Fostering more-effective public health by identifying administrative evidence-based practices: a review of the literature

Rural-urban disparities in health outcomes, clinical care, health behaviors, and social determinants of health and an action-oriented, dynamic tool for visualizing them

While rural-urban disparities in health and health outcomes have been demonstrated, because of their impact on (and intervenability to improve) health and health outcomes, we sought to examine cross-sectional and longitudinal inequities in health, clinical care, health behaviors, and social determinants of health (SDOH) between rural and non-rural counties in the pre-pandemic era (2015 to 2019), and to present a Health Equity Dashboard that can be used by policymakers and researchers to facilitate examining such disparities. Therefore, using data obtained from 2015-2022 County Health Rankings datasets, we used analysis of variance to examine differences in 33 county level attributes between rural and non-rural counties, calculated the change in values for each measure between 2015 and 2019, determined whether rural-urban disparities had widened, and used those data to create a Health Equity Dashboard that displays county-level individual measures or compilations of them. We followed STROBE guidelines in writing the manuscript. We found that rural counties overwhelmingly had worse measures of SDOH at the county level. With few exceptions, the measures we examined were getting worse between 2015 and 2019 in all counties, relatively more so in rural counties, resulting in the widening of rural-urban disparities in these measures. When rural-urban gaps narrowed, it tended to be in measures wherein rural counties were outperforming urban ones in the earlier period. In conclusion, our findings highlight the need for policymakers to prioritize rural settings for interventions designed to improve health outcomes, likely through improving health behaviors, clinical care, social and environmental factors, and physical environment attributes. Visualization tools can help guide policymakers and researchers with grounded information, communicate necessary data to engage relevant stakeholders, and track SDOH changes and health outcomes over time.

Understanding Health Equity in Public Health Practice in the United States

CONTEXT

Understanding the extent to which equity-focused work is occurring in public health departments (eg, in chronic disease programs) can identify areas of success and what is needed to move the needle on health equity.

OBJECTIVE

The study objective was to characterize the patterns and correlates of equity-related practices in US state and territorial public health practice.

DESIGN

The design was a multimethod (quantitative and qualitative), cross-sectional study.

SETTING

The setting included US state and territorial public health departments.

PARTICIPANTS

Chronic disease prevention practitioners (N = 600) completed self-report surveys in July 2022 through August 2022 (analyzed in September 2022 through December 2022).

MAIN OUTCOME MEASURES

Health equity data were obtained across 4 domains: (1) staff skills, (2) work unit practices, (3) organizational priorities and values, and (4) partnerships and networks.

RESULTS

There was a wide range in self-reported performance across the health equity variables. The highest values (those agreeing and strongly agreeing) were related to staff skills (eg, the ability to describe the causes of inequities [82%]). Low agreement was reported for multiple items, indicating the lack of systems for tracking progress on health equity (32%), the lack of hiring of staff members who represent disadvantaged communities (33%), and limited use of principles for community engagement (eg, sharing decision-making authority with partners [34%]). Qualitative data provided tangible examples showing how practitioners and their agencies are turning an array of health equity concepts into actions.

CONCLUSIONS

There is urgency in addressing health equity and our data suggest considerable room for enhancing health equity practices in state and territorial public health. To support these activities, our findings provide some of the first information on areas of progress, gaps in practice, and where to target technical assistance, capacity building efforts, and accreditation planning.

A Multiphase Mixed Methods Study on the Integration of a Population Health Approach in Sexual Health Programs and Services in Ontario Public Health Units

PURPOSE

This study investigated the extent of and factors influencing implementation of a population health approach within sexual health programming in public health.

METHOD

This sequential multi-phase mixed methods study combined findings from a quantitative survey assessing the extent that a population health approach was implemented in sexual health programs in Ontario public health units and qualitative interviews with sexual health managers and/or supervisors. Interviews explored factors influencing implementation and were analyzed using directed content analysis.

RESULTS

Staff from fifteen of 34 public health units completed surveys and ten interviews were completed with sexual health managers/supervisors. From the 8 Population Health Key Elements Template, 6 elements were moderately implemented and 2 had low implementation. Qualitative findings focused on enablers and barriers to implementing a population health approach in sexual health programs and services and explained most of the quantitative results. However, some of the quantitative findings were not explained by qualitative data (e.g., low implementation of using the principles of social justice).

CONCLUSION

Qualitative findings revealed factors influencing the implementation of a population health approach. A lack of resources available to health units, differing priorities between health units and community stakeholders, and access to evidence around population-level interventions influenced implementation.

Site-level evidence-based practice accreditation: A qualitative exploration using institutional theory

Accreditation is gaining ground in human services as leaders find ways to demonstrate the quality and legitimacy of services. This study examined site-level accreditation for SafeCare®, an evidence-based practice designed to prevent and reduce child maltreatment. We leveraged two waves of qualitative data to explore the perspectives of trainers, organizational and system leaders, and program developers who participated in an initial rollout of a site-level accreditation process for SafeCare. Institutional theory was used to frame accreditation's potential benefits, burden, and impact. Findings highlight specific considerations for the human service environment, including the inherent resource scarcity, interdependence among organizations, and the impact of cost and slow-moving bureaucratic processes.

Understanding Misimplementation in U.S. State Health Departments: An Agent-Based Model

INTRODUCTION

The research goal of this study is to explore why misimplementation occurs in public health agencies and how it can be reduced. Misimplementation is ending effective activities prematurely or continuing ineffective ones, which contributes to wasted resources and suboptimal health outcomes.

METHODS

The study team created an agent-based model that represents how information flow, filtered through organizational structure, capacity, culture, and leadership priorities, shapes continuation decisions. This agent-based model used survey data and interviews with state health department personnel across the U.S. between 2014 and 2020; model design and analyses were conducted with substantial input from stakeholders between 2019 and 2021. The model was used experimentally to identify potential approaches for reducing misimplementation.

RESULTS

Simulations showed that increasing either organizational evidence-based decision-making capacity or information sharing could reduce misimplementation. Shifting leadership priorities to emphasize effectiveness resulted in the largest reduction, whereas organizational restructuring did not reduce misimplementation.

CONCLUSIONS

The model identifies for the first time a specific set of factors and dynamic pathways most likely driving misimplementation and suggests a number of actionable strategies for reducing it. Priorities for training the public health workforce include evidence-based decision making and effective communication. Organizations will also benefit from an intentional shift in leadership decision-making processes. On the basis of this initial, successful application of agent-based model to misimplementation, this work provides a framework for further analyses.

Practices Among Local Public Health Agencies to Support Evidence-Based Decision Making: A Qualitative Study

OBJECTIVES

Evidence-based decision making (EBDM) capacity in local public health departments is foundational to meeting both organizational and individual competencies and fulfilling expanded roles. In addition to on-the-job training, organizational supports are needed to prepare staff; yet, less is known in this area. This qualitative study explores supportive management practices instituted as part of a training and technical assistance intervention.

DESIGN

This qualitative study used a semistructured interview guide to elicit participants' descriptions and perceptions via key informant interviews. Verbatim transcripts were coded and thematic analyses were conducted.

SETTING

Local public health departments in a US Midwestern state participated in the project.

PARTICIPANTS

Seventeen middle managers and staff from 4 local health departments participated in remote, audio-recorded interviews.

INTERVENTION

Following delivery of a 3½-day in-person training, the study team met with health department leadership teams for department selection of supportive agency policies and procedures to revise or newly create. Periodic remote meetings included collaborative problem-solving, sharing of informational resources, and encouragement.

MAIN OUTCOME MEASURES

Included management practices instituted to support EBDM and impact on day-to-day work as described by the interview participants.

RESULTS

Leadership and middle management practices deemed most helpful included dedicating staff; creating specific guidelines; setting expectations; and providing trainings, resources, and guidance. Health departments with a preexisting supportive organizational culture and climat e were able to move more quickly and fully to integrate supportive management practices. Workforce development included creation of locally tailored overviews for all staff members and onboarding of new staff. Staff wanted additional hands-on skill-building trainings. Several worked with partners to incorporate evidence-based processes into community health improvement plans.

CONCLUSIONS

Ongoing on-the-job experiential learning is needed to integrate EBDM principles into day-to-day public health practice. Management practices established by leadership teams and middle managers can create supportive work environments for EBDM integration.

Leading the way: competencies of leadership to prevent mis-implementation of public health programs

Public health agencies are increasingly concerned with ensuring that they are maximizing limited resources by delivering effective programs to enhance population-level health outcomes. Preventing mis-implementation (ending effective activities prematurely or continuing ineffective ones) is necessary to sustain public health efforts and resources needed to improve health and well-being. The purpose of this paper is to identify the important qualities of leadership in preventing mis-implementation of public health programs. In 2019, 45 state health department chronic disease employees were interviewed via phone and audio-recorded, and the conversations were transcribed verbatim. Thematic analysis focused on items related to mis-implementation and the manners in which leadership were involved in continuing ineffective programs. Final themes were based on a Public Health Leadership Competency Framework. The following themes emerged from their interviews regarding the important leadership competencies to prevent mis-implementation: '(1) leadership and communication; (2) collaborative leadership (3) leadership to adapt programs; (4) leadership and organizational learning and development; and (5) political leadership'. This first of its kind study showed the close interrelationship between mis-implementation and leadership. Increased attention to public health leader competencies might help to reduce mis-implementation in public health practice and lead to more effective and efficient use of limited resources.

Evaluating the sustainability of non-communicable diseases programs in Malaysia

BACKGROUND

The substantial rise in non-communicable diseases (NCDs) over the last two decades poses a major concern to the healthcare services in Malaysia. This study aimed to evaluate the sustainability of the current NCDs programs and identify the challenges and factors impeding the sustainability of the NCDs program implemented under the National Strategic Plan.

METHODS

This study applied the mixed-method approach using the Program Sustainability Assessment Tool (PSAT) to assess the eight domains for program sustainability combined with 5 open-ended questions. The survey was administered to key leaders from the district health offices in Malaysia. The mean score for each sustainability domain and the overall mean sustainability score were determined. Descriptive statistics and thematic analysis were conducted using Statistical Package for the Social Sciences (SPSS) version 25 and NVivo version 12, respectively.

RESULTS

A total of 80 key leaders responded to the survey. Overall seven domains scored an average of ≥ 4 with an overall mean sustainability score of 4.2. The highest domain mean scores were 4.5 (communications) and 4.4 (organizational capacity). The lowest mean score domain was 3.8 (funding stability). The open-ended responses revealed challenges faced by department heads, including implementation difficulties, factors impeding the planning of the NCDs program for sustainability, lack of financial resources, lack of human resources, and support for staff training which are largely consistent with the scores of each domain.

CONCLUSION

The sustainability factors affecting the NCDs program in Malaysia are qualitatively similar to other countries. For greater sustainability capacity, we should work towards strong leadership, strengthening funding stability, and incorporating evidence-based public health strategies in the implementation of the NCDs program.

Influences on the uptake of a population health approach to sexual health programs in Ontario public health units: a qualitative descriptive study

Aim

Population-level prevention initiatives are the cornerstone of public health practice. However, despite this normative practice, sexual health programming within public health has not utilized this approach to the same extent as other public health programs. Understanding requirements to put a population-level approach into practice is needed. The objective of this study was to explore the barriers and facilitators experienced by sexual health programs and services within public health when implementing a population health approach.

Subject design and methods

The principles of qualitative description guided all sampling, data collection and analysis decisions. Data collection involved in-depth semi-structured interviews with 12 sexual health managers and/or supervisors from ten Ontario public health units. Directed content analysis was used to code and synthesize the data. Data collection and analysis was guided using constructs from the Consolidated Framework for Implementation Research.

Results

Factors that served as either barriers and facilitators to implementing a population health approach, were mainly in the inner and outer setting domains of the Consolidated Framework for Implementation Research. Participants identified the presence of community partnerships, adequate staff training on population health, and access to data on population health served as facilitators. In comparison, barriers to implementation included a lack of resources (human, financial) and clinicians' value of and preferences for delivering services at the individual clinic level.

Conclusion

Some clear barriers and facilitators influenced if staff in sexual health programs and services could implement a population health approach. Results indicate where public health resources need to be enhanced to move toward a population health approach and provide insight into what worked and should be considered by public health organizations.

Designing for Dissemination and Sustainability to Promote Equitable Impacts on Health

Designing for dissemination and sustainability (D4DS) refers to principles and methods for enhancing the fit between a health program, policy, or practice and the context in which it is intended to be adopted. In this article we first summarize the historical context of D4DS and justify the need to shift traditional health research and dissemination practices. We present a diverse literature according to a D4DS organizing schema and describe a variety of dissemination products, design processes and outcomes, and approaches to messaging, packaging, and distribution. D4DS design processes include stakeholder engagement, participatory codesign, and context and situation analysis, and leverage methods and frameworks from dissemination and implementation science, marketing and business, communications and visualarts, and systems science. Finally, we present eight recommendations to adopt a D4DS paradigm, reflecting shifts in ways of thinking, skills and approaches, and infrastructure and systems for training and evaluation.

Impact of Contextual Factors on the Attendance and Role in the Evidence-Based Chronic Disease Prevention Programs Among Primary Care Practitioners in Shanghai, China

BACKGROUND

The implementation of evidence-based approaches by general practitioners (GPs) is new in the primary care setting, and few quantitative studies have evaluated the impact of contextual factors on the attendance of these approaches.

METHODS

In total, 892 GPs from 75 community healthcare centers (CHCs) in Shanghai completed our survey. We used logistic regression to analyze factors affecting the number of evidence-based chronic disease programs attended by GPs and whether they had held the lead position in such a program.

RESULTS

A total of 346 (38.8%) of the practitioners had never participated in any evidence-based chronic disease prevention (EBCDP) program. The EBCDP interventions in which the GPs had participated were predominantly related to hypertension, diabetes, and cardiovascular disease. However, the proportion of GPs in the lead role was relatively low, between 0.8% (programs involving prevention and control of asthma) and 5.0% (diabetes). Organizational factors and areas were significantly associated with evidence-based practices (EBPs) of the GP, while monthly income and department were the most significantly related to GPs who have the lead role in a program. The results indicated that GPs who had taken the lead position had higher scores for policy and economic impeding factors. GPs who were men, had a higher income, and worked in prevention and healthcare departments and urban areas were more likely to take the lead position.

CONCLUSION

Evidence-based programs for chronic diseases should be extended to different types of diseases. Personal, organizational, political, and economic factors and the factors of female sex, lower income, department type, and suburban area environment should be considered to facilitate the translation of evidence to practice.

A framework of evidence-based decision-making in health system management: a best-fit framework synthesis

BACKGROUND

Scientific evidence is the basis for improving public health; decision-making without sufficient attention to evidence may lead to unpleasant consequences. Despite efforts to create comprehensive guidelines and models for evidence-based decision-making (EBDM), there isn`t any to make the best decisions concerning scarce resources and unlimited needs. The present study aimed to develop a comprehensive applied framework for EBDM.

METHODS

This was a Best-Fit Framework (BFF) synthesis conducted in 2020. A comprehensive systematic review was done via six main databases including PUBMED, Scopus, Web of Science, Science Direct, EMBASE, and ProQuest using related keywords. After the evidence quality appraisal, data were extracted and analyzed via thematic analysis. Results of the thematic analysis and the concepts generated by the research team were then synthesized to achieve the best-fit framework applying Carroll et al. (2013) approach.

RESULTS

Four thousand six hundred thirteen studies were retrieved, and due to the full-text screening of the studies, 17 final articles were selected for extracting the components and steps of EBDM in Health System Management (HSM). After collecting, synthesizing, and categorizing key information, the framework of EBDM in HSM was developed in the form of four general scopes. These comprised inquiring, inspecting, implementing, and integrating, which included 10 main steps and 47 sub-steps.

CONCLUSIONS

The present framework provided a comprehensive guideline that can be well adapted for implementing EBDM in health systems and related organizations especially in underdeveloped and developing countries where there is usually a lag in updating and applying evidence in their decision-making process. In addition, this framework by providing a complete, well-detailed, and the sequential process can be tested in the organizational decision-making process by developed countries to improve their EBDM cycle.

Force field analysis of driving and restraining factors affecting the evidence-based decision-making in health systems; comparing two approaches

BACKGROUND

All policies and decisions need evidence examined by scientific methods. Moving toward evidence-based decision-making (EBDM) as a change in organizations, especially health systems (HSs), is inevitable. This study was conducted to identify the factors affecting EBDM in HSs from two approaches and to score them.

MATERIALS AND METHODS

A mixed-method study was carried out using the force field analysis regarding the change toward EBDM in HS in 2020. This study included six steps to identify and score the key driving forces (DFs) and restraining forces (RFs) to change toward the EBDM in HS: first, finding forces from literature; second, selecting key DFs and RFs through focus group discussion; third, scoring the first group of DFs and RFs by the experts through electronic forms; fourth, determining key DFs and RFs from the managers' perspective using qualitative interviews; fifth, scoring the second group of DFs and RFs by the experts; and sixth, comparison between forces resulted from two approaches.

RESULTS

According to the literature and experts' opinions, "relevant, reliable, interpretable, and understandable evidence" and "interaction between researchers and decision-makers" were the strongest forces to change, and "lack of organizational commitment and support" and "lack of relevant/high-quality evidence" were the strongest forces against the change toward EBDM in HS. Further, based on managers' perspective and scores by the experts, "suitable supervision and control" and "reforming the planning and decision-making system" were the strongest forces to change, and "inadequate knowledge of the managers and staff about the principles and contents of EBDM" and "issues beyond the authorities of managers" were the strongest forces against the change toward EBDM in HS.

CONCLUSIONS

Based on the findings, HSs' managers can focus to reduce RFs and promote DFs for implementing EBDM strategies, so they can provide better services by making more efficient decisions.

The Relationships Between State Health Department Practitioners' Perceptions of Organizational Supports and Evidence-Based Decision-Making Skills

OBJECTIVES

Evidence-based decision making (EBDM) allows public health practitioners to implement effective programs and policies fitting the preferences of their communities. To engage in EBDM, practitioners must have skills themselves, their agencies must engage in administrative evidence-based practices (A-EBPs), and leaders must encourage the use of EBDM. We conducted this longitudinal study to quantify perceptions of individual EBDM skills and A-EBPs, as well as the longitudinal associations between the 2.

METHODS

An online survey completed among US state health department practitioners in 2016 and 2018 assessed perceptions of respondents' skills in EBDM and A-EBPs. We used χ2 tests, t tests, and linear regressions to quantify changes over time, differences by demographic characteristics, and longitudinal associations between individual skills and A-EBPs among respondents who completed both surveys (N = 336).

RESULTS

Means of most individual EBDM skills and A-EBPs did not change significantly from 2016 to 2018. We found significant positive associations between changes in A-EBPs and changes in EBDM skill gaps: for example, a 1-point increase in the relationships and partnerships score was associated with a narrowing of the EBDM skill gap (β estimate = 0.38; 95% CI, 0.15-0.61). At both time points, perceived skills and A-EBPs related to financial practices were low.

CONCLUSIONS

Findings from this study can guide the development and dissemination of initiatives designed to simultaneously improve individual and organizational capacity for EBDM in public health settings. Future studies should focus on types of strategies most effective to build capacity in particular types of agencies and practitioners, to ultimately improve public health practice.

Strategic Development of the Public Health Workforce: A Unified Logic Model for a Multifaceted Program at the Centers for Disease Control and Prevention

CONTEXT

Public health has a responsibility to ensure the ability of its workforce to deliver essential services, including mastering the core public health competencies.

PROGRAM

The Division of Scientific Education and Professional Development (DSEPD) of the Centers for Disease Control and Prevention has a mission to improve health outcomes through a competent, sustainable, and empowered public health workforce. The DSEPD programs offer fellowships and other training opportunities, develop and disseminate quality public health training, and advance public health workforce development science.

EVALUATION

The DSEPD developed a unified division logic model to describe the combined activities and intended outcomes of all DSEPD programs and their intended contribution to a robust public health workforce and to support ongoing program planning and evaluation. The logic model has 4 streams of work that include (1) producing and disseminating quality learning products; (2) implementing and managing fellowship programs that support learning; (3) providing public health service through fellows; and (4) advancing workforce development science through collaboration with other public health leaders.The underlying program theory is that a robust workforce has sufficient workforce, organizational, and systems capacity to deliver public health essential services and, therefore, to protect the public's health. Three scientific theories support the program theory: the quality of learning; the accepted practice of competency-based programs and the service-learning model; and use of evidence-guided decision making in workforce development programs.

DISCUSSION

A unified division logic model allows DSEPD to describe its combined approaches to workforce development as a coherent portfolio with well-defined goals and measureable outcomes. The logic model effectively communicates the relationship among division programs, their shared outcomes, and their combined contributions to developing and maintaining a robust public health workforce. A unified logic model can serve as effective frame of reference for division evaluation and as evidence in public health workforce development science.

The Association Between Evidence-Based Decision Making and Accreditation of State Health Departments

OBJECTIVE

To assess the association between evidence-based decision making, including implementation of evidence-based interventions (EBIs), with accreditation of state health departments through the Public Health Accreditation Board (PHAB).

DESIGN

This was a cross-sectional, electronic survey of state health department practitioners. We utilized a survey instrument focused on evidence-based public health, de-implementation, and sustainability of public health programs. Survey questions were organized into 6 domains: (1) demographic information; (2) individual-level skills; (3) decision making on programs ending; (4) decision making on programs continuing; (5) organization/agency capacity; and (6) external influences.

PARTICIPANTS

The targeted practitioners were randomly selected from the 3000-person membership of National Association of Chronic Disease Directors and program manager lists from key Centers for Disease Control and Prevention-supported programs in cancer and cancer risk factors. The final target audience for the survey totaled 1329 practitioners, representing all 50 states.

MAIN OUTCOME MEASURE(S)

The main outcome measures included the strength of association between a state's PHAB accreditation status and variables related to evidence-based public health and use of EBIs that fell within the individual participant skills, organization/agency capacity, and external influences domains.

RESULTS

We received 643 valid responses (response rate = 48.4%), representing all 50 states, with 35 states being PHAB accredited. There was a statistically significant association between PHAB accreditation and state health department use of quality improvement processes (P = .002), leadership plans to implement EBIs (P = .009), and leadership reactions to EBI implementation issues (P = .004). Respondents from PHAB-accredited states were significantly more likely than participants from nonaccredited states to report greater engagement with legislators and governors regarding EBIs and 14% less likely to report the inappropriate termination of programs in their work unit (P = .05).

CONCLUSIONS

The importance of accreditation relates to both internally focused functions and externally focused activities, especially regarding policy-related impact.

Long-Term Evaluation of a Course on Evidence-Based Public Health in the U.S. and Europe

The evidence-based public health course equips public health professionals with skills and tools for applying evidence-based frameworks and processes in public health practice. To date, training has included participants from all the 50 U.S. states, 2 U.S. territories, and multiple other countries besides the U.S. This study pooled follow-up efforts (5 surveys, with 723 course participants, 2005-2019) to explore the benefits, application, and barriers to applying the evidence-based public health course content. All analyses were completed in 2020. The most common benefits (reported by >80% of all participants) were identifying ways to apply knowledge in their work, acquiring new knowledge, and becoming a better leader who promotes evidence-based approaches. Participants most frequently applied course content to searching the scientific literature (72.9%) and least frequently to writing grants (42.7%). Lack of funds for continued training (35.3%), not having enough time to implement evidence-based public health approaches (33.8%), and not having coworkers trained in evidence-based public health (33.1%) were common barriers to applying the content from the course. Mean scores were calculated for benefits, application, and barriers to explore subgroup differences. European participants generally reported higher benefits from the course (mean difference=0.12, 95% CI=0.00, 0.23) and higher frequency of application of the course content to their job (mean difference=0.17, 95% CI=0.06, 0.28) than U.S. participants. Participants from later cohorts (2012-2019) reported more overall barriers to applying course content in their work (mean difference=0.15, 95% CI=0.05, 0.24). The evidence-based public health course represents an important strategy for increasing the capacity (individual skills) for evidence-based processes within public health practice. Organization-level methods are also needed to scale up and sustain capacity-building efforts.

Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS)

BACKGROUND

Sepsis survivors experience high morbidity and mortality, and healthcare systems lack effective strategies to address patient needs after hospital discharge. The Sepsis Transition and Recovery (STAR) program is a navigator-led, telehealth-based multicomponent strategy to provide proactive care coordination and monitoring of high-risk patients using evidence-driven, post-sepsis care tasks. The purpose of this study is to evaluate the effectiveness of STAR to improve outcomes for sepsis patients and to examine contextual factors that influence STAR implementation.

METHODS

This study uses a hybrid type I effectiveness-implementation design to concurrently test clinical effectiveness and gather implementation data. The effectiveness evaluation is a two-arm, pragmatic, stepped-wedge cluster randomized controlled trial at eight hospitals in North Carolina comparing clinical outcomes between sepsis survivors who receive Usual Care versus care delivered through STAR. Each hospital begins in a Usual Care control phase and transitions to STAR in a randomly assigned sequence (one every 4 months). During months that a hospital is allocated to Usual Care, all eligible patients will receive usual care. Once a hospital transitions to STAR, all eligible patients will receive STAR during their hospitalization and extending through 90 days from discharge. STAR includes centrally located nurse navigators using telephonic counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted with suspected sepsis, defined by clinical criteria for infection and organ failure, are included. Planned enrollment is 4032 patients during a 36-month period. The primary effectiveness outcome is the composite of all-cause hospital readmission or mortality within 90 days of discharge. A mixed-methods implementation evaluation will be conducted before, during, and after STAR implementation.

DISCUSSION

This pragmatic evaluation will test the effectiveness of STAR to reduce combined hospital readmissions and mortality, while identifying key implementation factors. Results will provide practical information to advance understanding of how to integrate post-sepsis management across care settings and facilitate implementation, dissemination, and sustained utilization of best-practice post-sepsis management strategies in other heterogeneous healthcare delivery systems.

TRIAL REGISTRATION

NCT04495946 . Submitted July 7, 2020; Posted August 3, 2020.

Public Health Employees' Perceptions about the Impact of Emerging Public Health Trends on Their Day-to-Day Work: Effects of Organizational Climate and Culture

Objective: The purpose of this research was to assess the workforce characteristics associated with public health employees' perceived impact of emerging trends in public health on their day-to-day work. Methods: Multinomial logistic regression was performed to analyze data from the 2017 PH WINS, a cross-sectional survey utilizing a nationally representative sample of the United States public health workforce. Results: More than 55% of the public health workforce perceived that their day-to-day work was impacted by the emerging public health trends. Workplace environment was significantly associated with the perception of their day-to-day work being impacted by emerging public health trends such as quality improvement (QI) (AOR = 1.04, p < 0.001), and evidence-based public health practice (EBPH) (AOR = 1.04, p < 0.001). Race, ethnicity, and educational status were also positively associated with the perceived impact of the emerging public health trends. Conclusions: The organizational culture of a public health agency influences the engagement of the workforce and their perception of the meaningfulness of their work. As practitioners shift into chief health strategists, it will be imperative for them to have training in public health foundations and tools in order to efficiently serve their communities.

A mapping of facilitators and barriers to evidence-based management in health systems: a scoping review study

BACKGROUND

Healthcare settings are complex, and the decision-making process is usually complicated, too. Precise use of best evidence from different sources for increasing the desired outcomes is the result of EBM. Therefore, this study aimed to map the potential facilitators and barriers to EBM in health systems to help the healthcare managers to better implement EBM in their organizations.

METHODS

The present study was a scoping review (SR) conducted in 2020 based on the integration of the frameworks presented by Arksey and O'Malley (2005) and Levac et al. (2010) considering the Joanna Briggs Institute guideline (2015). These frameworks consist of 6 steps. After finalizing the search strategy, 7 databases were searched, and the PRISMA-ScR was used to manage the retrieval and inclusion of the evidence. Microsoft Excel 2013 was used to extract the data, and the graphic description was presented. The summative analysis approach was used applying MAXQDA10.

RESULTS

According to the systematic search, 4815 studies were retrieved after eliminating duplicates and unrelated articles, 49 articles remained to extract EBM facilitators and barriers. Six main aspects attitude toward EBM, external factors, contextual factors, resources, policies and procedures, and research capacity and data availability were summarized as EBM facilitators. The barriers to EBM were similarly summarized as attitude toward EBM, external factors, contextual factors, policies and procedures, limited resources, and research capacity and data availability. The streamgraphs describe that the international attention to the sub-aspects of facilitators and barriers of EBM has been increased since 2011.

CONCLUSIONS

The importance of decision-making regarding complex health systems, especially in terms of resource constraints and uncertainty conditions, requires EBM in the health system as much as possible. Identifying the factors that facilitate the use of evidence, as well as its barriers to management and decision-making in the organization, can play an important role in making systematic and reliable decisions that can be defended by the officials and ultimately lead to greater savings in organization resources and prevent them from being wasted.

Patterns and correlates of mis-implementation in state chronic disease public health practice in the United States

BACKGROUND

Much of the disease burden in the United States is preventable through application of existing knowledge. State-level public health practitioners are in ideal positions to affect programs and policies related to chronic disease, but the extent to which mis-implementation occurring with these programs is largely unknown. Mis-implementation refers to ending effective programs and policies prematurely or continuing ineffective ones.

METHODS

A 2018 comprehensive survey assessing the extent of mis-implementation and multi-level influences on mis-implementation was reported by state health departments (SHDs). Questions were developed from previous literature. Surveys were emailed to randomly selected SHD employees across the Unites States. Spearman's correlation and multinomial logistic regression were used to assess factors in mis-implementation.

RESULTS

Half (50.7%) of respondents were chronic disease program managers or unit directors. Forty nine percent reported that programs their SHD oversees sometimes, often or always continued ineffective programs. Over 50% also reported that their SHD sometimes or often ended effective programs. The data suggest the strongest correlates and predictors of mis-implementation were at the organizational level. For example, the number of organizational layers impeded decision-making was significant for both continuing ineffective programs (OR=4.70; 95% CI=2.20, 10.04) and ending effective programs (OR=3.23; 95% CI=1.61, 7.40).

CONCLUSION

The data suggest that changing certain agency practices may help in minimizing the occurrence of mis-implementation. Further research should focus on adding context to these issues and helping agencies engage in appropriate decision-making. Greater attention to mis-implementation should lead to greater use of effective interventions and more efficient expenditure of resources, ultimately to improve health outcomes.

Use and Awareness of The Community Guide in State and Local Health Department Chronic Disease Programs

INTRODUCTION

The Community Guide (Guide) is a user-friendly, systematic review system that provides information on evidence-based interventions (EBIs) in public health practice. Little is known about what predicts Guide awareness and use in state health departments (SHDs) and local health departments (LHDs).

METHODS

We pooled data from 3 surveys (administered in 2016, 2017, and 2018) to employees in chronic disease programs at SHDs and LHDs. Participants (n = 1,039) represented all 50 states. The surveys asked about department practices and individual, organizational, and external factors related to decisions about EBIs. We used χ2 tests of independence for analyses.

RESULTS

Eighty-one percent (n = 498) of SHD and 54% (n = 198) of LHD respondents reported their agency uses the Guide. Additionally, 13% of SHD participants reported not being aware of the Guide. Significant relationships were found between reporting using the Guide and academic collaboration, population size, rated importance of forming partnerships, and accreditation.

CONCLUSION

Awareness and use of the Guide in LHD and SHD chronic disease programs is widespread. Awareness of the Guide can be vital to implementation practice, because it enhances implementation of EBI practices. However, awareness of the Guide alone is likely not enough for health departments to implement EBIs. Changes at the organizational level, including sharing information about the Guide and providing training on how to best use it, may increase its awareness and use.

Rugged landscapes: complexity and implementation science

BACKGROUND

Mis-implementation-defined as failure to successfully implement and continue evidence-based programs-is widespread in public health practice. Yet the causes of this phenomenon are poorly understood.

METHODS

We develop an agent-based computational model to explore how complexity hinders effective implementation. The model is adapted from the evolutionary biology literature and incorporates three distinct complexities faced in public health practice: dimensionality, ruggedness, and context-specificity. Agents in the model attempt to solve problems using one of three approaches-Plan-Do-Study-Act (PDSA), evidence-based interventions (EBIs), and evidence-based decision-making (EBDM).

RESULTS

The model demonstrates that the most effective approach to implementation and quality improvement depends on the underlying nature of the problem. Rugged problems are best approached with a combination of PDSA and EBI. Context-specific problems are best approached with EBDM.

CONCLUSIONS

The model's results emphasize the importance of adapting one's approach to the characteristics of the problem at hand. Evidence-based decision-making (EBDM), which combines evidence from multiple independent sources with on-the-ground local knowledge, is a particularly potent strategy for implementation and quality improvement.

Assessing Organizational Supports for Evidence-Based Decision Making in Local Public Health Departments in the United States: Development and Psychometric Properties of a New Measure

CONTEXT

Fostering evidence-based decision making (EBDM) within local public health departments and among local health department (LHD) practitioners is crucial for the successful translation of research into public health practice to prevent and control chronic disease.

OBJECTIVE

The purpose of this study was to identify organizational supports for EBDM within LHDs and determine psychometric properties of a measure of organizational supports for EBDM in LHDs.

DESIGN

Cross-sectional, observation study.

SETTING

Local public health departments in the United States.

PARTICIPANTS

Local health department practitioners (N = 376) across the United States participated in the study.

MAIN OUTCOME MEASURES

Local health department practitioners completed a survey containing 27 items about organizational supports for EBDM. Most items were adapted from previously developed surveys, and input from researchers and practitioners guided survey development. Confirmatory factor analysis was used to test and refine the psychometric properties of the measure.

RESULTS

The final solution included 6 factors of 22 items: awareness of EBDM (3 items), capacity for EBDM (7 items), resources availability (3 items), evaluation capacity (3 items), EBDM climate cultivation (3 items), and partnerships to support EBDM (3 items). This factor solution achieved acceptable fit (eg, Comparative Fit Index = 0.965). Logistic regression models showed positive relationships between the 6 factors and the number of evidence-based interventions delivered.

CONCLUSIONS

This study identified important organizational supports for EBDM within LHDs. Results of this study can be used to understand and enhance organizational processes and structures to support EBDM to improve LHD performance and population health. Strong measures are important for understanding how LHDs support EBDM, evaluating interventions to improve LHD capacity, and to guide programmatic and policy efforts within LHDs.

Organizational Supports for Research Evidence Use in State Public Health Agencies: A Latent Class Analysis

OBJECTIVE

Use of research evidence in public health decision making can be affected by organizational supports. Study objectives are to identify patterns of organizational supports and explore associations with research evidence use for job tasks among public health practitioners.

DESIGN

In this longitudinal study, we used latent class analysis to identify organizational support patterns, followed by mixed logistic regression analysis to quantify associations with research evidence use.

SETTING

The setting included 12 state public health department chronic disease prevention units and their external partnering organizations involved in chronic disease prevention.

PARTICIPANTS

Chronic disease prevention staff from 12 US state public health departments and partnering organizations completed self-report surveys at 2 time points, in 2014 and 2016 (N = 872).

MAIN OUTCOME MEASURES

Latent class analysis was employed to identify subgroups of survey participants with distinct patterns of perceived organizational supports. Two classify-analyze approaches (maximum probability assignment and multiple pseudo-class draws) were used in 2017 to investigate the association between latent class membership and research evidence use.

RESULTS

The optimal model identified 4 latent classes, labeled as "unsupportive workplace," "low agency leadership support," "high agency leadership support," and "supportive workplace." With maximum probability assignment, participants in "high agency leadership support" (odds ratio = 2.08; 95% CI, 1.35-3.23) and "supportive workplace" (odds ratio = 1.74; 95% CI, 1.10-2.74) were more likely to use research evidence in job tasks than "unsupportive workplace." The multiple pseudo-class draws produced comparable results with odds ratio = 2.09 (95% CI, 1.31-3.30) for "high agency leadership support" and odds ratio = 1.74 (95% CI, 1.07-2.82) for "supportive workplace."

CONCLUSIONS

Findings suggest that leadership support may be a crucial element of organizational supports to encourage research evidence use. Organizational supports such as supervisory expectations, access to evidence, and participatory decision making may need leadership support as well to improve research evidence use in public health job tasks.

Examining the Reproducibility of 6 Published Studies in Public Health Services and Systems Research

OBJECTIVE

Research replication, or repeating a study de novo, is the scientific standard for building evidence and identifying spurious results. While replication is ideal, it is often expensive and time consuming. Reproducibility, or reanalysis of data to verify published findings, is one proposed minimum alternative standard. While a lack of research reproducibility has been identified as a serious and prevalent problem in biomedical research and a few other fields, little work has been done to examine the reproducibility of public health research. We examined reproducibility in 6 studies from the public health services and systems research subfield of public health research.

DESIGN

Following the methods described in each of the 6 papers, we computed the descriptive and inferential statistics for each study. We compared our results with the original study results and examined the percentage differences in descriptive statistics and differences in effect size, significance, and precision of inferential statistics. All project work was completed in 2017.

RESULTS

We found consistency between original and reproduced results for each paper in at least 1 of the 4 areas examined. However, we also found some inconsistency. We identified incorrect transcription of results and omitting detail about data management and analyses as the primary contributors to the inconsistencies.

RECOMMENDATIONS

Increasing reproducibility, or reanalysis of data to verify published results, can improve the quality of science. Researchers, journals, employers, and funders can all play a role in improving the reproducibility of science through several strategies including publishing data and statistical code, using guidelines to write clear and complete methods sections, conducting reproducibility reviews, and incentivizing reproducible science.

Perspectives on program mis-implementation among U.S. local public health departments

BACKGROUND

Public health resources are limited and best used for effective programs. This study explores associations of mis-implementation in public health (ending effective programs or continuing ineffective programs) with organizational supports for evidence-based decision making among U.S. local health departments.

METHODS

The national U.S. sample for this cross-sectional study was stratified by local health department jurisdiction population size. One person was invited from each randomly selected local health department: the leader in chronic disease, or the director. Of 600 selected, 579 had valid email addresses; 376 completed the survey (64.9% response). Survey items assessed frequency of and reasons for mis-implementation. Participants indicated agreement with statements on organizational supports for evidence-based decision making (7-point Likert).

RESULTS

Thirty percent (30.0%) reported programs often or always ended that should have continued (inappropriate termination); organizational supports for evidence-based decision making were not associated with the frequency of programs ending. The main reason given for inappropriate termination was grant funding ended (86.0%). Fewer (16.4%) reported programs often or always continued that should have ended (inappropriate continuation). Higher perceived organizational supports for evidence-based decision making were associated with less frequent inappropriate continuation (odds ratio = 0.86, 95% confidence interval 0.79, 0.94). All organizational support factors were negatively associated with inappropriate continuation. Top reasons were sustained funding (55.6%) and support from policymakers (34.0%).

CONCLUSIONS

Organizational supports for evidence-based decision making may help local health departments avoid continuing programs that should end. Creative mechanisms of support are needed to avoid inappropriate termination. Understanding what influences mis-implementation can help identify supports for de-implementation of ineffective programs so resources can go towards evidence-based programs.

Practitioner perspectives on building capacity for evidence-based public health in state health departments in the United States: a qualitative case study

BACKGROUND

Public health agencies are responsible for implementing effective, evidence-based public health programs and policies to reduce the burden of chronic diseases. Evidence-based public health can be facilitated by modifiable administrative evidence-based practices (A-EBPs) (e.g., workforce development, organizational climate), yet little is known about how practitioners view A-EBPs. Thus, the purpose of this qualitative study was to understand state health department practitioners' perceptions about how A-EBPs are implemented and what facilitators and barriers exist to using A-EBPs.

METHODS

Chronic disease prevention and health promotion program staff who were members of the National Association of Chronic Disease Directors were recruited to participate in telephone interviews using a snowball sampling technique. Interviews were transcribed verbatim, and transcripts were analyzed using a common codebook and the a priori method in NVivo.

RESULTS

Twenty seven interviews were conducted with practitioners in four states (5-8 interviews per state). All practitioners felt that their work unit culture is positive and that leadership encouraged and expected staff to use evidence-based processes. Participants discussed the provision of trainings and technical assistance as key to workforce development and how leaders communicate their expectations. Access to evidence, partnerships, and funding restrictions were the most commonly discussed barriers to the use of A-EBPs and EBDM.

CONCLUSIONS

Results of this study highlight practitioners' perspectives on promoting evidence-based public health in their departments. Findings can inform the development and refinement of resources to improve A-EBP use and organizational and leadership capacity of state health departments.

Local Health Department Accreditation Is Associated With Organizational Supports for Evidence-Based Decision Making

Introduction: Recent studies show that health department accreditation from the U.S. Public Health Accreditation Board (PHAB) drives performance management and quality improvement. PHAB standards call for agencies to use evidence in decision making. It is unknown whether accreditation is associated with organizational supports for evidence-based decision making (EBDM). Self-report data from a 2017 survey of U.S. local health departments were analyzed to test relationships of accreditation status with organizational supports for EBDM.

Methods: A cross-sectional survey was conducted in this observational study. A total of 579 local health departments were invited to complete an online survey; 350 (60.4%) provided complete data for the present study. The dependent variables were six factors of organizational supports for EBDM previously validated through confirmatory factor analyses. Accreditation status (PHAB-accredited, preparing, not preparing) was the independent variable of interest. Logistic regression analyses controlled for governance (presence of a local board of health; state, local, or shared state and local governance) and jurisdiction population size.

Results: PHAB-accredited health departments were more likely to report higher capacity for EBDM, resource availability for EBDM, and evaluation capacity than health departments that reported not yet preparing for accreditation. Health departments that reported preparing for PHAB accreditation showed a non-significant pattern of higher perceived supports for EBDM compared to departments not preparing for accreditation.

Conclusion: PHAB standards and the accreditation process may help stimulate health department organizational supports for EBDM.

Integrating local health departments to reduce suicide-related emergency department visits among people with substance use disorders - Evidence from the state of Maryland

Individuals with a substance use disorder (SUD) are six times as likely than those without a SUD to attempt suicide, however just 18% of the SUD population has received treatment. One of the barriers to treatment is appropriate and timely mental health services. This resulted in a substantial increase in emergency department (ED) visits related to SUD and suicide. This study sought to determine if the number of suicide-related ED visits for patients with SUD is associated with the types of mental health activities provided by their local health department (LHD). Specifically, we examined whether patients with a SUD aged 18-64 experienced reductions in suicide-related ED visits when their LHD directly engaged in mental health activities, such as (1) primary prevention for mental illness or (2) mental health services. Using linked datasets for 2012 from the National Profile of Local Health Departments, U.S. Census data, Area Health Resource File, and Maryland's State Emergency Department Databases (SEDD), we employed multivariable logistic regressions and instrumental variable models to examine this association. After adjusting for the endogeneity of LHDs' activity measures and controlling for individual-, hospital-, LHD-, and county-level characteristics, results demonstrated patients with a SUD experienced a 6% and 5% reduction in suicide-related ED visits when their LHD directly provided primary prevention for mental illness and mental health services, respectively. The results are small but significant, with robust standard errors. This study suggests LHDs may be key players in preventing suicide-related ED visits among the SUD population.

Structured, proactive care coordination versus usual care for Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS): a pragmatic, randomized controlled trial

Background

Hospital mortality for patients with sepsis has recently declined, but sepsis survivors still suffer from significant long-term mortality and morbidity. There are limited data that support effective strategies to address post-discharge management of patients hospitalized with sepsis.

Methods

The Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS) study is a pragmatic, randomized controlled trial at three hospitals within a single healthcare delivery system comparing clinical outcomes between sepsis survivors who receive usual care versus care delivered through the Sepsis Transition and Recovery (STAR) program. The STAR program includes a centrally located nurse navigator using telephone counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies for patients during hospitalization and the 30 days after hospital discharge, including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted through the Emergency Department with suspected infection (i.e., antibiotics initiated, bacterial cultures drawn) and deemed, by previously developed risk-stratification models, high risk for readmission or death are included. Eligible patients are randomly allocated 1:1 to either Arm 1, usual care or Arm 2, STAR. Planned enrollment is 708 patients during a 6-month period. The primary outcome is the composite of all-cause hospital readmissions and mortality assessed 30 days post discharge. Secondary outcomes include 30- and 90-day hospital readmissions, mortality, emergency department visits, acute care-free days alive, and acute care and total costs.

Discussion

This pragmatic evaluation provides the most comprehensive assessment to date of a strategy to improve delivery of recommended post-sepsis care.

Trial registration

ClinicalTrials.gov, NCT03865602. Registered retrospectively on 6 March 2019.

High-Performing Local Health Departments Relate Their Experiences at Community Engagement in Emergency Preparedness

CONTEXT

Local health departments (LHDs) are implementing a national mandate to engage community partners, including individuals, businesses, and community- and faith-based organizations in the larger public health emergency preparedness (PHEP) enterprise.

OBJECTIVE

Investigate how LHDs of varying size and resource levels successfully engage the community in PHEP to help uncover "best practices" that aspiring agencies can replicate, particularly in low-resource environments.

DESIGN

In-depth, semistructured qualitative interviews with practitioners from 9 highly performing LHDs.

SETTING

Participating agencies comprised equal amounts of small (serving <50 000 residents), medium (serving 50 000-500 000 residents), and large (serving >500 000 residents) LHDs and were diverse in terms of geographic region, rural-urban environment, and governance structure.

PARTICIPANTS

A cross section of LHD staff (n = 34) including agency leaders, preparedness coordinators, public information officers, and health educators/promoters.

MAIN OUTCOME MEASURE

Local health department performance at community engagement as determined by top scores in 2 national LHD surveys (2012, 2015) regarding community engagement in PHEP.

RESULTS

Based on key informant accounts, high-performing LHDs show a holistic, organization-wide commitment to, rather than discrete focus on, community engagement. Best practices clustered around 5 domains: administration (eg, top executive who models collaborative behavior), organizational culture (eg, solicitous rather than prescriptive posture regarding community needs), social capital (eg, mining preexisting community connections held by other LHD programs), workforce skills (eg, cultural competence), and methods/tactics (eg, visibility in community events unrelated to PHEP).

CONCLUSIONS

For LHDs that wish to enhance their performance at community engagement in PHEP, change will entail adoption of evidence-based interventions (the technical "what") as well as evidence-based administrative approaches (the managerial "how"). Smaller, rural LHDs should be encouraged that, in the case of PHEP community engagement, they have unique social assets that may help offset advantages that larger, more materially resourced metropolitan health departments may have.

Core Competencies for Chronic Disease Prevention Practice

Chronic disease prevention practice is an important specialization within public health and health care that connects chronic conditions, causes, prevention tactics, and population-based health promotion modalities. Required competencies for successful chronic disease prevention and health promotion encompass leadership, epidemiology, program practice, and evaluation, among others. In 2007, the National Association of Chronic Disease Directors (NACDD) developed and codified the Core Chronic Disease Prevention Competencies (Competencies), a standard set of competencies for professionals in chronic disease prevention and control. NACDD also devised support tools to assist individuals and managers in increasing capacity and opportunities for member growth, thereby benefitting the agencies they serve. In revisiting the Competencies in 2015 through 2018, the NACDD Professional Development Committee reviewed uses, conducted member surveys, polled NACDD councils, and produced recommendations. The goal of this process was to recognize rapid changes in the environments, practices, and characteristics that affect chronic disease prevention, both at the population level and for individual groups at risk during the past 10 years. In addition, opportunities existed to benefit from the changes in technology that have increased demands on health professionals, who as a result have had to adapt to these changes. We worked with the NACDD Learning and Professional Development Committee and reviewed learning offerings, other related competency sets, and tools for performance assessment. The results of the review include a final set of Competencies and subcompetencies, a guide to using the competencies, and a fully integrated interactive assessment tool used by individuals, managers, and teams. Going forward, NACDD’s strategic focus includes a regular review of the Competencies and building chronic disease learning assets.

Lessons Learned in Promoting Evidence-Based Public Health: Perspectives from Managers in State Public Health Departments

Evidence-based public health (EBPH) practice, also called evidence-informed public health, can improve population health and reduce disease burden in populations. Organizational structures and processes can facilitate capacity-building for EBPH in public health agencies. This study involved 51 structured interviews with leaders and program managers in 12 state health department chronic disease prevention units to identify factors that facilitate the implementation of EBPH. Verbatim transcripts of the de-identified interviews were consensus coded in NVIVO qualitative software. Content analyses of coded texts were used to identify themes and illustrative quotes. Facilitator themes included leadership support within the chronic disease prevention unit and division, unit processes to enhance information sharing across program areas and recruitment and retention of qualified personnel, training and technical assistance to build skills, and the ability to provide support to external partners. Chronic disease prevention leaders’ role modeling of EBPH processes and expectations for staff to justify proposed plans and approaches were key aspects of leadership support. Leaders protected staff time in order to identify and digest evidence to address the common barrier of lack of time for EBPH. Funding uncertainties or budget cuts, lack of political will for EBPH, and staff turnover remained challenges. In conclusion, leadership support is a key facilitator of EBPH capacity building and practice. Section and division leaders in public health agencies with authority and skills can institute management practices to help staff learn and apply EBPH processes and spread EBPH with partners.

Community mobilization for rural suicide prevention: Process, learning and behavioral outcomes from Promoting Community Conversations About Research to End Suicide (PC CARES) in Northwest Alaska

RATIONALE

This study evaluates the process and preliminary outcomes of Promoting Community Conversations About Research to End Suicide (PC CARES), an intervention that brings key stakeholders together so they can discuss suicide prevention research and find ways to put it into practice. Originally piloted in remote and rural Alaskan communities, the approach shows promise.

METHOD

Using a multi-method design, the study describes a series of locally-facilitated "learning circles" over 15 months and their preliminary results. Sign-in sheets documented participation. Transcriptions of audio-recorded sessions captured facilitator fidelity, accuracy, and the dominant themes of community discussions. Linked participant surveys (n=83) compared attendees' perceived knowledge, skills, attitudes, and their 'community of practice' at baseline and follow-up. A cross-sectional design compared 112 participants' with 335 non-participants' scores on knowledge and prevention behaviors, and considered the social impact with social network analyses.

RESULTS

Demonstrating feasibility in small rural communities, local PC CARES facilitators hosted 59 two to three hour learning circles with 535 participants (376 unique). Local facilitators achieved acceptable fidelity to the model (80%), and interpreted the research accurately 81% of the time. Discussions reflected participants' understanding of the research content and its use in their lives. Participants showed positive changes in perceived knowledge, skills, and attitudes and strengthened their 'community of practice' from baseline to follow-up. Social network analyses indicate PC CARES had social impact, sustaining and enhancing prevention activities of non-participants who were 'close to' participants. These close associates were more likely take preventive actions than other non-participants after the intervention.

CONCLUSION

PC CARES offers a practical, scalable method for community-based translation of research evidence into selfdetermined, culturally-responsive suicide prevention practice.

Integrated Knowledge Translation with Public Health Policy Makers: A Scoping Review

Integrated knowledge translation (iKT) refers to the engagement of knowledge users (e.g., policy makers, clinicians, patients) as active participants in the research process. Theoretically, this involvement enhances research relevancy and usefulness, thereby supporting health system change. However, evidence to support best practices for iKT is lacking, particularly in a public health context and with non-clinical decision-makers. The objectives of this research were to report how decision-maker involvement in public health iKT research has been described and operationalized and whether the process was evaluated. We conducted a scoping review of published literature from January 2005 to December 2017 and extracted information related to iKT involvement, barriers and facilitators and outcomes. Studies typically did not distinguish between different kinds of knowledge users, making it impossible to comment specifically on decision-makers' involvement. Authors believed knowledge user involvement was beneficial to the quality and potential impact of research activities, although corroborating evaluation data were unavailable. Broad research-knowledge user partnerships spanning multiple projects, as well as flexible involvement of knowledge users, enhanced engagement and supported the iKT process.

Simulation Modeling for Psychiatric Service Planning: Protocol for a Mixed-Methods Study

Background

Mental health service managers must take into account multiple factors when making decisions about the best way to deliver care to clients across increasingly larger service areas. This task is made more difficult by the lack of evidence and tools historically available to inform these decisions. In recent decades, the increasing availability of epidemiological and service use data for mental illness has solved the problem of evidence, but there still exists a challenge to make these data easily accessible and understandable for managers.

Objective

This study aims to develop a simulation modeling tool to allow managers to explore various service configurations in virtual reality, enabling predictions to be made about the cost and quality of care.

Methods

This is a longitudinal, mixed-methods case study, comprising overlapping intervention and evaluation phases. In partnership with senior managers of a mental health program, the researchers will develop a series of simulation models in Arena to address key strategic issues facing the service. Thematic and content analyses of semistructured interviews, meeting observations, and document analysis will be used to evaluate the process of model implementation and the outcomes for both researchers and managers. The study is being conducted in Australia.

Results

Data collection has been ongoing since late 2013. To date, 3 prototype simulation models have been developed and presented to senior managers, and 18 evaluation interviews have been conducted. The project is expected to conclude in late 2018.

Conclusions

Findings of this study have the potential to shape decision making in mental health service delivery, by providing key examples of how to integrate patient data using simulation modeling. In addition, the results will provide key insights into how researchers and consultants can effectively implement simulation modeling in real-world health care organizations.

International Registered Report Identifier (IRRID)

RR1-10.2196/11119

Scaling Up Evidence-Based Public Health Training

Evidence-based public health (EBPH) is the process of integrating science-based interventions with community preferences. Training in EBPH improves the knowledge and skills of public health practitioners. To reach a wider audience, we conducted scale-up efforts including a train-the-trainer version of the EBPH course to build states' capacity to train additional staff. In this essay, we describe formats for course delivery and local adaptations to content, and we review success factors and barriers for state-based replication of the EBPH training course. Findings were based on our experiences and interviews. EBPH training was delivered in varied blended formats as well as in person and in distance courses, each with advantages and disadvantages. Adaptations were made to meet the needs of learners. Success factors included having committed and competent coordinators and trainers, organizational incentives, leadership support, funding, internal and external collaborators, the infrastructure to support training, and models to learn from. Barriers reported included insufficient staff or trainer capacity; time constraints for organizers, trainers, and participants; and lack of sustained funding. We hope our experience and findings will be a guide for states that are committed to building and sustaining capacity through continued EBPH training. Our lessons may also apply more generally to other workforce development training efforts.

Preparing Public Health Professionals to Make Evidence-Based Decisions: A Comparison of Training Delivery Methods in the United States

Background: Evidence-based decision making (EBDM) in health programs and policies can reduce population disease burden. Training in EBDM for the public health workforce is necessary to continue capacity building efforts. While in-person training for EBDM is established and effective, gaps in skills for practicing EBDM remain. Distance and blended learning (a combination of distance and in-person) have the potential to increase reach and reduce costs for training in EBDM. However, evaluations to-date have focused primarily on in-person training. Here we examine effectiveness of in-person trainings compared to distance and blended learning.

Methods: A quasi-experimental pre-post design was used to compare gaps in skills for EBDM among public health practitioners who received in-person training, distance and blended learning, and controls. Nine training sites agreed to replicate a course in EBDM with public health professionals in their state or region. Courses were conducted either in-person (n = 6) or via distance or blended learning (n = 3). All training participants, along with controls, were asked to complete a survey before the training and 6 months post-training. Paired surveys were used in linear mixed models to compare effectiveness of training compared to controls.

Results: Response rates for pre and post-surveys were 63.9 and 48.8% for controls and 81.6 and 62.0% for training groups. Participants who completed both pre and post-surveys (n = 272; 84 in-person, 67 distance or blended, and 121 controls) were mostly female (89.0%) and about two-thirds (65.3%) were from local health departments. In comparison to controls, overall gaps in skills for EBDM were reduced for participants of both in-person training (β = −0.55, SE = 0.27, p = 0.041) and distance or blended training (β = −0.64, SE = 0.29, p = 0.026).

Conclusions: This study highlights the importance of using diverse methods of learning (including distance or blended in-person approaches) for scaling up capacity building in EBDM. Further exploration into effective implementation strategies for EBDM trainings specific to course delivery type and understanding delivery preferences are important next steps.

Comparing Knowledge, Accessibility, and Use of Evidence-Based Chronic Disease Prevention Processes Across Four Countries

Background: Evidence-based chronic disease prevention (EBCDP) effectively reduces incidence rates of many chronic diseases, but contextual factors influence the implementation of EBCDP worldwide. This study aims to examine the following contextual factors across four countries: knowledge, access, and use of chronic disease prevention processes. Methods: In this cross-sectional study, public health practitioners (N = 400) from Australia (n = 121), Brazil (n = 76), China (n = 102), and the United States (n = 101) completed a 26-question survey on EBCDP. One-way ANOVA and Pearson's Chi-Square tests were used to assess differences in contextual factors of interest by country. Results: Practitioners in China reported less knowledge of EBCDP processes (p < 0.001) and less use of repositories of evidence-based interventions, than those from other countries (p < 0.001). Academic journals were the most frequently used method for accessing information about evidence-based interventions across countries. When selecting interventions, Brazilian and Chinese practitioners were more likely to consider implementation ease while the Australian and United States practitioners were more likely to consider effectiveness (p < 0.001). Conclusions: These findings can help inform and improve within and across country strategies for implementing EBCDP interventions.

Factors affecting engagement between academic faculty and decision-makers: learnings and priorities for a school of public health

Background

Schools of public health (SPHs) are increasingly being recognised as important contributors of human, social and intellectual capital relevant to health policy and decision-making. Few studies within the implementation science literature have systematically examined knowledge exchange experiences within this specific organisational context. The purpose of this study was therefore to elicit whether documented facilitators and barriers to engaging with government decision-makers resonates within an academic SPH context. We sought to understand the variations in such experiences at four different levels of government decision-making. Furthermore, we sought to elicit intervention priorities as identified by faculty.

Methods

Between May and December 2016, 211 (34%) of 627 eligible full-time faculty across one SPH in the United States of America participated in a survey on engagement with decision-makers at the city, state, federal and global government levels. Surveys were administered face-to-face or via Skype. Descriptive data as well as tests of association and logistic regression analyses were conducted using STATA.

Results

Over three-quarters of respondents identified colleagues with ties to decision-makers, institutional affiliation and conducting policy-relevant research as the highest facilitators. Several identified time constraints, academic incentives and financial support as important contributors to engagement. Faculty characteristics, such as research areas of expertise, career track and faculty rank, were found to be statistically significantly associated with facilitators. The top three intervention priorities that emerged were (1) creating incentives for engagement, (2) providing funding for engagement and (3) inculcating an institutional culture around engagement.

Conclusions

The data suggest that five principal categories of factors – individual characteristics, institutional environment, relational dynamics, research focus and funder policies – affect the willingness and ability of academic faculty to engage with government decision-makers. This study suggests that SPHs could enhance the relevance of their role in health policy decision-making by (1) periodically measuring engagement with decision-makers; (2) enhancing individual capacity in knowledge translation and communication, taking faculty characteristics into account; (3) institutionalising a culture that supports policies and practices for engagement in decision-making processes; and (4) creating a strategy to expand and nurture trusted, relevant networks and relationships with decision-makers.

Management Practices to Build Evidence-Based Decision-Making Capacity for Chronic Disease Prevention in Georgia: A Case Study

BACKGROUND

Research shows that training can improve skills needed for evidence-based decision making, but less is known about instituting organizational supports to build capacity for evidence-based chronic disease prevention.

COMMUNITY CONTEXT

The objectives of this case study were to assess facilitators and challenges of applying management practices to support evidence-based decision making in chronic disease prevention programs in the public health system in Georgia through key informant interviews and quantitatively test for changes in perceived management practices and skills through a pre-post survey.

METHODS

Leadership of the chronic disease prevention section hosted a multiday training, provided regular supplemental training, restructured the section and staff meetings, led and oversaw technical assistance with partners, instituted transparent performance-based contracting, and made other changes. A 65-item online survey measured perceived importance of skills and the availability of skilled staff, organizational supports, and use of research evidence at baseline (2014) and in 2016 (after training). A structured interview guide asked about management practices, context, internal and external facilitators and barriers, and recommendations.

CAPACITY-BUILDING ACTIVITIES AND SURVEY FINDINGS

Seventy-four staff members and partners completed both surveys (70.5% response). Eleven participants also completed a 1-hour telephone interview. Interview participants deemed leadership support and implementation of multiple concurrent management practices key facilitators to increase capacity. Main challenges included competing priorities, lack of political will, and receipt of requests counter to evidence-based approaches. At posttest, health department staff had significantly reduced gaps in skills overall (10-item sum) and in 4 of 10 individual skills, and increased use of research evidence to justify interventions. Use of research evidence for evaluation, but not skills, increased among partners.

INTERPRETATION

The commitment of leaders with authority to establish multiple management practices to help staff members learn and apply evidence-based decision-making processes is key to increased use of evidence-based chronic disease prevention to improve population health.

Barriers and facilitators to intraorganizational collaboration in public health: Relational coordination across public health services targeting individuals and populations

BACKGROUND

Modern public health emphasizes population-focused services, which may require collaborative work both across and within organizations. Studies have explored interorganizational collaborations, but there are little data regarding collaborations within public health organizations.

PURPOSE

We measured intraorganizational collaboration and identified barriers and facilitators to collaboration within a large public health department through a mixed-methods study.

METHODOLOGY/APPROACH

Our study occurred at the Maricopa County (Arizona) Department of Public Health, the third largest local public health jurisdiction in the United States. To measure collaboration, we surveyed staff using the relational coordination tool. To identify barriers and facilitators to collaboration, we performed key informant interviews with department personnel.

RESULTS

Relational coordination scores varied according to the focus of the service; clinical services had significantly lower levels of relational coordination than population-focused services (p < .01). We found high levels of mutual respect and lower levels of shared knowledge across services. Facilitators to collaboration included purposive cross-program meetings around specific topics, the organization's structure and culture, and individuals' social identities. Barriers included raised expectations for collaboration, low slack resources, member's self-interest, and trust.

CONCLUSION

The relational coordination of services varied significantly according to the focus of the service. Population-focused public health services had higher levels of relational coordination than individually focused services. Collaboration was facilitated and impeded by both well-known and potentially emergent factors, such as purposive cross-service meetings and organizational culture.

PRACTICE IMPLICATIONS

Population-focused services possessed higher levels of collaboration than individually focused services. Intraorganizational collaboration for improved population health relies on deliberate support from senior management and structured activities to increase shared knowledge and mutual respect.

Building Capacity for Evidence-Based Public Health: Reconciling the Pulls of Practice and the Push of Research

Timely implementation of principles of evidence-based public health (EBPH) is critical for bridging the gap between discovery of new knowledge and its application. Public health organizations need sufficient capacity (the availability of resources, structures, and workforce to plan, deliver, and evaluate the preventive dose of an evidence-based intervention) to move science to practice. We review principles of EBPH, the importance of capacity building to advance evidence-based approaches, promising approaches for capacity building, and future areas for research and practice. Although there is general agreement among practitioners and scientists on the importance of EBPH, there is less clarity on the definition of evidence, how to find it, and how, when, and where to use it. Capacity for EBPH is needed among both individuals and organizations. Capacity can be strengthened via training, use of tools, technical assistance, assessment and feedback, peer networking, and incentives. Modest investments in EBPH capacity building will foster more effective public health practice.

Toward optimal implementation of cancer prevention and control programs in public health: a study protocol on mis-implementation

BACKGROUND

Much of the cancer burden in the USA is preventable, through application of existing knowledge. State-level funders and public health practitioners are in ideal positions to affect programs and policies related to cancer control. Mis-implementation refers to ending effective programs and policies prematurely or continuing ineffective ones. Greater attention to mis-implementation should lead to use of effective interventions and more efficient expenditure of resources, which in the long term, will lead to more positive cancer outcomes.

METHODS

This is a three-phase study that takes a comprehensive approach, leading to the elucidation of tactics for addressing mis-implementation. Phase 1: We assess the extent to which mis-implementation is occurring among state cancer control programs in public health. This initial phase will involve a survey of 800 practitioners representing all states. The programs represented will span the full continuum of cancer control, from primary prevention to survivorship. Phase 2: Using data from phase 1 to identify organizations in which mis-implementation is particularly high or low, the team will conduct eight comparative case studies to get a richer understanding of mis-implementation and to understand contextual differences. These case studies will highlight lessons learned about mis-implementation and identify hypothesized drivers. Phase 3: Agent-based modeling will be used to identify dynamic interactions between individual capacity, organizational capacity, use of evidence, funding, and external factors driving mis-implementation. The team will then translate and disseminate findings from phases 1 to 3 to practitioners and practice-related stakeholders to support the reduction of mis-implementation.

DISCUSSION

This study is innovative and significant because it will (1) be the first to refine and further develop reliable and valid measures of mis-implementation of public health programs; (2) bring together a strong, transdisciplinary team with significant expertise in practice-based research; (3) use agent-based modeling to address cancer control implementation; and (4) use a participatory, evidence-based, stakeholder-driven approach that will identify key leverage points for addressing mis-implementation among state public health programs. This research is expected to provide replicable computational simulation models that can identify leverage points and public health system dynamics to reduce mis-implementation in cancer control and may be of interest to other health areas.

Administrative Evidence-based Practices in State Chronic Disease Practitioners

INTRODUCTION

Research and lessons from community implementation have informed evidence-based practices that can improve the effectiveness of health initiatives. Administrative evidence-based practices (A-EBPs) facilitate the role of public health departments in implementing the most effective programs and policies. The purpose of this study is to describe A-EBPs in relation to characteristics of chronic disease practitioners in state health departments.

METHODS

Randomly selected chronic disease practitioners who worked in state health departments were invited to complete an online survey in 2016. The survey included questions on five domains of A-EBPs: workforce development, leadership, culture and climate, relationships and partners, and financial practices. State-level variables that could potentially affect the use of A-EBPs were collected and used in a regression model.

RESULTS

Analysis was conducted in 2016 on data from 571 respondents. Mean percentages of those who strongly agreed/agreed were lowest for financial practices (41.49%) and leadership (42.33%) with higher means for culture and climate (54.52%) and relationships and partners (58.71%). State poverty level was the only significant predictor of A-EBP scores after adjusting for other covariates in a regression model.

CONCLUSIONS

These results show several areas of high agreement with A-EBP within the domains measured as well as opportunities for improvement. Highlighting the importance of A-EBPs to public health leadership level may enhance practice. There is also need for developing plans for an aging workforce and cultivating partnerships with health care and other sectors. Findings can be used to target training for enhancement of A-EBPs within state health departments.

Patterns and correlates of use of evidence-based interventions to control diabetes by local health departments across the USA

OBJECTIVE

The nearly 3000 local health departments (LHDs) nationwide are the front line of public health and are positioned to implement evidence-based interventions (EBIs) for diabetes control. Yet little is currently known about use of diabetes-related EBIs among LHDs. This study used a national online survey to determine the patterns and correlates of the Centers for Disease Control and Prevention Community Guide-recommended EBIs for diabetes control in LHDs.

RESEARCH DESIGN AND METHODS

A cross-sectional study was conducted to survey a stratified random sample of LHDs regarding department characteristics, respondent characteristics, evidence-based decision making within the LHD, and delivery of EBIs (directly or in collaboration) within five categories (diabetes-related, nutrition, physical activity, obesity, and tobacco). Associations between delivering EBIs and respondent and LHD characteristics and evidence-based decision making were explored using logistic regression models.

RESULTS

Among 240 LHDs there was considerable variation among the EBIs delivered. Diabetes prevalence in the state was positively associated with offering the Diabetes Prevention Program (OR=1.28 (95% CI 1.02 to 1.62)), diabetes self-management education (OR=1.32 (95% CI 1.04 to 1.67)), and identifying patients and determining treatment (OR=1.27 (95% CI 1.05 to 1.54)). Although all organizational supports for evidence-based decision making factors were related in a positive direction, the only significant association was between evaluation capacity and identifying patients with diabetes and determining effective treatment (OR=1.54 (95% CI 1.08 to 2.19)).

CONCLUSION

Supporting evidence-based decision making and increasing the implementation of these EBIs by more LHDs can help control diabetes nationwide.

Controlling Chronic Diseases Through Evidence-Based Decision Making: A Group-Randomized Trial

Introduction

Although practitioners in state health departments are ideally positioned to implement evidence-based interventions, few studies have examined how to build their capacity to do so. The objective of this study was to explore how to increase the use of evidence-based decision-making processes at both the individual and organization levels.

Methods

We conducted a 2-arm, group-randomized trial with baseline data collection and follow-up at 18 to 24 months. Twelve state health departments were paired and randomly assigned to intervention or control condition. In the 6 intervention states, a multiday training on evidence-based decision making was conducted from March 2014 through March 2015 along with a set of supplemental capacity-building activities. Individual-level outcomes were evidence-based decision making skills of public health practitioners; organization-level outcomes were access to research evidence and participatory decision making. Mixed analysis of covariance models was used to evaluate the intervention effect by accounting for the cluster randomized trial design. Analysis was performed from March through May 2017.

Results

Participation 18 to 24 months after initial training was 73.5%. In mixed models adjusted for participant and state characteristics, the intervention group improved significantly in the overall skill gap (P = .01) and in 6 skill areas. Among the 4 organizational variables, only access to evidence and skilled staff showed an intervention effect (P = .04).

Conclusion

Tailored and active strategies are needed to build capacity at the individual and organization levels for evidence-based decision making. Our study suggests several dissemination interventions for consideration by leaders seeking to improve public health practice.

Suggestions for the promotion of evidence-based public health in South Korea

Evidence-based public health (EBPH) is defined as public health decision-making based on current best evidence. Debates about the latent tuberculosis infection control program suggested by the Korea Centers for Disease Control and Prevention in 2017 highlight the need to promote EBPH. Three strategies have been proposed, including providing necessary evidence by evaluating policy-evidence gaps; delivering high-quality, relevant, and timely evidence by conducting systematic reviews and adapting public health guidelines; and making value-driven decisions by training and educating public health policymakers.