Applying health services research to public health practice: an emerging priority

Implementation research: Road map from research to practice

The challenge today is to make sure that the evidence available gets implemented for betterment of human wellbeing. The research which is closely associated with implementation, challenges and outcome of evidence in real life scenario is Implementation research (IR). The current prespective explains why there is a focus on IR by all icluding researchers, practitioners and policy makers. The approaches and study designs commonly used in the IR have been described. The IR is multi-disciplinary, multilevel and contextual in nature. The outcomes in IR are proximal. The article further describes the ethical issue and the way forward for IR. We need to do capacity building of practitioners, researchers and policymakers in IR.

Qualitative Insights From Governmental Public Health Employees About Experiences Serving During the COVID-19 Pandemic, PH WINS 2021

OBJECTIVE

The purpose of the current study was to examine governmental public health employee experiences during the COVID-19 pandemic.

DESIGN AND SETTING

A total of 5169 responses to a PH WINS 2021 open-ended question were qualitatively coded. The question asked employees to share their experiences during the COVID-19 response. The 15 most common themes are discussed.

PARTICIPANTS

Responses from governmental public health employees in state health agencies (SHAs), big cities (Big City Health Coalition or BCHC agencies), and local health departments (LHDs) across all 50 states were included.

RESULTS

The most frequently identified theme was pride in public health work and/or the mission of public health (20.8%), followed by leadership (17.2%), burnout or feeling overwhelmed (14%), communication (11.7%), and overtime/extra work (9.7%). Among the top 15 themes identified, comments about pride in public health work and/or the mission of public health (95.9%), teamwork (81.5%), and telework (61%) were predominantly positive. Co-occurring themes for responses that expressed pride in public health work and/or the mission of public health were often countered with explanations of why respondents remain frustrated, including feeling burned out or overwhelmed , disappointment with the community's sense of responsibility or trust in science , and feeling unappreciated either by the community or their agency. All of these co-occurring themes were predominantly negative.

CONCLUSIONS

Employees are proud to work in public health and value teamwork but often felt overworked and unappreciated during the COVID-19 pandemic. Reviewing existing emergency preparedness protocols in the context of lessons learned during the COVID-19 pandemic and listening to employees' experiences with teleworking and task sharing may better prepare agencies for future challenges. Creating channels for clear communication during a period of changing information and guidelines may help employees feel more prepared and valued during an emergency response.

An American Perspective of the Dental and Public Health Initiatives in Cuba

Aim:

To compare following the Cuban Revolution, Cuba’s economy and civil society was transformed by the initiation of a program of nationalization and political consolidation. The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the healthcare of its citizens. Other industrialized nations continue to surpass the US in health-related outcomes indicating areas of improvement in its healthcare system. Assessing the successes and failures as well as the advantages and disadvantages of other countries’ healthcare systems may be instrumental in the development of modifications to the organization and delivery system of healthcare in the US. This paper aims to report the information attained from previous literature as well as from first-hand observations from a public health trip to Cuba in order to compare the healthcare systems in Cuba and the United States.

Materials and Methods:

A group of New York University College of Dentistry faculty and students traveled to Cuba in April 2019 for professional research and professional meetings (CFR 515.564). While in Cuba, the researchers took written notes of the lecture-based material and conversations. Upon return to the United States, published literature was searched for the collection of any additional data and all qualitative data and quantitative data was compiled and organized. Since 1959, Cuba has made continuous adjustments and improvements to its universal, free and accessible healthcare system.

Results:

There have been notable improvements to the country’s public health status, such as the implementation of an immunization program and subsequent eradication of communicable diseases, such as polio and rubella. Additionally, the implementation of the National Program on Dentistry guarantees dental care to all Cuban children under the age of 19. Today, the Cuban National Health System (NHS) initiatives have evolved to combat the novel coronavirus (COVID-19) pandemic.

Conclusion:

Recognizing the advantages as well as the disadvantages of the Cuba’s National Health System (NHS) would be useful for future policymakers in the United States. Cuban approaches to health could be tailored to the United States environment to improve healthcare effectiveness and population health status in the future.

An RCT to Facilitate Implementation of School Practices Known to Increase Physical Activity

INTRODUCTION

Although comprehensive school-based physical activity interventions are efficacious when tested under research conditions, they often require adaptation in order for implementation at scale. This paper reports the effectiveness of an adapted efficacious school-based intervention in improving children's moderate to vigorous physical activity. The impact of strategies to support program implementation was also assessed.

DESIGN

A cluster RCT of low socioeconomic elementary schools in New South Wales, Australia.

SETTING/PARTICIPANTS

Consenting schools were randomized (25 intervention, 21 control) using a computerized random number function. Follow-up measures were taken at 6 months post-randomization (May-August 2015) by blinded research assistants. The multicomponent school-based intervention, based on an efficacious school-based physical activity program (Supporting Children's Outcomes using Rewards, Exercise and Skills), consisted of four physical activity strategies and seven implementation support strategies. The intervention was adapted for scalability and delivery by a local health service over 6 months. The primary outcome was accelerometer assessed, student mean daily minutes spent in moderate to vigorous physical activity. Physical education lesson quality and other school physical activity practices were also assessed.

RESULTS

Participants (n=1,139, 49% male) were third- through sixth-grade students at follow-up (May-August 2015). Valid wear time and analysis of data were provided for 989 (86%) participants (571 intervention, 568 control). At 6-month follow-up, there were no significant effects in overall daily minutes of moderate to vigorous physical activity between groups (1.96 minutes, 95% CI= -3.49, 7.41, p=0.48). However, adjusted difference in mean minutes of overall vigorous physical activity (2.19, 95% CI=0.06, 4.32, p=0.04); mean minutes of school day moderate to vigorous physical activity (2.90, 95% CI=0.06, 5.85, p=0.05); and mean minutes of school day vigorous physical activity (1.81, 95% CI=0.78, 2.83, p≤0.01) were significantly different in favor of the intervention group. Physical education lesson quality and school physical activity practices were significantly different favoring the intervention group (analyzed October 2015-January 2016).

CONCLUSIONS

The modified intervention was not effective in increasing children's overall daily minutes of moderate to vigorous physical activity, when adapted for implementation at scale. However, the intervention did improve daily minutes of vigorous physical activity and school day moderate to vigorous physical activity, lesson quality, and school physical activity practices.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12615000437561.

Knowing Where Public Health Is Going: Levels and Determinants of Workforce Awareness of National Public Health Trends

CONTEXT

Several recent developments are trending in public health, providing an important window into the future of policy and practice in the field. The extent to which public health workforce is aware of these trends has not been assessed.

OBJECTIVE

This research examined the extent to which the public health workforce is familiar with 8 important developments and trends in public health and explored factors associated with variation in awareness levels.

DESIGN

This study characterizes an observational cross-sectional design, based on analysis of secondary data collected by the Association of State and Territorial Health Officials through the Public Health Workforce Interests and Needs Survey (PH WINS).

SETTING

Our study used data from those states for which representative samples for the local health department (LHD) employees were also available.

PARTICIPANTS

We included survey responses from employees of state health agencies' central offices and LHDs.

MAIN OUTCOME MEASURE

The primary outcome variable for the analysis was the level of awareness about emerging public health trends in the public health workforce.

RESULTS

Awareness of emerging trends was lowest for Public Health Systems and Services Research; roughly 1 in 4 employees were aware of this trend. The second least heard of trends were Health in All Policies, and cross-jurisdictional sharing. The public health trends about which the highest proportion of public health employees had heard were implementation of the Patient Protection and Affordable Care Act and evidence-based public health practice. Awareness about public health trends was generally higher among state health agency employees than among LHD employees. Work environment, supervisory status, employee education, and female gender were significantly associated with higher awareness levels for both state health agency and LHD employees.

CONCLUSIONS

Public health trends that are important for health agencies should be brought to the spotlight in national dialogue in order to increase practitioner involvement in those initiatives.

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

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

The Double Disparity Facing Rural Local Health Departments

Residents of rural jurisdictions face significant health challenges, including some of the highest rates of risky health behaviors and worst health outcomes of any group in the country. Rural communities are served by smaller local health departments (LHDs) that are more understaffed and underfunded than their suburban and urban peers. As a result of history and current need, rural LHDs are more likely than their urban peers to be providers of direct health services, leading to relatively lower levels of population-focused activities. This review examines the double disparity faced by rural LHDs and their constituents: pervasively poorer health behaviors and outcomes and a historical lack of investment by local, state, and federal public health entities.

Adoption of Evidence-Based Interventions in Local Health Departments: "1-2-3 Pap NC"

Descriptions of barriers and facilitators to adoption of evidence-based interventions in local health departments (LHDs) are limited. This study was conducted by the North Carolina Public Health Practice-Based Research Network to identify factors associated with adoption of an evidence-based human papillomavirus video intervention, "1-2-3 Pap NC," in North Carolina LHDs. A sequential mixed-method study design was used. Data from the 2013 National Profile of Local Health Departments were used to test associations between LHD characteristics and adoption of the intervention. Qualitative, key stakeholder interviews with LHD directors provided the context for quantitative data. Data collection and analysis continued from March 3, 2014, to September 15, 2014. Overall, 28% of North Carolina health jurisdictions (33 of 100 counties) implemented the intervention. Of the three channels used to deliver the intervention to clients, most LHDs opted to show the video in the exam room (42%), followed by website/other social media (36%) and video loop in the lobby/waiting room (22%). In logistic regression, gender of the director (female) was significantly and positively associated with adoption of the intervention (AOR=4.44, p<0.05). Being a first-time director was marginally significant (AOR=0.28, p=0.074), suggesting first-time directors were less likely to adopt. Qualitative results suggested that aspects of communication (awareness and positive attitudes) and agency directors' evaluation of resources, balanced against intervention complexity and flexibility, competing priorities, and mandates, influenced adoption. Adoption of evidence-based interventions by LHDs is critical to improve population health. Practice-based research can contribute to understanding facilitators and modifying barriers to this process.

A case study examination of structure and function in a state health department chronic disease unit

OBJECTIVES

I explored the structural and operational practices of the chronic disease prevention and control unit of a state health department and proposed a conceptual model of structure, function, and effectiveness for future study.

METHODS

My exploratory case study examined 7 elements of organizational structure and practice. My interviews with staff and external stakeholders of a single chronic disease unit yielded quantitative and qualitative data that I coded by perspective, process, relationship, and activity. I analyzed these for patterns and emerging themes.

RESULTS

Chi-square analysis revealed significant correlations among collaboration with goal ambiguity, political support, and responsiveness, and evidence-based decisions with goal ambiguity and responsiveness.

CONCLUSIONS

Although my study design did not permit conclusions about causality, my findings suggested that some elements of the model might facilitate effectiveness for chronic disease units and should be studied further. My findings might have important implications for identifying levers around which capacity can be built that may strengthen effectiveness.

Defining information needs for public health systems and services research

BACKGROUND

People who lead or manage public health agencies have multiple needs for information in order to do their jobs effectively. In seeking to investigate "what works" in public health practice, investigators in the field of public health systems and services research (PHSSR) have largely overlapping information needs but often require a greater detail, specificity, or comprehensiveness than is routinely available in public health data systems.

PHSSR DATA NEEDS MEETING

On April 24, 2014, the PHSSR Center of the University of Kentucky and AcademyHealth convened a 1-day meeting of public health practitioners and PHSSR investigators to identify PHSSR information needs. Meeting participants considered data needs for three PHSSR domains: the organization of public health agencies and services, the use of rapidly evolving health information technologies, and the financing and economic evaluation of public health activities.

FUTURE DATA NEEDS

Identifying data needs in these and other PHSSR domains requires clarification of research questions, consideration of research methods, a balance of imagination and practicality, and investments to extend the information captured in existing administrative, financial, and population health monitoring systems.

Public health research implementation and translation: evidence from practice-based research networks

BACKGROUND

Research on how best to deliver efficacious public health strategies in heterogeneous community and organizational contexts remains limited. Such studies require the active engagement of public health practice settings in the design, implementation, and translation of research. Practice-based research networks (PBRNs) provide mechanisms for research engagement, but until now they have not been tested in public health settings.

PURPOSE

This study uses data from participants in 14 public health PBRNs and a national comparison group of public health agencies to study processes influencing the engagement of public health settings in research implementation and translation activities.

METHODS

A cross-sectional network analysis survey was fielded with participants in public health PBRNs approximately 1 year after network formation (n=357) and with a nationally representative comparison group of U.S. local health departments not participating in PBRNs (n=625). Hierarchic regression models were used to estimate how organizational attributes and PBRN network structures influence engagement in research implementation and translation activities. Data were collected in 2010-2012 and analyzed in 2012.

RESULTS

Among PBRN participants, both researchers and practice agencies reported high levels of engagement in research activities. Local public health agencies participating in PBRNs were two to three times more likely than nonparticipating agencies to engage in research implementation and translation activities (p<0.05). Participants in less densely connected PBRN networks and in more peripheral locations within these networks reported higher levels of research engagement, greater perceived benefits from engagement, and greater likelihood of continued participation.

CONCLUSIONS

PBRN networks can serve as effective mechanisms for facilitating research implementation and translation among public health practice settings.

Applying evidence to patient care: from population health to individual patient values

What are the health status and health needs of people with epilepsy? How do clinicians and patients choose between alternative interventions for the same condition? Are health interventions used effectively in the community, and do they improve health? How can we translate findings from regulatory clinical trials to the real world? These and similar questions are the subject of applied translational research. This evolving and broad-ranging area of research involves the application of basic sciences such as epidemiology, biostatistics, economics, and behavioral science to the assessment of health, health interventions, and outcomes. However, despite its palpable importance, applied translational research remains underfunded and underutilized. Using their own innovative research as a prototype, two young and promising investigators provide insights not only into the enormous potential but also the gaps and hurdles of two specific areas of applied translational research, i.e., clinical decision analysis and health services research. The message is clear that if we are to understand and improve the health of people with epilepsy in clinics, hospitals, and communities, we must substantially increase research capacity to address the many gaps that thwart our progress in applied research in epilepsy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Local Legal Infrastructure and Population Health

Objectives. We explored the association between the legal infrastructure of local public health, as expressed in the exercise of local fiscal and legislative authority, and local population health outcomes.

Methods. Our unit of analysis was public health jurisdictions with at least 100 000 residents. The dependent variable was jurisdiction premature mortality rates obtained from the Mobilize Action Toward Community Health (MATCH) database. Our primary independent variables represented local public health’s legal infrastructure: home rule status, board of health power, county government structure, and type of public health delivery system. Several control variables were included. We used a regression model to test the relationship between the varieties of local public health legal infrastructure identified and population health status.

Results. The analyses suggested that public health legal infrastructure, particularly reformed county government, had a significant effect on population health status as a mediator of social determinants of health.

Conclusions. Because states shape the legal infrastructure of local public health through power-sharing arrangements, our findings suggested recommendations for state legislation that positions local public health systems for optimal impact. Much more research is needed to elucidate the complex relationships among law, social capital, and population health status.

The curious case of Cuba

As health professionals in the United States consider how to focus health care and coverage to ensure better, more equitable patient and population health outcomes, the experience of Cuba's National Health System over the last 5 decades may provide useful insights. Although mutual awareness has been limited by long-term political hostilities between the United States and Cuban governments, the history and details of the Cuban health system indicate that their health system merits attention as an example of a national integrated approach resulting in improved health status. More extensive analysis of the principles, practices, and outcomes in Cuba is warranted to inform health system transformation in the United States, despite differences in political-social systems and available resources.

Moving from intersection to integration: public health law research and public health systems and services research

CONTEXT

For three decades, experts have been stressing the importance of law to the effective operation of public health systems. Most recently, in a 2011 report, the Institute of Medicine recommended a review of state and local public health laws to ensure appropriate authority for public health agencies; adequate access to legal counsel for public health agencies; evaluations of the health effects and costs associated with legislation, regulations, and policies; and enhancement of research methods to assess the strength of evidence regarding the health effects of public policies. These recommendations, and the continued interest in law as a determinant of health system performance, speak to the need for integrating the emerging fields of Public Health Law Research (PHLR) and Public Health Systems and Services Research (PHSSR).

METHODS

Expert commentary.

FINDINGS

This article sets out a unified framework for the two fields and a shared research agenda built around three broad inquiries: (1) the structural role of law in shaping the organization, powers, prerogatives, duties, and limitations of public health agencies and thereby their functioning and ultimately their impact on public health ("infrastructure"); (2) the mechanisms through which public health system characteristics influence the implementation of interventional public health laws ("implementation"); and (3) the individual and system characteristics that influence the ability of public health systems and their community partners to develop and secure enactment of legal initiatives to advance public health ("innovation"). Research to date has laid a foundation of evidence, but progress requires better and more accessible data, a new generation of researchers comfortable in both law and health research, and more rigorous methods.

CONCLUSIONS

The routine integration of law as a salient factor in broader PHSSR studies of public health system functioning and health outcomes will enhance the usefulness of research in supporting practice and the long-term improvement of system performance.

A national research agenda for public health services and systems

The field of public health services and systems research (PHSSR) has emerged over the past decade to produce the evidence needed to address critical uncertainties about how best to organize, finance, and deliver effective public health strategies to all Americans. To advance these efforts, a national PHSSR research agenda-setting process was used to identify a broad inventory of information needs and uncertainties that public health stakeholders face in the domains of public health workforce, public health system structure and performance, public health financing, and public health information and technology. This paper presents the results of an expert review process used to transform the identified information needs into a concise set of research questions that can be pursued through new scientific inquiry in PHSSR. Established research frameworks were used to specify the contexts, mechanisms of action, and outcomes within the public health system that require further study. A total of 72 research questions were developed from the 113 original items in the PHSSR inventory of information needs. The questions include both persistent problems and newly emerging needs in public health practice and policy. The resulting research agenda provides a starting point for mobilizing the public health scientific enterprise around contemporary, high-priority uncertainties identified by broad cross sections of public health stakeholders. Regular updates to this agenda will be required to achieve continuous improvements in both the science and practice of public health.

Methods in public health services and systems research: a systematic review

CONTEXT

Public Health Services and Systems Research (PHSSR) is concerned with evaluating the organization, financing, and delivery of public health services and their impact on public health. The strength of the current PHSSR evidence is somewhat dependent on the methods used to examine the field. Methods used in PHSSR articles, reports, and other documents were reviewed to assess their methodologic strengths and challenges in light of PHSSR goals.

EVIDENCE ACQUISITION

A total of 364 documents from the PHSSR library met the inclusion criteria as empirical and based in the U.S. After additional exclusions, 327 of these were analyzed.

EVIDENCE SYNTHESIS

A detailed codebook was used to classify articles in terms of (1) study design; (2) sampling; (3) instrumentation; (4) data collection; (5) data analysis; and (6) study validity. Inter-coder reliability was assessed for the codebook; once it was found reliable, the available empirical documents were coded.

CONCLUSIONS

Although there has been a dramatic increase in the amount of published PHSSR recently, methods used remain primarily cross-sectional and descriptive. Moreover, although appropriate for exploratory and foundational work in a new field, these approaches are limiting progress toward some PHSSR goals. Recommendations are given to advance and strengthen the methods used in PHSSR to better meet the goals and challenges facing the field.

Resources that may matter: the impact of local health department expenditures on health status

OBJECTIVES

This study examines the association between changes in local health department (LHD) expenditures, aggregated to the state level, and changes in state-level measures of health, from 1993 to 2005. The literature on the impact of LHD resources on health status has been limited by cross-sectional designs. With repeated surveys of LHDs, it is now possible to use longitudinal designs to explore the association between LHD inputs and outcomes.

METHODS

This was a retrospective cohort study. We used a fixed-effects regression model to assess the association between LHD expenditures, aggregated to the state level, and seven separate health measures. We derived LHD expenditure data from the National Association of County and City Health Officials' surveys of LHDs in 1993, 1997, and 2005. We obtained secondary data on seven health measures--smoking and obesity prevalence, infectious disease morbidity, infant mortality, deaths due to cardiovascular disease and cancer, and overall premature death--through the America's Health Rankings® reports, 1990-2008. Usable data were available for 1,470 LHDs, representing 37 states.

RESULTS

An increase in LHD expenditures, aggregated to the state level, was associated with a statistically significant decline in state-level infectious disease morbidity (t= -3.28, p=0.002) and in years of potential life lost (YPLL) (t= -2.73, p=0.008). For every $10 increase in aggregated LHD expenditures per capita, infectious disease morbidity decreased by 7.4%, and YPLL decreased by 1.5%.

CONCLUSION

LHD resources are associated with improvements in preventable causes of morbidity and mortality.

Extent and patterns of community collaboration in local health departments: An exploratory survey

Background

Local public health departments (LHDs) in the United States have been encouraged to collaborate with various other community organizations and individuals. Current research suggests that many forms of active partnering are ongoing, and there are numerous examples of LHD collaboration with a specific organization for a specific purpose or program. However, no existing research has attempted to characterize collaboration, for the defined purpose of setting community health status priorities, between a defined population of local officials and a defined group of alternative partnering organizations. The specific aims of this study were to 1) determine the range of collaborative involvement exhibited by a study population of local public health officials, and, 2) characterize the patterns of the selection of organizations/individuals involved with LHDs in the process of setting community health status priorities.

Methods

Local health department officials in North Carolina (n = 53) responded to an exploratory survey about their levels of involvement with eight types of possible collaborator organizations and individuals. Descriptive statistics and the stochastic clustering technique of Self-Organizing Maps (SOM) were used to characterize their collaboration.

Results

Local health officials vary extensively in their level of collaboration with external collaborators. While the range of total involvement varies, the patterns of involvement for this specific function are relatively uniform. That is, regardless of the total level of involvement (low, medium or high), officials maintain similar hierarchical preference rankings with Community Advisory Boards and Local Boards of Health most involved and Experts and Elected Officials least involved.

Conclusion

The extent and patterns of collaboration among LHDs with other community stakeholders for a specific function can be described and ultimately related to outcome measures of LHD performance.

Mapping the multidisciplinary field of public health services and systems research

CONTEXT

Public health services and systems research (PHSSR) is the field of study charged with evaluating the public health system. PHSSR currently lacks a clear identity integrating the many theories, approaches, and disciplines contributing to the field.

EVIDENCE ACQUISITION

Experts in PHSSR were consulted to identify 11 key published PHSSR studies. With these articles as a starting point, a newly developed citation data collection system was used to collect a sample of 2986 documents connected to the key articles through citation linkages. Data were collected in October 2009.

EVIDENCE SYNTHESIS

Citation network methods and latent position cluster modeling were used to examine the network of documents. A subset of 108 documents comprising the backbone of the network was identified through main-path analysis. Four unique clusters were identified within the main path. The core cluster consisted of older articles focused on local health department activities, partnerships, and effectiveness. The three non-core clusters focused on public health law, behavioral interventions, and national performance standards. Although all non-core clusters cited the core, there was little crosstalk among the non-core clusters, a pattern consistent with multidisciplinary fields.

CONCLUSIONS

PHSSR appears to be a multidisciplinary field with research happening in silos across different research areas. Developing transdisciplinary research connections across PHSSR is necessary to meet national PHSSR goals.