Partnership capacity for community health improvement plan implementation: findings from a social network analysis

Local Public Health Strategies for Addressing Social Determinants of Health-Analysis of Recent Community Health Improvement Plans

CONTEXT

The Public Health 3.0 (PH3.0) framework encourages local health departments (LHDs) to address the social determinants of health (SDOHs) that impact health equity.

OBJECTIVE

This study sought to understand how often LHDs are working to address SDOH, which SDOHs are most often being addressed, as well as the mix of strategies that have been proposed to address this work.

DESIGN

We reviewed recent Community Health Improvement Plans (CHIPs) to analyze the current involvement of LHDs in addressing SDOH.

SETTING

CHIPs published from 2020.

PARTICIPANTS

Accredited LHDs from across the United States (n = 80).

MAIN OUTCOME MEASURES

We developed a qualitative guidebook to characterize CHIP strategies based on the SDOH domain they addressed and the strategic mechanism they proposed.

RESULTS

Across our entire sample, CHIPs were roughly 1.5 times more likely to address Health Care Access than Food Insecurity and Access to Healthy Food (65%), Neighborhood Infrastructure (61%), or Affordable Housing (65%), and they were 3 to 4 times more likely to address Health Care Access than Safe Housing (23%), Education Access and Quality (31%), or Economic Stability (24%). Across all major domains, a few concerned policy changes and a handful focused on improving systems or developing the built environment. Most strategies focused on service provision through events or the education of the public and professionals on health-related topics.

CONCLUSIONS

The results of this study demonstrate that not all SDOHs are addressed equally by LHDs within their CHIPs. There is significant variation in how SDOHs are addressed along at 2 dimensions: first, in the likelihood that a CHIP addresses the domain and, second, in the mechanism by which each domain is addressed. Practically, the list of strategies we documented from the 80 CHIPs included in our sample may serve as the basis for strategies that other communities may wish to consider when addressing SDOH.

Inclusive and intersectoral: community health improvement planning opportunities to advance the social determinants of health and health equity

BACKGROUND

Community health improvement plans (CHIPs) are strategic planning tools that help local communities identify and address their public health needs. Many local health departments have developed a CHIP, yet there is a lack of research on the extent to which these plans address root causes of health disparities such as the social determinants of health. This study aims to inventory the social determinants of health included in 13 CHIPs and examine facilitators and challenges faced by local health departments and partners when trying to include the social determinants of health.

METHODS

We conducted a comparative plan evaluation by scoring 13 CHIPs on their inclusion of equity orientation, inclusive planning processes, and five social determinants of health: health care access and quality, the neighborhood and built environment, economic stability, social and community context, and education access and quality. To supplement the plan evaluation, we conducted 32 in-depth interviews with CHIP leaders and stakeholders to understand the factors contributing to the inclusion and exclusion of the social determinants of health in the planning process.

RESULTS

CHIPs received an average score of 49/100 for the inclusion of the social determinants of health. Most plans addressed health care access and quality and the neighborhood and built environment, but they often did not address economic stability, the social and community context, and education access and quality. Regarding their overall equity orientation, CHIPs received an average score of 35/100, reflecting a relative lack of attention to equity and inclusive planning processes in the plans. Interviews revealed that challenges engaging partners, making clear connections between CHIPs and social determinants, and a lack of capacity or public and partner support often led to the exclusion of the social determinants of health. Recommendations to improve planning processes include improving data infrastructure, providing resources for dedicated planning staff and community engagement incentives, and centering equity throughout the planning process.

CONCLUSIONS

Although local health departments can leverage CHIPs to improve population health and address health disparities, they face a range of challenges to including the social determinants of health in CHIPs. Additional resourcing and improved data are needed to facilitate broader inclusion of these determinants, and more work is needed to elevate equity throughout these planning processes.

Challenges and opportunities for improvement in the management and financing system of Health Promotion Offices in Hungary

Background

One hundred ten Health Promotion Offices (HPOs) have started operating in Hungary in response to public health challenges. Many of them have been active for almost 10 years, yet their operational experience has not been evaluated. The specific objectives of our study were: (1) to describe the current operational and funding system of HPOs, (2) to identify challenges related to the current management and funding practices, and (3) to formulate recommendations for improvement based on gathered experience and international experience.

Design

In order to gain a deeper insight into the operational experience of HPOs, an online survey was conducted with the professional or economic managers of HPOs. A scoping review was carried out to gather international experiences about best practices to formulate recommendations for improvement in developing the operational and financing scheme for HPOs.

Results

We found that current HPO network in Hungary faces three main challenges: a deficient management system, inflexible financing scheme, and unequal ability to purchase or provide services for the population.

Conclusions

Based on the survey complemented by international experiences, we propose the overhaul of the professional management system and switching toa combination of fixed and performance-based financing scheme for the HPOs in Hungary.

Recommendations to Improve the Nature and Extent of Relationships Among Organizations Within a Network to Enhance Supports for Transgender Survivors of Sexual Assault

CONTEXT

To enhance the provision of comprehensive supports to transgender (trans) survivors of sexual assault, a structurally marginalized group with complex care needs, we developed an intersectoral network of trans-positive health care and community organizations in Ontario, Canada.

OBJECTIVE

As a baseline evaluation of the network, we conducted a social network analysis to determine the extent and nature of collaboration, communication, and connection among members.

DESIGN

Relational data (eg, activities of collaboration) were collected from June to July 2021, and analyzed using a validated survey tool, Program to Analyze, Record, and Track Networks to Enhance Relationships (PARTNER). We shared findings in a virtual consultation session with key stakeholders and facilitated discussion to generate action items. Consultation data were synthesized into 12 themes through conventional content analysis.

SETTING

An intersectoral network in Ontario, Canada.

PARTICIPANTS

Of the 119 representatives of trans-positive health care and community organizations invited to participate in this study, 78 (65.5%) completed the survey.

MAIN OUTCOME MEASURES

Proportion/count of organizations collaborating with other organizations. Network scores for value and trust.

RESULTS

Almost all (97.5%) invited organizations were listed as collaborators, representing 378 unique relationships. The network achieved a value score of 70.4% and trust score of 83.4%. The most prominent themes were "Communication and knowledge exchange channels," "Clearer roles and contributions," "Indicators of success," and "Client voices at the centre."

CONCLUSION

As key antecedents of network success, high value and trust indicate that network member organizations are well positioned to further foster knowledge sharing, define their roles and contributions, prioritize the integration of trans voices in all activities, and, ultimately, achieve common goals with clearly defined outcomes. There is great potential to optimize network functioning and advance the network's mission to improve services for trans survivors by mobilizing these findings into recommendations.

Exploratory Analysis of Social Networks Linked to the Provision of Beverages in Costa Rican Schools

Sugar-sweetened beverages (SSBs) are implicated in weight gain and adverse cardiometabolic heath. Social networks of stakeholders involved in providing potable water and sugar-sweetened beverages (SSBs) in high schools in Costa Rica were studied using social analysis network. In public and private schools, the interactions between the stakeholders in charge of providing beverages are fragmented and their role in preventing the availability of SSBs is weak. School canteen owners ultimately decide what beverages are available at school, which may cause students to choose beverages that increase the risk of overweight/obesity. It is therefore urgently necessary to improve the capacity for two-way interactions between the stakeholders to enhance their roles in the provision of beverages. Hence, it is essential to reinforce the stakeholders' leadership, and set up innovative ways to exert it in order to develop a shared vision of the types of drinks that should be available in the school environment.

Community health improvement plan: Study protocol for Kansas City's intervention and implementation evaluation

Objectives

Community health improvement plans (CHIPs) are foundational public health practice, yet no studies have been conducted to understand implementation of these plans. This evaluation study of the Kansas City CHIP aims to 1) identify implementation strategies used in the CHIP, 2) assess changes in implementation, service, and client outcomes, 3) assess contextual factors associated with implementation, and 4) understand social networks of coalitions who implement the Kansas City CHIP.

Study design

This study protocol uses a unique, mixed methods approach to evaluating process and outcomes of the Kansas City CHIP. This study is supported by Proctor's Model of Implementation, RE-AIM (reach, effectiveness, adoption, implementation, maintenance), and the practical, robust implementation and sustainability model (PRISM).

Methods

Staff and community members involved in implementing the Kansas City, Missouri CHIP will be invited to participate in an annual online survey, a series of focus groups, and quarterly implementation logs to assess implementation and sustainability.

Results

RE-AIM and PRISM constructs are the primary and secondary outcomes of interest. Results of this study will be available from the first year of implementation in 2023, with future results provided annually.

Conclusions

This project will fill a much-needed gap in the literature by understanding how large-scale coalitions implement projects that aim to improve population health and health equity. CHIPs have the potential to improve population health, yet few studies have been conducted on CHIPs, with no studies to date assessing outcomes. To support effective implementation and sustainability as well as improve public health outcomes, researchers need to evaluate CHIPs and develop models of implementation that can quickly be integrated into practice to improve populations' health.

Advancing community-engaged research during the COVID-19 pandemic: Insights from a social network analysis of the trans-LINK Network

Collaboration across sectors is critical to address complex health problems, particularly during the current COVID-19 pandemic. We examined the ability to collaborate during the pandemic as part of a baseline evaluation of an intersectoral network of healthcare and community organizations established to improve the collective response to transgender (trans) persons who have been sexually assaulted (the trans-LINK Network). A validated social network analysis survey was sent to 119 member organizations in Ontario, Canada. Survey respondents were asked, ‘Has COVID-19 negatively affected your organization’s ability to collaborate with other organizations on the support of trans survivors of sexual assault?’ and ‘How has COVID-19 negatively affected your organization’s ability to collaborate within the trans-LINK Network?’. Data were analyzed using descriptive statistics. Seventy-eight member organizations participated in the survey (response rate = 66%). Most organizations (79%) indicated that the pandemic had affected their ability to collaborate with others in the network, citing most commonly, increased workload (77%), increased demand for services (57%), and technical and digital challenges (50%). Survey findings were shared in a stakeholder consultation with 22 representatives of 21 network member organizations. Stakeholders provided suggestions to prevent and address the challenges, barriers, and disruptions in serving trans survivors experienced during the pandemic, which were organized into themes. Seven themes were generated and used as a scaffold for the development of recommendations to advance the network, including: increase communication and knowledge exchange among member organizations through the establishment of a network discussion forum and capacity building group workshops; enhance awareness of network organizations by developing a member-facing directory of member services, their contributions, and ability to provide specific supports; strengthen capacity to provide virtual and in-person services and programs through enhanced IT support and increased opportunities for knowledge sharing and skill development; and adopt a network wide syndemic approach that addresses co-occurring epidemics (COVID-19 + racism, housing insecurity, transphobia, xenophobia) that impact trans survivors of sexual assault.

Community networks of sport and physical activity promotion: an analysis of structural properties and conditions of cooperation

BACKGROUND

The importance of intersectoral cooperation networks among community organizations located in people's immediate environments in addressing population health problems such as physical inactivity has come into focus in recent years. To date, there is limited evidence on how and why such networks emerge. Therefore, the aims of this study were (a) to analyze the structural properties and (b) to identify the conditions of cooperation in interorganizational community networks of sport and physical activity promotion.

METHODS

Survey data on cooperative relationships and organizational attributes of sports and physical activity providers as well as sports administrating organizations in two community networks located in urban districts in southern Germany were collected (Network I: n = 133 organizations; Network II: n = 50 organizations). Two quantitative descriptive procedures - network analysis and stochastic analyses of network modeling (exponential random graphs) - were applied.

RESULTS

Similar structures and conditions of cooperation were found in the networks (e.g. low density, centralization). The community sports administrations had the most central positions in both networks. Exponential random graph modeling showed that cooperation took place more frequently in triangular structures (closure effect) and revolved around a few central actors (preferential attachment effect). Organizations from different sectors cooperated more often than organizations from the same sector (heterophily effect).

CONCLUSION

The study provided valid and robust findings on significant mechanisms and conditions of interorganizational cooperation in community networks focused on sport and physical activity promotion. Based on the results, implications for the development and most efficient governance of these networks can be derived.

Facilitators of Multisector Collaboration for Delivering Cancer Control Interventions in Rural Communities: A Descriptive Qualitative Study

Purpose and Objectives

Multisector collaboration is a widely promoted strategy to increase equitable availability, access, and use of healthy foods, safe places for physical activity, social supports, and preventive health care services. Yet fewer studies and resources exist for collaboration among governmental and nongovernmental agencies to address public problems in rural areas, despite an excess burden of risk factors for cancer morbidity and mortality. We aimed to learn about cancer prevention activities and collaboration facilitators among rural informal interagency networks.

Evaluation Methods

In 2020, researchers conducted semistructured interviews with staff from rural public health and social services agencies, community health centers, and extension offices. Agency staff were from 5 service areas across 27 rural counties in Missouri and Illinois with high poverty rates and excess cancer risks and mortality. We conducted a thematic analysis to code interview transcripts and identify key themes.

Results

Exchanging information, cohosting annual or one-time events, and promoting other agencies’ services and programs were the most commonly described collaborative activities among the 32 participants interviewed. Participants indicated a desire to improve collaborations by writing more grants together to codevelop ongoing prevention programs and further share resources. Participants expressed needs to increase community outreach, improve referral systems, and expand screenings. We identified 5 facilitator themes: commitment to address community needs, mutual willingness to collaborate, long-standing relationships, smaller community structures, and necessity of leveraging limited resources. Challenges included lack of funding and time, long travel distances, competing priorities, difficulty replacing staff in remote communities, and jurisdictional boundaries. Although the COVID-19 pandemic further limited staff availability for collaboration, participants noted benefits of remote collaborative meetings.

Implications for Public Health

Rural areas need consistent funding and other resources to support health-improving multisector initiatives. Existing strengths found in the rural underresourced areas can facilitate multisector collaborations for cancer prevention, including long-standing relationships, small community structures, and the need to leverage limited resources.

Network Analysis for a Community-Based School- and Family-Based Obesity Prevention Program

Rising childhood obesity with its detrimental health consequences poses a challenge to the health care system. Community-based, multi-setting interventions with the participatory involvement of relevant stakeholders are emerging as promising. To gain insights into the structural and processual characteristics of stakeholder networks, conducting a network analysis (NA) is advisable. Within the program “Family+—Healthy Living Together in Families and Schools”, a network analysis was conducted in two rural model regions and one urban model region. Relevant stakeholders were identified in 2020–2021 through expert interviews and interviewed by telephone to elicit key variables such as frequency of contact and intensity of collaboration. Throughout the NA, characteristics such as density, centrality, and connectedness were analyzed and are presented graphically. Due to the differences in the number of inhabitants and the rural or urban structure of the model regions, the three networks (network#1, network#2, and network#3) included 20, 14, and 12 stakeholders, respectively. All networks had similar densities (network#1, 48%; network#2, 52%; network#3, 42%), whereas the degree centrality of network#1 (0.57) and network#3 (0.58) was one-third higher compared with network#2 (0.39). All three networks differed in the distribution of stakeholders in terms of field of expertise and structural orientation. On average, stakeholders exchanged information quarterly and were connected on an informal level. Based on the results of the NA, it appears to be useful to initialize a community health facilitator to involve relevant stakeholders from the education, sports, and health systems in projects and to strive for the goal of sustainable health promotion, regardless of the rural or urban structure of the region. Participatory involvement of relevant stakeholders can have a positive influence on the effective dissemination of information and networking with other stakeholders.

Exploring the Multidimensionality of Trust in Participatory Health Partnerships - A Network Approach

Introduction

Previous studies have identified “trust” as a key mechanism to achieve sustainable partnerships in participatory health research, which themselves can represent social networks. A recent review discussed the potential for social network analysis to investigate the development and maintenance of trust and its effects on partnership functioning in participatory health research partnerships. This review also recommended considering a comprehensive, nuanced and multidimensional approach to conceptualizing, operationalizing and measuring trust in research partnerships. Thus, this study aims to explore empirically the conceptualizing, operationalizing and measuring of trust in a multidimensional manner, approaching each trust dimension as an individual trust network, as well as combined as an overall trust network.

Methods

We sampled the whole network, recruiting from a newly established network of 57 individuals that must collaborate to achieve a common goal. These individuals represented academic, service and community organizations of an existing participatory partnership, the Public and Patient Involvement Ignite Network in Ireland. Of the 57 individuals invited to take part in the study, 75% (n = 43) individuals completed the network survey. A survey about trust was designed based on literature in the area and was administered via Qualtrics. The survey included eight network questions: one on collaboration, and seven on specific dimensions of trust. From this, we constructed a network for each trust dimension. We compared several core network measures of each to identify structural differences between the dimensions of trust. To statistically validate them, we compared them to a random and preferential null model.

Results

All the networks had a high reciprocity but were decentralized. Key differences were identified across trust dimensions, particularly in terms of integrity and shared values, visions and goals. None of the networks compared well to the null models indicating participants did not randomly or preferentially (based on how much trust they receive for a particular trust dimension) trust other partners.

Discussion/Conclusion

This novel empirical social network analysis of trust in a real-world partnership elucidates the nuances and multidimensional nature of trust. This provides support for expanding this research direction to enhance understanding of and interventions for trust in participatory health research.

Conceptualising, operationalising, and measuring trust in participatory health research networks: a scoping review

BACKGROUND

There are many described benefits of community-based participatory research (CBPR), such as increased relevance of research for those who must act on its findings. This has prompted researchers to better understand how CBPR functions to achieve these benefits through building sustainable research partnerships. Several studies have identified "trust" as a key mechanism to achieve sustainable partnerships, which themselves constitute social networks. Although existing literature discusses trust and CBPR, or trust and social networks, preliminary searches reveal that none link all three concepts of trust, CBPR, and social networks. Thus, we present our scoping review to systematically review and synthesize the literature exploring how trust is conceptualised, operationalised, and measured in CBPR and social networks.

METHODS

This review follows the guidance and framework of Peters et al. which is underpinned by the widely used framework of Levac and colleagues. Levac and colleagues provided enhancements to the methodological framework of Arksey and O'Malley. We explored several electronic databases including Scopus, Medline, PubMed, Web of Science, CINAHL, Cochrane Library, Google Scholar, and PsychINFO. A search strategy was identified and agreed upon by the team in conjunction with a research librarian. Two independent reviewers screened articles by title and abstract, then by full-text based on pre-determined exclusion/inclusion criteria. A third reviewer arbitrated discrepancies regarding inclusions/exclusions. A thematic analysis was then conducted to identify relevant themes and sub-themes.

RESULTS

Based on the 26 extracted references, several key themes and sub-themes were identified which highlighted the complexity and multidimensionality of trust as a concept. Our analysis revealed an additional emergent category that highlighted another important dimension of trust-outcomes pertaining to trust. Further, variation within how the studies conceptualised, operationalised, and measured trust was illuminated. Finally, the multidimensionality of trust provided important insight into how trust operates as a context, mechanism, and outcome.

CONCLUSIONS

Findings provide support for future research to incorporate trust as a lens to explore the social-relational aspects of partnerships and the scope to develop interventions to support trust in partnerships.

Understanding the Development, Evaluation, and Sustainability of Community Health Networks Using Social Network Analysis: A Scoping Review

OBJECTIVE

Identify the scope of the literature which reports use of social network analysis to inform, support, or evaluate health promotion-focused community network/partnership development.

DATA SOURCE

A comprehensive search (not date-limited) of PubMed, CINAHL, Web of Science Core Collection, PsycInfo, and the Cochrane Library Database for Systematic Reviews.

INCLUSION AND EXCLUSION CRITERIA

Criteria for inclusion included published in the English language and used social network analysis to inform, support, or evaluate development of community networks/partnerships aiding health promotion efforts. Studies were excluded if they did not use social network analysis or were not focused upon health promotion.

DATA EXTRACTION

Three of the four authors extracted data using a summary chart to document information regarding study aims, target issue/population, methods, and key outcomes of the social network analysis.

DATA SYNTHESIS

The extracted data were qualitatively analyzed by 3 authors to categorize key social network analysis outcomes into categories.

RESULTS

Ninety-seven studies representing 9 geographical regions were included, with the majority (69) published after 2010. Key outcomes included the effectiveness of social network analysis to identify network characteristics, track network change over time, compare similar networks across locations, and correlate network attributes with outcomes.

CONCLUSION

Findings support the utility of social network analysis to inform, support, and evaluate development of sustainable health promotion-focused networks/partnerships.

Physical activity promotion in an urban district: Analyzing the mechanisms of interorganizational cooperation

Past research has identified the importance of cooperation among community-based organizations from different sectors to address public health problems such as insufficient physical activity. However, little is known about how and why interorganizational cooperation occurs. The present study sought to analyze the structure and emergent patterns of interorganizational cooperation within a network promoting physical activity based in an urban district neighborhood of a city in Southwestern Germany. Survey data on cooperative relations among 61 network organizations and organizational attributes (e.g., possession of sport facilities) were collected. Social network analysis was applied to examine network properties and exponential random graph models were estimated to test hypotheses concerning mechanisms and conditions of cooperative tie formation. The results show that the network of cooperation is sparse but characterized by a tendency for cooperation to occur in triangular structures. Other significant mechanisms of cooperative tie formation are preferential attachment, with the community department for education and sports being the most central network actor, and heterophily regarding the cooperation of organizations from different sectors. This study provides valid and reliable findings on conditions of network formation and significant mechanisms of interorganizational cooperation in the field of physical activity promotion. Knowledge about these mechanisms can help to manage networks effectively and efficiently and reveal potentials for improvement and intensification of interorganizational cooperation in both the present and other research areas of health promotion.

Organizational partnerships for a trauma-informed community: A community-wide social network study

We investigated whether Peace4Tarpon's trauma-responsive community capacity activities led to greater collaboration among community partners. We conducted longitudinal social network analysis (SNA) among organizations within Peace4Tarpon's network in 2016 and 2018 to capture cooperation around adverse childhood experiences-related topics. We examined network structure, cohesion, organizational collaboration, and associations between centrality and organizational practices. Peace4Tarpon's network included diverse sectors, with a group of organizations forming the network core and collaborating over time. The network displayed a small increase in cohesion, more cross-sector collaboration, and less heterophily over time. We found a significant difference between the mean betweenness centralities of organizations who assessed resilience and those who did not in the 2018 average union network. This is one of the first studies using SNA to investigate a trauma-informed community network. Findings from this type of analysis may assist community organizations in strengthening outreach and strategically engaging organizations within a trauma-informed network.

Interorganizational Networks in Physical Activity Promotion: A Systematic Review

Public health challenges such as physical inactivity are multiplex and cannot be effectively addressed by single organizations or sectors. For this reason, public health policies have to involve various sectors and foster partnerships among organizations. Social network analysis (SNA) provides a methodological toolkit that enables the investigation of relationships between organizations to reveal information about the structure and cooperation within networks. This systematic review provides an overview of studies utilizing SNA to analyze the structure of networks that promote physical activity, including the structural set-up, types, and conditions of cooperation, the existence or absence of key actors, the characteristics of organizations working together, and potential barriers limiting collaboration. In total, eight eligible studies were identified. To evaluate the quality of these studies, a quality assessment tool for SNA was created. Relevant aspects from each study were systematically outlined using a data extraction template developed for network studies. The studies reported low to moderate density scores with many ties not being realized. Organizations tend to work side by side than as real partners, whereas organizations of the same type are more strongly connected. Most of the studies identified governmental health organizations as key players in their networks. Network maturity influences network outcomes. Shared goals and geographic proximity are potential facilitators for network development. For future research, more sophisticated methods and longitudinal studies are required to describe how networks, with the aim of promoting physical activity, develop and change to identify predicting factors for an effective network structure.

Network-Based Delivery and Sustainment of Evidence-Based Prevention in Community-Clinical Partnerships Addressing Health Equity: A Qualitative Exploration

Background: Increased delivery of evidence-based preventive services can improve population health and increase health equity. Community-clinical partnerships offer particular promise, but delivery and sustainment of preventive services through these systems face several challenges related to service integration and collaboration. We used a social network analysis perspective to explore (a) the range of contributions made by community-clinical partnership network members to support the delivery of evidence-based preventive services and (b) important influences on the ability of these partnerships to sustain service delivery. Methods: Data come from an implementation evaluation of the Prevention and Wellness Trust Fund initiative, which supported nine Massachusetts communities to coordinate delivery of evidence-based prevention and address inequities in hypertension, pediatric asthma, falls among older adults, or tobacco use. In 2016, we conducted semi-structured interviews with (a) leadership teams representing nine community-level partnerships and (b) practitioners from four high-implementation partnerships (n = 23). We managed data using NVivo11 and utilized a framework analysis approach. Results: Key network contributions for delivery of evidence-based preventive services included creating referrals, delivering services, providing links to community members, and administration and leadership. Less emphasized contributions included wraparound services, technical assistance, and venue provision. Implementers from high-implementation partnerships also highlighted contributions such as program adaptation, creating buy-in, and sharing information to improve service delivery. Expected drivers of program sustainability included the ability to develop a business case, ongoing network facilitation, technology support, continued integrated action, and sufficient staffing to maintain programming. Conclusion: The study highlights the need to take a long-term, infrastructure-focused approach when designing community-clinical partnerships. Strategic partnership composition, including identifying sources of necessary network contributions, in conjunction with efforts from the outset to link systems, align effort, and build a long-term funding structure can support the required coordinated action around preventive services needed to improve health equity.

Impact of Local Boards of Health on Local Health Department Accreditation, Community Health Assessment, Community Health Improvement Planning, and Strategic Planning

INTRODUCTION

Local health departments (LHDs) are increasingly using national standards to meet the challenges presented by the complex environments in which these agencies operate. Local boards of health (LBoHs) might play an instrumental role in improving LHDs' engagement in activities to meet these standards.

OBJECTIVES

To assess the impact of LBoH performance of governance functions on LHDs having a current (completed within 5 years) community health assessment (CHA), community health improvement plan (CHIP), strategic plan, and level of engagement in the Public Health Accreditation Board (PHAB) accreditation program.

METHODS

Binary and multinomial logistic regression models were used to analyze linked data from 329 LHDs participating in both the 2015 Local Board of Health Survey and the 2016 National Profile of LHDs Survey.

RESULTS

Higher performance of LBoH governance functions, measured by an overall scale of LBoH taxonomy consisting of 60 items, had a significant positive effect on LHDs having completed CHA (P < .001), CHIP (P = .01), and strategic plan (P < .001). LHDs operating in communities with a higher score on the overall scale of LBoH taxonomy had significantly higher odds (P = .03) of having higher level of participation in the PHAB national voluntary accreditation program-that is, being accredited, having submitted application for accreditation, or being in the e-PHAB system (eg, by submitting a letter of intent).

CONCLUSIONS

LBoHs serve as governance bodies for roughly 71% of LHDs and can play a significant role in encouraging LHDs' participation in these practices. That positive influence of LBoHs can be seen more clearly if the complexity and richness of LBoH governance functions and other characteristics are measured appropriately. The study findings suggest that LBoHs are a significant component of the public health system in the United States, having positive influence on LHDs having a CHA, CHIP, strategic plan, and participation in accreditation.

Social Network Analysis of Patient Movement Across Health Care Entities in Orange County, Florida

OBJECTIVE

Multidrug-resistant organisms (MDROs) are continually emerging and threatening health care systems. Little attention has been paid to the effect of patient transfers on MDRO dissemination among health care entities in health care systems. In this study, the Florida Department of Health in Orange County (DOH-Orange) developed a baseline social network analysis of patient movement across health care entities in Orange County, Florida, and regionally, within 6 surrounding counties in Central Florida.

MATERIALS AND METHODS

DOH-Orange constructed 2 directed network sociograms-graphic visualizations that show the direction of relationships (ie, county and regional)-by using 2016 health insurance data from the Centers for Medicare & Medicaid Services, which include metrics that could be useful for local public health interventions, such as MDRO outbreaks.

RESULTS

We found that both our county and regional networks were sparse and centralized. The county-level network showed that acute-care hospitals had the highest influence on controlling the flow of patients between health care entities that would otherwise not be connected. The regional-level network showed that post-acute-care hospitals and other facilities (behavioral hospitals and mental health/substance abuse facilities) served as the primary controls for flow of patients between health care entities. The most prominent health care entities in both networks were the same 2 acute-care hospitals.

PRACTICE IMPLICATIONS

Social network analysis can help local public health officials respond to MDRO outbreak investigations by determining which health care facilities are the main contributors of dissemination of MDROs or are at high risk of receiving patients with MDROs. This information can help epidemiologists prioritize prevention efforts and develop county- or regional-specific interventions to control and halt MDRO transmission across a health care network.

The Importance of Governmental and Nongovernmental Investments in Public Health and Social Services for Improving Community Health Outcomes

OBJECTIVE

To explore whether health outcomes are influenced by both governmental social services spending and hospital provision of community health services.

DESIGN

We combined hospital provision of community health services data from the American Hospital Association with local governmental spending data from the US Census Bureau. Longitudinal models regressed community health outcomes for 2012-2016 on local government spending on health, social services, and education from 5 years previously, controlling for sociodemographic and hospital marketplace characteristics, spatial autocorrelation, and state-level random effects. For counties with hospitals, models also included county-level data on hospitals' provision of community health services.

SETTING

All analyses were performed at the county level for US counties between 2012 and 2016.

PARTICIPANTS

Complete spending, hospital, and health outcomes data were available for a total of 2379 counties.

MAIN OUTCOME MEASURES

We examined relationships between governmental spending, hospital service provision, and 5 population health outcome measures: years of potential life lost prior to age 75 years per 100 000 population, percentage of population in fair or poor health, percentage of adults who are physically inactive, deaths due to injury per 100 000 population, and percentage of births that are of low birth weight.

RESULTS

Governmental investments in health, social services, and education positively impacted key health outcomes but mainly in counties with 1 or more hospitals present. Hospitals' provision of community health services also had a significant positive impact on health outcomes.

CONCLUSIONS

Hospital provision of community health services and increases in local governmental health and social services spending were both associated with improved health. Collaboration between local governments and hospitals may help ensure that public and private community health resources synergistically contribute to the public's health. Local policy makers should consider service provision by the private sector to leverage the public investments in health and social services.

Government Health and Social Services Spending Show Evidence of Single-Sector Rather Than Multi-Sector Pursuit of Population Health

Population health improvements can be achieved through work made possible by government spending on health care, public health, and social services. The extent to which spending allocations across these sectors is synergistic with or trade-off against one another is unknown. Achieving a balanced portfolio with multi-sector contributions is key to improving health outcomes. This study tested competing hypotheses regarding achievement of balanced multi-sector resources for health. County-level U.S. Census Bureau data on all local governmental spending measured each county’s average per capita local government spending for public hospitals, public health, social services, and education. American Hospital Association (AHA) Annual Survey data on hospital community health service provision were used to calculate an index of hospital community service provision aggregated to county level by year. County Health Rankings data measured each county’s health outcomes and health factors. Longitudinal mixed-effects regression models (n = 1877 counties) predicted changes in spending for each government spending category based on two sets of predictors (government spending vs community health services and needs) from current and prior year. Models account for average spending in each category and county-, state-, and time-trends. Models showed that spending increases in each of the four spending categories examined (public hospitals, public health, social services, and education) were not associated with changes in spending across other categories in current or prior years. For all categories, an increase from baseline spending levels in Year 1 was always significantly associated with an increase from baseline spending level in that same category in Year 2 (ie, spending stayed above baseline in Year 2). Multi-sector initiatives to health outcomes require funding across sectors, yet there was little evidence to suggest that communities that invest in public hospitals, public health, or other social services see commensurate increases in other areas. Underlying funding decisions may reflect strategic decisions within a community to scale up single sectors, constrained resources for multi-sector scale up, or a host of additional factors not measured here.

Social Network Gap Analysis Evaluation: A Case Study of the Southeastern Health Equity Council

Despite the growing emphasis on collaboration in public health, there remains a dearth of literature providing tools for the evaluation of coalitions and councils. This study employed social network gap analysis as an evaluation tool. Survey data collected from the Southeastern Health Equity Council members were used to assess connections among members as a whole, by committee, by state, and by health specialty area. Analysis of how well Southeastern Health Equity Council met the representation outlined in its strategic plan was also conducted. Recommendations for improving the network and opportunities to effectively recruit and advance the work of Southeastern Health Equity Council are discussed.

Applying Social Network Analysis to Evaluate Implementation of a Multisector Population Health Collaborative That Uses a Bridging Hub Organization

Background: Multisector collaboratives are increasingly popular strategies for improving population health. To be comprehensive, collaboratives must coordinate the activities of many organizations across a geographic region. Many policy-relevant models encourage creation and use of centralized hub organizations to do this work, yet there is little guidance on how to evaluate implementation of such hubs and track their network reach. We sought to demonstrate how social network analysis (SNA) could be used for this purpose.

Methods: Through formative research, we defined and conceptualized key characteristics of a bridging hub network and identified a set of candidate measures—(1) network membership, (2) network interaction, (3) role and reach of the bridging hub, and (4) network collaboration—to evaluate its implementation within a pre-determined geographic region of Southeast Minnesota, USA. We then developed and administered a survey to assess outcomes as part of a SNA. We commented on the feasibility and usefulness of the methods.

Results: The initial surveyed network consisted of 50 healthcare organizational sites and 50 community organizations representing sectors of public health, education, research, health promotion, social services, and long-term care and supports. Fifty-three of these organizations responded to the survey. The network's level of collaboration was “Cooperation” (level 2 of 5) and reported levels of collaboration varied by organization. Thirty-eight additional, unsurveyed organizations were identified as collaborators by respondents, pushing the theoretical network denominator up to 138 organizations. These additional organizations included grocery stores, ambulance services, and smaller, independent healthcare and community-based services focused on meeting the needs of underserved populations. The bridging hub organization had the highest betweenness centrality and was in good position to bridge healthcare and the community, although its organizational reach was estimated at only 51%. The SNA methods were feasible and useful for identifying opportunities and guiding implementation.

Conclusions: Bridging hub organizations are not likely to link—or even be aware of—all relevant organizations in a geographic region at initial implementation. SNA may be a useful method for evaluating the value and reach of a bridging hub organization and guiding ongoing implementation efforts.

Trial registration: http://ClinicalTrials.gov; #NCT03046498

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.

Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies

Background

Cancer is now viewed as a chronic disease, presenting challenges to follow-up and survivorship care. Models to shift from haphazard, suboptimal and fragmented episodes of care to an integrated cancer care continuum must be developed, tested and implemented. Numerous studies demonstrate improved care when follow-up is assured by both oncology and primary care providers rather than either group alone. However, there is little data on the roles assumed by specialized oncology teams and primary care providers and the extent to which they work together. This study aims to develop, pilot test and measure outcomes of an innovative risk-based coordinated cancer care model for patients transitioning from specialized oncology teams to primary care providers.

Methods/design

This multiple case study using a sequential mixed-methods design rests on a theory-driven realist evaluation approach to understand how transitions might be improved. The cases are two health regions in Quebec, Canada, defined by their geographic territory. Each case includes a Cancer Centre and three Family Medicine Groups selected based on differences in their determining characteristics. Qualitative data will be collected from document review (scientific journal, grey literature, local documentation), semi-directed interviews with key informants, and observation of care coordination practices. Qualitative data will be supplemented with a survey to measure the outcome of the coordinated model among providers (scope of practice, collaboration, relational coordination, leadership) and patients diagnosed with breast, colorectal or prostate cancer (access to care, patient-centredness, communication, self-care, survivorship profile, quality of life). Results from descriptive and regression analyses will be triangulated with thematic analysis of qualitative data. Qualitative, quantitative, and mixed methods data will be interpreted within and across cases in order to identify context-mechanism associations that explain outcomes.

Discussion

The study will provide empirical data on a risk-based coordinated model of cancer care to guide actions at different levels in the health system. This in-depth multiple case study using a realist approach considers both the need for context-specific intervention research and the imperative to address research gaps regarding coordinated models of cancer care.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2785-z) contains supplementary material, which is available to authorized users.

Joining the dots: the role of brokers in nutrition policy in Australia

Background

Poor diet is the leading preventable risk factor contributing to the burden of disease in Australia. A range of cost-effective, comprehensive population-focussed strategies are available to address these dietary-related diseases. However, despite evidence of their effectiveness, minimal federal resources are directed to this area. To better understand the limited public health nutrition policy action in Australia, we sought to identify the key policy brokers in the Australian nutrition policy network and consider their level of influence over nutrition policymaking.

Methods

A social network analysis involving four rounds of data collection was undertaken using a modified reputational snowball method to identify the nutrition policy network of individuals in direct contact with each other. Centrality measures, in particular betweenness centrality, and a visualisation of the network were used to identify key policy brokers.

Results

Three hundred and ninety (390) individual actors with 1917 direct ties were identified within the Australian nutrition policy network. The network revealed two key brokers; a Nutrition Academic and a General Health professional from a non-government organisation (NGO), with the latter being in the greatest strategic position for influencing policymakers.

Conclusion

The results of this social network analysis illustrate there are two dominant brokers within the nutrition policy network in Australia. However their structural position in the network means their brokerage roles have different purposes and different levels of influence on policymaking. The results suggest that brokerage in isolation may not adequately represent influence in nutrition policy in Australia. Other factors, such as direct access to decision–makers and the saliency of the solution, must also be considered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4217-8) contains supplementary material, which is available to authorized users.