A national research agenda for public health services and systems

A Uniform Chart of Accounts: Strengthening Public Health Practice and Research Through Standardized Financial Data

CONTEXT

The COVID-19 pandemic made the long-standing need for a national uniform financial reporting standard for governmental public health agencies clear, as little information was available to quantify state and local public health agencies' financial needs during the pandemic response. Such a uniform system would also inform resource allocation to underresourced communities and for specific services, while filling other gaps in practice, research, and policy making. This article describes lessons learned and recommendations for ensuring broad adoption of a national Uniform Chart of Accounts (UCOA) for public health departments.

PROGRAM

Leveraging previous efforts, the UCOA for public health systems was developed through collaboration with public health leaders. The UCOA allows state and local public health agencies to report spending on activities and funding sources, along with practice-defined program areas and capabilities.

IMPLEMENTATION

To date, 78 jurisdictions have utilized the UCOA to crosswalk financial information at the program level, enabling comparisons with peers.

EVALUATION

Jurisdictions participating in the UCOA report perceptions of substantial up-front time investment to crosswalk their charts of accounts to the UCOA standard but derive a sense of valuable potential for benchmarking against peers, ability to engage in resource allocation, use of data for accountability, and general net positive value of engagement with the UCOA.

IMPLICATIONS FOR POLICY AND PRACTICE

The UCOA is considered a need among practice partners. Implementing the UCOA at scale will require government involvement, a reporting requirement and/or incentives, technical assistance, financial support for agencies to participate, and a means of visualizing the data.

COVID-19 Revealed Shortcomings Of The US Public Health System And The Need To Strengthen Funding And Accountability

The US governmental public health system, which includes federal, state, and local agencies, is seen by many observers as having a money problem, stemming from a lack of resources. During the COVID-19 pandemic, this lack of resources has had unfortunate consequences for the communities that public health practice leaders are expected to protect. Yet the money problem is complex and involves understanding the nature of chronic public health underinvestment, identifying what money is spent in public health and what the country gets for it, and determining how much money is needed to do the work of public health in the future. This Commentary elucidates each of these issues and provides recommendations for making public health services more financially sustainable and accountable. Well-functioning public health systems require adequate funding, but a modernized public health financial data system is also key to the systems' success. There is a great need for standardization and accountability in public health finance, along with incentives and the generation of research evidence demonstrating the value of and most effective delivery for a baseline of public health services that every community should expect.

Challenges Facing Public Health Nursing Faculty in the United States: COVID-19 as a Catalyst for Change

We present an analysis of challenges facing public health nursing faculty members (PHNF) in the United States and their broader societal implications. The COVID-19 pandemic has exacerbated these challenges, making them untenable. Current academic structures-influenced by the broader sociopolitical climate-are problematic for PHNF: they disincentivize PHNF from researching social determinants of health and public health systems, teaching systems-level content that may be deemed "controversial" and that is not included on licensure exams, and engaging in service through advocacy and community partnerships. The fault lines within health care, public health systems, and higher education indicate that it is time to reevaluate how to incentivize socially just and equitable outcomes. Toward this goal, we propose that collective action and systemic change, including the perspectives of PHNF, is needed to better realize our shared goals. The analysis serves as a catalyst for conversations about academic structures, health care systems, the role of public health, and the kind of society we envision for ourselves and future generations. (Am J Public Health. 2022;112(S3):S314-S320. https://doi.org/10.2105/AJPH.2022.306819).

Perceived Benefits of Collaboration Between Local Health Departments and Schools and Programs of Public Health: A Mixed-Methods Study

OBJECTIVES

Collaboration between local health departments (LHDs) and schools and programs of public health (SPPH) may be a way to improve practice, education, and research. However, little is known about why LHDs and SPPH collaborate. This mixed-methods study addressed this issue by exploring what LHDs and SPPH perceive to be beneficial about their collaboration.

METHODS

A mixed-methods study using quantitative and qualitative data was conducted. A survey of 2000 LHDs that completed the 2013 National Profile of LHDs measured how important and effective LHDs perceived 30 indicators of the 10 essential public health services to be for collaboration with SPPH. Focus groups were held with LHD officials and the faculty from SPPH to further explore their perceptions of the mutual benefits of their collaboration.

RESULTS

This study showed that LHD officials and the faculty from SPPH valued their collaborative work because it can improve education and training, support public health accreditation, enhance LHD credibility, enhance LHD technological capabilities, and improve research and evidence-based practice. Benefits increased with an increase in the degree of collaboration. This also showed that LHD officials would like to collaborate more closely with SPPH.

CONCLUSION

Collaboration between LHDs and SPPH is mutually beneficial, and close collaboration can help transform public health practice, education, and research. In light of this, more attention should be paid to developing goals and objectives for a collaborative agenda. Attention should be paid not only to the immediate needs of the organizations and individuals involved but also to their long-term goals and underlying desires. Funding opportunities to support the development of partnerships between LHDs and SPPH are needed to provide tangible tasks and opportunities for taking a more long-term and strategic view for collaborative relationships.

Strengthening complex systems for chronic disease prevention: a systematic review

BACKGROUND

While frameworks exist for strengthening health care systems and public health systems, there are no practical frameworks to describe, assess and strengthen systems for chronic disease prevention (CDP) using complex systems approaches.

METHODS

A systematic and integrative review of peer reviewed literature was conducted to answer the following questions: How can systems for CDP be defined? What are key attributes of effective systems? How are complex systems approaches discussed? Search terms were identified and the Medline, SCOPUS, and Global Health databases were searched December 2017 and January 2018. Reference lists and selected journals were hand searched. A working definition for a system for CDP was developed to provide a guideline for inclusion. Key exclusion criteria were literature did not address the research questions or working definition; was published in a language other than English and before 2000; focused on specific chronic diseases and/or risk factors and not CDP broadly; concentrated on the health care sector and clinical services and/or health status and surveillance data; and described evaluations of setting specific actions such as policies, programs, interventions, approaches, projects, laws, or regulations. Selected literature (n = 141) was coded in terms of the extent to which the research questions and the working definition of systems for CDP were addressed. Data was then analysed and synthesized to determine key themes.

RESULTS

A revised definition of systems for CDP and seven attributes of effective systems for CDP are reported (collaborative capacity, health equity paradigm, leadership and governance, resources, implementation of desired actions, information and complex systems paradigm). A framework was developed to provide a foundation for describing, assessing and strengthening systems for CDP.

CONCLUSIONS

The results of this literature review provide a strong foundation for a framework to help strengthen systems for CDP. The framework consolidates not only well-established attributes of effective CDP but also highlights theoretical and practical insights from complex systems perspectives.

Transplanting hepatitis C virus-positive livers into hepatitis C virus-negative patients with preemptive antiviral treatment: A modeling study

Under current guidelines, hepatitis C virus (HCV)-positive livers are not transplanted into HCV-negative recipients because of adverse posttransplant outcomes associated with allograft HCV infection. However, HCV can now be cured post-LT (liver transplant) using direct-acting antivirals (DAAs) with >90% success; therefore, HCV-negative patients on the LT waiting list may benefit from accepting HCV-positive organs with preemptive treatment. Our objective was to evaluate whether and in which HCV-negative patients the potential benefit of accepting an HCV-positive (i.e., viremic) organ outweighed the risks associated with HCV allograft infection. We developed a Markov-based mathematical model that simulated a virtual trial of HCV-negative patients on the LT waiting list to compare long-term outcomes in patients: (1) willing to accept any (HCV-negative or HCV-positive) liver versus (2) those willing to accept only HCV-negative livers. Patients receiving HCV-positive livers were treated preemptively with 12 weeks of DAA therapy and had a higher risk of graft failure than those receiving HCV-negative livers. The model incorporated data from published studies and the United Network for Organ Sharing (UNOS). We found that accepting any liver regardless of HCV status versus accepting only HCV-negative livers resulted in an increase in life expectancy when Model for End-Stage Liver Disease (MELD) was ≥20, and the benefit was highest at MELD 28 (0.172 additional life-years). The magnitude of clinical benefit was greater in UNOS regions with higher HCV-positive donor organ rates, that is, Regions 1, 2, 3, 10, and 11. Sensitivity analysis demonstrated that model outcomes were robust.

CONCLUSION

Transplanting HCV-positive livers into HCV-negative patients with preemptive DAA therapy could improve patient survival on the LT waiting list. Our analysis can help inform clinical trials and minimize patient harm. (Hepatology 2018;67:2085-2095).

Economic and Policy Analytic Approaches to Inform the Acceleration of HIV Prevention in the United States: Future Directions for the Field

The fields of economic and policy analysis have long played a role in quantifying the burden of the HIV epidemic and informing how to best deploy interventions and policies aimed at maximizing HIV care and reducing transmission. Looking towards the ultimate goal of ending the AIDS epidemic, we describe five areas for further development and application towards HIV policies: (1) setting measurable objectives to create a vision and monitor progress, (2) taking a health and wellness approach to goal-setting, (3) using impact matrices to inform quantitative analysis to explicitly address health disparities, (4) conducting budget impact analyses to project annual program costs and benefits, and (5) advancing the public health systems and services research agenda.

Cross-Jurisdictional Resource Sharing in Local Health Departments: Implications for Services, Quality, and Cost

Background

Forty one percent of local health departments in the U.S. serve jurisdictions with populations of 25,000 or less. Researchers, policymakers, and advocates have long questioned how to strengthen public health systems in smaller municipalities. Cross-jurisdictional sharing may increase quality of service, access to resources, and efficiency of resource use.

Objective

To characterize perceived strengths and challenges of independent and comprehensive sharing approaches, and to assess cost, quality, and breadth of services provided by independent and sharing health departments in Connecticut (CT) and Massachusetts (MA).

Methods

We interviewed local health directors or their designees from 15 comprehensive resource-sharing jurisdictions and 54 single-municipality jurisdictions in CT and MA using a semi-structured interview. Quantitative data were drawn from closed-ended questions in the semi-structured interviews; municipal demographic data were drawn from the American Community Survey and other public sources. Qualitative data were drawn from open-ended questions in the semi-structured interviews.

Results

The findings from this multistate study highlight advantages and disadvantages of two common public health service delivery models – independent and shared. Shared service jurisdictions provided more community health programs and services, and invested significantly more ($120 per thousand (1K) population vs. $69.5/1K population) on healthy food access activities. Sharing departments had more indicators of higher quality food safety inspections (FSIs), and there was a non-linear relationship between cost per FSI and number of FSI. Minimum cost per FSI was reached above the total number of FSI conducted by all but four of the jurisdictions sampled. Independent jurisdictions perceived their governing bodies to have greater understanding of the roles and responsibilities of local public health, while shared service jurisdictions had fewer staff per 1,000 population.

Implications

There are trade-offs with sharing and remaining independent. Independent health departments serving small jurisdictions have limited resources but strong local knowledge. Multi-municipality departments have more resources but require more time and investment in governance and decision-making. When making decisions about the right service delivery model for a given municipality, careful consideration should be given to local culture and values. Some economies of scale may be achieved through resource sharing for municipalities <25,000 population.

Criteria-Based Resource Allocation: A Tool to Improve Public Health Impact

OBJECTIVE

Resource allocation in local public health (LPH) has been reported as a significant challenge for practitioners and a Public Health Services and Systems Research priority. Ensuring available resources have maximum impact on community health and maintaining public confidence in the resource allocation process are key challenges. A popular strategy in health care settings to address these challenges is Program Budgeting and Marginal Analysis (PBMA). This case study used PBMA in an LPH setting to examine its appropriateness and utility.

DESIGN

The criteria-based resource allocation process PBMA was implemented to guide the development of annual organizational budget in an attempt to maximize the impact of agency resources. Senior leaders and managers were surveyed postimplementation regarding process facilitators, challenges, and successes.

SETTING

Canada's largest autonomous LPH agency.

RESULTS

PBMA was used to shift 3.4% of the agency budget from lower-impact areas (through 34 specific disinvestments) to higher-impact areas (26 specific reinvestments). Senior leaders and managers validated the process as a useful approach for improving the public health impact of agency resources. However, they also reported the process may have decreased frontline staff confidence in senior leadership.

CONCLUSIONS

In this case study, PBMA was used successfully to reallocate a sizable portion of an LPH agency's budget toward higher-impact activities. PBMA warrants further study as a tool to support optimal resource allocation in LPH settings.

Development of a Research Agenda Focused on Academic Health Departments

An academic health department (AHD) is a formal partnership between an academic institution and a governmental public health agency. Case studies have described the value of individual AHDs in the areas of student engagement, practice-based research, workforce development, and service. With growing interest in AHDs and the increasing importance of academic-practice linkages in both academic programs' and public health agencies' accreditation processes, articulating a research agenda focused on the AHD model can be useful for stimulating the research and practice fields to further develop the evidence base for AHDs. We provide a research agenda, developed through an iterative process involving academicians, practitioners, and others interested in academic-practice linkages.

State Health Agency and Local Health Department Workforce: Identifying Top Development Needs

OBJECTIVES

To identify occupations with high-priority workforce development needs at public health departments in the United States.

METHODS

We surveyed 46 state health agencies (SHAs) and 112 local health departments (LHDs). We asked respondents to prioritize workforce needs for 29 occupations and identify whether more positions, more qualified candidates, more competitive salaries for recruitment or retention, or new or different staff skills were needed.

RESULTS

Forty-one SHAs (89%) and 36 LHDs (32%) participated. The SHAs reported having high-priority workforce needs for epidemiologists and laboratory workers; LHDs for disease intervention specialists, nurses, and administrative support, management, and leadership positions. Overall, the most frequently reported SHA workforce needs were more qualified candidates and more competitive salaries. The LHDs most frequently reported a need for more positions across occupations and more competitive salaries. Workforce priorities for respondents included strengthening epidemiology workforce capacity, adding administrative positions, and improving compensation to recruit and retain qualified employees.

CONCLUSIONS

Strategies for addressing workforce development concerns of health agencies include providing additional training and workforce development resources, and identifying best practices for recruitment and retention of qualified candidates.

Macro Trends and the Future of Public Health Practice

Public health practice in the twenty-first century is in a state of significant flux. Several macro trends are impacting the current practice of governmental public health and will likely have effects for many years to come. These macro trends are described as forces of change, which are changes that affect the context in which the community and its public health system operate. This article focuses on seven such forces of change: the Patient Protection and Affordable Care Act, public health agency accreditation, climate change, health in all policies, social media and informatics, demographic transitions, and globalized travel. Following the description of each of these, this article then turns to possible approaches to measuring, tracking, and understanding the impact of these forces of change on public health practice, including the use of evidence-based public health, practice-based research, and policy surveillance.

Applying Community-Based Participatory Research Partnership Principles to Public Health Practice-Based Research Networks

With real-world relevance and translatability as important goals, applied methodological approaches have arisen along the participatory continuum that value context and empower stakeholders to partner actively with academics throughout the research process. Community-based participatory research (CBPR) provides the gold standard for equitable, partnered research in traditional communities. Practice-based research networks (PBRNs) also have developed, coalescing communities of practice and of academics to identify, study, and answer practice-relevant questions. To optimize PBRN potential for expanding scientific knowledge, while bridging divides across knowledge production, dissemination, and implementation, we elucidate how PBRN partnerships can be strengthened by applying CBPR principles to build and maintain research collaboratives that empower practice partners. Examining the applicability of CBPR partnership principles to public health (PH) PBRNs, we conclude that PH-PBRNs can serve as authentic, sustainable CBPR partnerships, ensuring the co-production of new knowledge, while also improving and expanding the implementation and impact of research findings in real-world settings.

The Public Health Nurse Workforce in U.S. State and Local Health Departments, 2012

OBJECTIVE

Public health nurses (PHNs) represent the single largest group of public health practitioners working in U.S. state and local health departments. Despite the important role of PHNs in the delivery and administration of public health services, little research has been conducted on this group and relatively little is known about PHN education, training, and retirement intentions. We describe the findings of a nationally representative survey of PHNs working in state and local health departments by characterizing their educational background and plans for retirement.

METHODS

An advisory committee convened by the University of Michigan Center of Excellence in Public Health Workforce Studies developed the Public Health Nurse Workforce Survey and disseminated it in 2012 to 50 U.S. state and 328 local health departments.

RESULTS

The 377 responding state and local health departments reported an estimated 34,521 full-time equivalent registered nurses in their employ, with PHNs or community health nurses as the largest group of workers (63%). Nearly 20% of state health department PHNs and 31% of local health department PHNs were educated at the diploma or associate's degree level. Approximately one-quarter of PHNs were determined to be eligible for retirement by 2016. Professional development and promotion opportunities, competitive benefits and salary, and hiring procedures were among the recruitment and retention issues reported by health departments.

CONCLUSION

PHNs were reported to have highly variable occupational classifications and educational backgrounds in health departments. Additional training opportunities are needed for PHNs with diploma and associate's degrees. A shortage of PHNs is possible due to retirement eligibility and administrative barriers to recruitment and retention.

Strategic Methodologies in Public Health Cost Analyses

CONTEXT

The National Research Agenda for Public Health Services and Systems Research states the need for research to determine the cost of delivering public health services in order to assist the public health system in communicating financial needs to decision makers, partners, and health reform leaders.

OBJECTIVE

The objective of this analysis is to compare 2 cost estimation methodologies, public health manager estimates of employee time spent and activity logs completed by public health workers, to understand to what degree manager surveys could be used in lieu of more time-consuming and burdensome activity logs.

DESIGN

Employees recorded their time spent on communicable disease surveillance for a 2-week period using an activity log. Managers then estimated time spent by each employee on a manager survey. Robust and ordinary least squares regression was used to measure the agreement between the time estimated by the manager and the time recorded by the employee.

MAIN OUTCOME MEASURES

The 2 outcomes for this study included time recorded by the employee on the activity log and time estimated by the manager on the manager survey.

SETTING

This study was conducted in local health departments in Colorado.

PARTICIPANTS

Forty-one Colorado local health departments (82%) agreed to participate.

RESULTS

Seven of the 8 models showed that managers underestimate their employees' time, especially for activities on which an employee spent little time. Manager surveys can best estimate time for time-intensive activities, such as total time spent on a core service or broad public health activity, and yet are less precise when estimating discrete activities.

CONCLUSIONS

When Public Health Services and Systems Research researchers and health departments are conducting studies to determine the cost of public health services, there are many situations in which managers can closely approximate the time required and produce a relatively precise approximation of cost without as much time investment by practitioners.

What Matters in Recruiting Public Health Employees: Considerations for Filling Workforce Gaps

We examined factors that influence the decision to join the public health workforce. In this cross-sectional study, we used 2010 secondary data representing 6939 public health workers. Factors influencing the decision to take jobs in public health were significantly associated with specific previous employment settings. Respondents generally rated organizational factors as more influential than personal factors in terms of their decision to work in governmental public health. Leaders should consider tailoring recruitment efforts to maximize job uptake and enhance the potential for long-term retention.

How to Identify Success Among Networks That Promote Active Living

OBJECTIVES

We evaluated organization- and network-level factors that influence organizations' perceived success. This is important for managing interorganizational networks, which can mobilize communities to address complex health issues such as physical activity, and for achieving change.

METHODS

In 2011, we used structured interview and network survey data from 22 states in the United States to estimate multilevel random-intercept models to understand organization- and network-level factors that explain perceived network success.

RESULTS

A total of 53 of 59 "whole networks" met the criteria for inclusion in the analysis (89.8%). Coordinators identified 559 organizations, with 3 to 12 organizations from each network taking the online survey (response rate = 69.7%; range = 33%-100%). Occupying a leadership position (P < .01), the amount of time with the network (P < .05), and support from community leaders (P < .05) emerged as correlates of perceived success.

CONCLUSIONS

Organizations' perceptions of success can influence decisions about continuing involvement and investment in networks designed to promote environment and policy change for active living. Understanding these factors can help leaders manage complex networks that involve diverse memberships, varied interests, and competing community-level priorities.

Economic Evaluation Enhances Public Health Decision Making

Contemporary public health professionals must address the health needs of a diverse population with constrained budgets and shrinking funds. Economic evaluation contributes to evidence-based decision making by helping the public health community identify, measure, and compare activities with the necessary impact, scalability, and sustainability to optimize population health. Asking "how do investments in public health strategies influence or offset the need for downstream spending on medical care and/or social services?" is important when making decisions about resource allocation and scaling of interventions.

Marshaling the evidence: the prioritized public health accreditation research agenda

A national public health department accreditation program was recently developed and implemented by the Public Health Accreditation Board (PHAB) to improve the quality and performance of public health departments. Because of its potential to transform public health, it is critical that the evidence base around accreditation be strong. With input from public health practitioners and researchers, PHAB developed a research agenda that highlights priority questions related to barriers and facilitators to seeking and obtaining accreditation, the PHAB standards and review process, metrics to determine the impact of accreditation, and benefits and outcomes associated with accreditation for the departments that undergo the process. We present that agenda, discuss the potential challenges of conducting accreditation research, and call on researchers to build a greater base of evidence related to accreditation.

Minimum package of public health services: the adoption of core services in local public health agencies in Colorado

OBJECTIVES

We examined the effect of a state law in Colorado that required local public health agencies to deliver a minimum package of public health services.

METHODS

We used a longitudinal, pre-post study design, with baseline data collected in 2011 and follow-up data collected in 2013. We conducted means testing to analyze the change in service delivery and activities. We conducted linear regression to test for system structure effects on the implementation of core services.

RESULTS

We observed statistically significant increases in several service areas within communicable disease, prevention and population health promotion, and environmental health. In addition to service and program areas, specific activities had significant increases. The significant activity increases were all in population- and systems-based services.

CONCLUSIONS

This project provided insight into the likely effect of national adoption of a minimum package as recommended by the Institute of Medicine. The implementation of a minimum package showed significant changes in service delivery, with specific service delivery measurement over a short period of time. Our research sets up a research framework to further explore core service delivery measure development.

Advancing the use of evidence-based decision-making in local health departments with systems science methodologies

OBJECTIVES

We assessed how systems science methodologies might be used to bridge resource gaps at local health departments (LHDs) so that they might better implement evidence-based decision-making (EBDM) to address population health challenges.

METHODS

We used the New York Academy of Medicine Cardiovascular Health Simulation Model to evaluate the results of a hypothetical program that would reduce the proportion of people smoking, eating fewer than 5 fruits and vegetables per day, being physically active less than 150 minutes per week, and who had a body mass index (BMI) of 25 kg/m(2) or greater. We used survey data from the Behavioral Risk Factor Surveillance System to evaluate health outcomes and validate simulation results.

RESULTS

Smoking rates and the proportion of the population with a BMI of 25 kg/m(2) or greater would have decreased significantly with implementation of the hypothetical program (P < .001). Two areas would have experienced a statistically significant reduction in the local population with diabetes between 2007 and 2027 (P < .05).

CONCLUSIONS

The use of systems science methodologies might be a novel and efficient way to systematically address a number of EBDM adoption barriers at LHDs.

Building the evidence for decision-making: the relationship between local public health capacity and community mortality

OBJECTIVES

We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina.

METHODS

We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality.

RESULTS

Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and children's services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05).

CONCLUSIONS

Our findings, in the context of other studies, provide support for investment in local public health services to improve community health.

Defining and assessing quality improvement outcomes: a framework for public health

We describe an evidence-based framework to define and assess the impact of quality improvement (QI) in public health. Developed to address programmatic and research-identified needs for articulating the value of public health QI in aggregate, this framework proposes a standardized set of measures to monitor and improve the efficiency and effectiveness of public health programs and operations. We reviewed the scientific literature and analyzed QI initiatives implemented through the Centers for Disease Control and Prevention's National Public Health Improvement Initiative to inform the selection of 5 efficiency and 8 effectiveness measures. This framework provides a model for identifying the types of improvement outcomes targeted by public health QI efforts and a means to understand QI's impact on the practice of public health.

Answering the call for integrating population health: insights from health system executives

PURPOSE

The Affordable Care Act is transforming health care practice nationwide through emphasis on population health and prevention. Health care organizations are increasingly required to address population health needs. However, they may be ill equipped to answer that call.

DESIGN/METHODOLOGY/APPROACH

This study identified ways that health care organizations might better integrate public and population health efforts to better respond to this new emphasis on population health. Employing semi-structured key informant interviews, barriers to and facilitators of integration were explored and implications for health care and public health leaders were developed.

FINDINGS

- Participants (n = 17)--including senior hospital executives, group practice administrators, and health department officials--dentified strategies for health care and public health leaders to more effectively integrate in order to achieve better performance and popula-ion health gains. These strategies and their implications are discussed. OORIGINALITY/VALUE:The results of this study provide important value to health care administrators leading efforts to integrate population and public health.

Federal Public Health Workforce Development: An Evidence-Based Approach for Defining Competencies

OBJECTIVE

This study reports the use of exploratory factor analysis to describe essential skills and knowledge for an important segment of the domestic public health workforce-Centers for Disease Control and Prevention (CDC) project officers-using an evidence-based approach to competency development and validation.

DESIGN

A multicomponent survey was conducted. Exploratory factor analysis was used to examine the underlying domains and relationships between competency domains and key behaviors. The Cronbach α coefficient determined the reliability of the overall scale and identified factors.

SETTING AND PARTICIPANTS

All domestic (US state, tribe, local, and territorial) grantees who received funding from the CDC during fiscal year 2011 to implement nonresearch prevention or intervention programs were invited to participate in a Web-based questionnaire.

MAIN OUTCOME MEASURE(S)

A total of 34 key behaviors representing knowledge, skills, and abilities, grouped in 7 domains-communication, grant administration and management, public health applied science and knowledge, program planning and development, program management, program monitoring and improvement, and organizational consultation-were examined.

RESULTS

There were 795 responses (58% response rate). A total of 6 factors were identified with loadings of 0.40 or more for all 34 behavioral items. The Cronbach α coefficient was 0.95 overall and ranged between 0.73 and 0.91 for the factors.

CONCLUSIONS

This study provides empirical evidence for the construct validity of 6 competencies and 34 key behaviors important for CDC project officers and serves as an important first step to evidence-driven workforce development efforts in public health.

Designing for dissemination: lessons in message design from "1-2-3 pap"

Despite a large number of evidence-based health communication interventions tested in private, public, and community health settings, there is a dearth of research on successful secondary dissemination of these interventions to other audiences. This article presents the case study of "1-2-3 Pap," a health communication intervention to improve human papillomavirus (HPV) vaccination uptake and Pap testing outcomes in Eastern Kentucky, and explores strategies used to disseminate this intervention to other populations in Kentucky, North Carolina, and West Virginia. Through this dissemination project, we identified several health communication intervention design considerations that facilitated our successful dissemination to these other audiences; these intervention design considerations include (a) developing strategies for reaching other potential audiences, (b) identifying intervention message adaptations that might be needed, and (c) determining the most appropriate means or channels by which to reach these potential future audiences. Using "1-2-3 Pap" as an illustrative case study, we describe how careful planning and partnership development early in the intervention development process can improve the potential success of enhancing the reach and effectiveness of an intervention to other audiences beyond the audience for whom the intervention messages were originally designed.

Effects of performance improvement programs on preparedness capacities

OBJECTIVE

In response to public health systems and services research priorities, we examined the extent to which participation in accreditation and performance improvement programs can be expected to enhance preparedness capacities.

METHODS

Using data collected by the Local Health Department Preparedness Capacities Assessment Survey, we applied a series of weighted least-squares models to examine the effect of program participation on each of the eight preparedness domain scores. Participation was differentiated across four groups: North Carolina (NC) accredited local health departments (LHDs), NC non-accredited LHDs, national comparison LHDs that participated in performance or preparedness programs, and national comparison LHDs that did not participate in any program.

RESULTS

Domain scores varied among the four groups. Statistically significant positive participation effects were observed on six of eight preparedness domains for NC accreditation programs, on seven domains for national comparison group LHDs that participated in performance programs, and on four domains for NC non-accredited LHDs.

CONCLUSIONS

Overall, accreditation and other performance improvement programs have a significant and positive effect on preparedness capacities. While we found no differences among accredited and non-accredited NC LHDs, this lack of significant difference in preparedness scores among NC LHDs is attributed to NC's robust statewide preparedness program, as well as a likely exposure effect among non-accredited NC LHDs to the accreditation program.

Public health workforce taxonomy

Thoroughly characterizing and continuously monitoring the public health workforce is necessary for ensuring capacity to deliver public health services. A prerequisite for this is to develop a standardized methodology for classifying public health workers, permitting valid comparisons across agencies and over time, which does not exist for the public health workforce. An expert working group, all of whom are authors on this paper, was convened during 2012-2014 to develop a public health workforce taxonomy. The purpose of the taxonomy is to facilitate the systematic characterization of all public health workers while delineating a set of minimum data elements to be used in workforce surveys. The taxonomy will improve the comparability across surveys, assist with estimating duplicate counting of workers, provide a framework for describing the size and composition of the workforce, and address other challenges to workforce enumeration. The taxonomy consists of 12 axes, with each axis describing a key characteristic of public health workers. Within each axis are multiple categories, and sometimes subcategories, that further define that worker characteristic. The workforce taxonomy axes are occupation, workplace setting, employer, education, licensure, certification, job tasks, program area, public health specialization area, funding source, condition of employment, and demographics. The taxonomy is not intended to serve as a replacement for occupational classifications but rather is a tool for systematically categorizing worker characteristics. The taxonomy will continue to evolve as organizations implement it and recommend ways to improve this tool for more accurate workforce data collection.

Evidence-based public health practice among program managers in local public health departments

OBJECTIVES

We assessed the use of administrative-evidence based practices (A-EBPs) among managers of programs in chronic diseases, environmental health, and infectious diseases from a sample of local health departments (LHDs) in the United States.

DESIGN

Program managers completed a survey consisting of 6 sections (biographical data, use of A-EBPs, diffusion attributes, use of resources, and barriers to, and competencies in, evidence-based public health), with a total of 66 questions.

PARTICIPANTS

The survey was sent electronically to 168 program managers in chronic diseases, 179 in environmental health, and 175 in infectious diseases, representing 228 LHDs. The survey had previously been completed by 517 LHD directors.

MEASURES

The use of A-EBPs was scored for 19 individual A-EBPs, across the 5 A-EBP domains, and for all domains combined. Individual characteristics were derived from the survey responses, with additional data on LHDs drawn from linked National Association of County & City Health Officials Profile survey data. Results for program managers were compared across the 3 types of programs and to responses from the previous survey of LHD directors. The scores were ordered and categorized into tertiles. Unconditional logistic regression models were used to calculate odds ratios and 95% confidence intervals, comparing individual and agency characteristics for those with the highest third of A-EBPs scores with those with the lowest third.

RESULTS

The 332 total responses from program managers represented 196 individual LHDs. Program managers differed (across the 3 programs, and compared with LHD directors) in demographic characteristics, education, and experience. The use of A-EBPs varied widely across specific practices and individuals, but the pattern of responses from directors and program managers was very similar for the majority of A-EBPs.

CONCLUSIONS

Understanding the differences in educational background, experience, organizational culture, and performance of A-EBPs between program managers and LHD directors is a necessary step to improving competencies in evidence-based public health.

Using an integrated knowledge translation approach to build a public health research agenda

BACKGROUND

Public Health Systems Research is an emerging field of research that is gaining importance in Canada.

METHODS

On October 22 and 23, 2012, public health researchers, practitioners, and policy-makers came together at the Accelerating Public Health Systems Research in Ontario: Building an Agenda think tank to develop a research agenda for the province.

RESULTS

This agenda included the identification of the six top priorities for research in Ontario: public health performance, evidence-based practice, public health organization and structure, public health human resources, public health infrastructure, and partnerships/linkages.

CONCLUSIONS

This paper explores the priorities in detail and hopes to bring more attention to this area of research.

A partnership of two U.S. research networks to improve public health

Strategic collaborations are essential in moving public health research and practice forward1 , particularly in light of escalating fiscal and environmental challenges facing the public health community. This commentary provides background and context for an emerging partnership between two national networks, Prevention Research Centers (PRCs) and Public Health Practice-Based Research Networks (PBRNs), to impact public health practice. Supported by CDC, PRCs are celebrating over 25 years of transdisciplinary applied prevention research grounded in community and stakeholder engagement. Public Health PBRNs, funded by the Robert Wood Johnson Foundation, conduct innovative public health services and systems research with public health agencies and community partners to improve public health decision-making. By utilizing each of the networks’ respective strengths and resources, collaborative ventures between PRCs and Public Health PBRNs can enhance the translation of applied prevention research to evidence-based practice and empirically investigate novel public health practices developed in the field. Three current PRC-Public Health PBRNs projects are highlighted and future research directions are discussed. Improving the interconnectedness of prevention research and public health practice is essential to improve the health of the Nation.

Creating a national home visiting research network

Home visiting can play a key role in the early childhood system of services. For home visiting to achieve its potential, decision-makers must make informed choices regarding adoption, adaptation, coordination, scale-up, and sustainment. We need a coordinated, focused, and theory-based home visiting research infrastructure to inform such decisions. The transdisciplinary Home Visiting Research Network (HVRN) was established in July 2012 with funding from the Health Resources and Services Administration. Its goal is to promote the translation of research findings into policy and practice. Its objectives are to (1) develop a national home visiting research agenda, (2) advance the use of innovative research methods; and (3) provide a research environment that is supportive of the professional development of emerging researchers interested in home visiting. A Management Team designs and directs activities to achieve these objectives through Work Teams. A Steering Committee of national leaders representing stakeholder groups oversees progress. HVRN's Coordinating Center supports the Work Teams and HVRN's Home visiting Applied Research Collaborative, a practice-based research network of home visiting programs. This article describes HVRN's rationale, approach, and anticipated products. We use home visiting-primary care coordination as an illustration, noting potential roles for pediatric practices and pediatric researchers and research educators in HVRN activities. HVRN creates the infrastructure for a rigorous program of research to inform policy and practice on home visiting as part of the system of services to improve family functioning, parenting, and child outcomes.

An integrative review of information systems and terminologies used in local health departments

OBJECTIVE

The purpose of this integrative review based on the published literature was to identify information systems currently being used by local health departments and to determine the extent to which standard terminology was used to communicate data, interventions, and outcomes to improve public health informatics at the local health department (LHD) level and better inform research, policy, and programs.

MATERIALS AND METHODS

Whittemore and Knafl's integrative review methodology was used. Data were obtained through key word searches of three publication databases and reference lists of retrieved articles and consulting with experts to identify landmark works. The final sample included 45 articles analyzed and synthesized using the matrix method.

RESULTS

The results indicated a wide array of information systems were used by LHDs and supported diverse functions aligned with five categories: administration; surveillance; health records; registries; and consumer resources. Detail regarding specific programs being used, location or extent of use, or effectiveness was lacking. The synthesis indicated evidence of growing interest in health information exchange groups, yet few studies described use of data standards or standard terminology in LHDs.

DISCUSSION

Research to address these gaps is needed to provide current, meaningful data that inform public health informatics research, policy, and initiatives at and across the LHD level.

CONCLUSIONS

Coordination at a state or national level is recommended to collect information efficiently about LHD information systems that will inform improvements while minimizing duplication of efforts and financial burden. Until this happens, efforts to strengthen LHD information systems and policies may be significantly challenged.

Expanding delivery system research in public health settings: lessons from practice-based research networks

BACKGROUND

Delivery system research to identify how best to organize, finance, and implement health improvement strategies has focused heavily on clinical practice settings, with relatively little attention paid to public health settings-where research is made more difficult by wide heterogeneity in settings and limited sources of existing data and measures. This study examines the approaches used by public health practice-based research networks (PBRNs) to expand delivery system research and evidence-based practice in public health settings.

METHODS

Practice-based research networks employ quasi-experimental research designs, natural experiments, and mixed-method analytic techniques to evaluate how community partnerships, economic shocks, and policy changes impact delivery processes in public health settings. In addition, network analysis methods are used to assess patterns of interaction between practitioners and researchers within PBRNs to produce and apply research findings.

RESULTS

Findings from individual PBRN studies elucidate the roles of information exchange, community resources, and leadership and decision-making structures in shaping implementation outcomes in public health delivery. Network analysis of PBRNs reveals broad engagement of both practitioners and researchers in scientific inquiry, with practitioners in the periphery of these networks reporting particularly large benefits from research participation.

CONCLUSIONS

Public health PBRNs provide effective mechanisms for implementing delivery system research and engaging practitioners in the process. These networks also hold promise for accelerating the translation and application of research findings into public health settings.