather credible evidence, 5) justify conclusions, and 6) ensure use and share lessons learned.

Results

Evaluation stakeholders represented a range of sectors, including public health departments, partner organizations, and community members. Public health departments were the primary stakeholders for 4 of the 7 evaluations. Four PRCs used logic models to describe the initiatives being evaluated. Their evaluations typically included both process and outcome questions and used mixed methods. Evaluation findings most commonly focused on contextual factors influencing change (process) and the adoption or implementation of PSE-change strategies (outcome). Evaluators shared lessons learned through various channels to reach local stakeholders and broader public health audiences.

Conclusion

Framework for Program Evaluation in Public Health is applicable to evaluations of PSE-change initiatives. Using this framework to guide such evaluations builds practice-based evidence for strategies that are increasingly being used to promote healthful behaviors.

Social Entrepreneurship for Obesity Prevention: What Are the Opportunities?

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.

A comparison of three policy approaches for tobacco retailer reduction

BACKGROUND

The Institute of Medicine recommends that public health agencies restrict the number and regulate the location of tobacco retailers as a means of reducing tobacco use. However, the best policy strategy for tobacco retailer reduction is unknown.

PURPOSE

The purpose of this study is to test the percent reduction in the number and density of tobacco retailers in North Carolina resulting from three policies: (1) prohibiting sales of tobacco products in pharmacies or stores with a pharmacy counter, (2) restricting sales of tobacco products within 1000 ft of schools, and (3) regulating to 500 ft the minimum allowable distance between tobacco outlets.

METHODS

This study uses data from two lists of tobacco retailers gathered in 2012, one at the statewide level, and another "gold standard" three-county list. Retailers near schools were identified using point and parcel boundaries in ArcMap. Python programming language generated a random lottery system to remove retailers within 500 ft of each other. Analyses were conducted in 2014.

RESULTS

A minimum allowable distance policy had the single greatest impact and would reduce density by 22.1% at the state level, or 20.8% at the county level (range 16.6% to 27.9%). Both a pharmacy and near-schools ban together would reduce density by 29.3% at the state level, or 29.7% at the county level (range 26.3 to 35.6%).

CONCLUSIONS

The implementation of policies restricting tobacco sales in pharmacies, near schools, and/or in close proximity to another tobacco retailer would substantially reduce the number and density of tobacco retail outlets.