Public Health Practice-based Research Networks Research Articles

Primary Care and Public Health Perspectives on Integration at the Local Level: A Multi-State Study.

The Institute of Medicine argues that the integration of primary care (PC) and public health (PH) is of paramount importance. We undertook this qualitative study to better understand how these collaborations function. Investigators from PC and PH practice-based research networks in Colorado, Minnesota, Washington, and Wisconsin identified 40 key informants from the PH and PC fields within their respective states. The key informants participated in standardized, semistructured interviews. Coinvestigators from each state conducted telephone interviews. The interviews were recorded, transcribed, and analyzed using NVivo 10. Participants described 2 main types of themes. One, which we have termed "foundational" aspects of partnership, includes leadership, communication, mutual awareness, formal processes, history and values. The other, which we have characterized as "energizing" aspects of partnerships, includes having a shared strategic vision, opportunity, and the shifting culture in PC and PH. While the vast majority of participants described the value of foundational aspects of partnership, those who reported having more active collaborations were more likely to also describe the energizing aspects of partnerships. Our findings indicate that interactions between foundational aspects and energizing aspects of partnerships are dynamic. Further exploration of these aspects may help us to understand how best to support the integration of PC and PH.

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.

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.

Local health department food safety and sanitation expenditures and reductions in enteric disease, 2000-2010.

In collaboration with Public Health Practice-Based Research Networks, we investigated relationships between local health department (LHD) food safety and sanitation expenditures and reported enteric disease rates. We combined annual infection rates for the common notifiable enteric diseases with uniquely detailed, LHD-level food safety and sanitation annual expenditure data obtained from Washington and New York state health departments. We used a multivariate panel time-series design to examine ecologic relationships between 2000-2010 local food safety and sanitation expenditures and enteric diseases. Our study population consisted of 72 LHDs (mostly serving county-level jurisdictions) in Washington and New York. While controlling for other factors, we found significant associations between higher LHD food and sanitation spending and a lower incidence of salmonellosis in Washington and a lower incidence of cryptosporidiosis in New York. Local public health expenditures on food and sanitation services are important because of their association with certain health indicators. Our study supports the need for program-specific LHD service-related data to measure the cost, performance, and outcomes of prevention efforts to inform practice and policymaking.

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

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

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

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

Local Public Health Resource Allocation

Local health department leaders are expected to improve the health of their populations as they "use and contribute to" the evidence base for practice, but effectively providing and utilizing data and evidence for local public health decision making has proven difficult. This study was conducted in 2011 and initiated by Washington State's public health practice-based research network to identify factors influencing local resource allocation and programmatic decisions among public health leaders facing severe funding losses. Quantitative data informed sampling for the collection of interview data. Qualitative methods were used to capture diverse insights of Washington State's local public health leaders in making decisions regarding resource allocation. Local decision-making authority was perceived as greatly restricted by what public health activities were legally mandated and the categoric nature of funding sources, even as some leaders exercised deliberate strategic approaches. One's workforce and board of health were also influential in making decisions regarding resource allocations. Challenges were expressed regarding making use of data and research evidence for decision making. Data were analyzed in 2011-2012. Programmatic mandates, funding restrictions, local stakeholders, and workforce capacity appear to trump factors such as research evidence and perceived community need in public health resource allocation. Study findings highlight tensions between the literature descriptions of what "should" influence decision making in local public health and the realities of practice. Advancements in practice-based research and evidence-based decision making, however, provide opportunities for strengthening the development of evidence and research translation for local decision making to maximize resources and promote effective service provision.

Factors Affecting Evidence-Based Decision Making in Local Health Departments

Data indicating the extent to which evidence-based decision making (EBDM) is used in local health departments (LHDs) are limited. This study aims to determine use of decision-making processes by New York State LHD leaders and upper-level staff and identify facilitators and barriers to the use of EBDM in LHDs. The New York Public Health Practice-Based Research Network implemented a mixed-methods study in 31 LHDs. There were 20 individual interviews; five small-group interviews (two or three participants each); and two focus groups (eight participants each) conducted with people who had decision-making authority. Information was obtained about each person's background and position, decision-making responsibilities, how decisions are made within their LHD, knowledge and experience with EBDM, use of each step of the EBDM process, and barriers and facilitators to EBDM implementation. Data were collected from June to November 2010 and analyzed in 2011. Overall, participants supported EBDM and expressed a desire to increase their department's use of it. Although most people understood the concept, a relatively small number had substantial expertise and experience with its practice. Many indicated that they applied EBDM unevenly. Factors associated with use of EBDM included strong leadership; workforce capacity (number and skills); resources; funding and program mandates; political support; and access to data and program models suitable to community conditions. EBDM is used inconsistently in LHDs in New York. Despite knowledge and interest among LHD leadership, the LHD capacity, resources, appropriate programming, and other issues serve as impediments to EBDM and optimal implementation of evidence-based strategies.

Revenue Sources for Essential Services in Florida

The Florida Public Health Practice-Based Research Network conducted the study of Florida county health departments (CHDs) to assess relationships between self-assessed performance on essential services (ESs) and sources of funding. Primary data were collected using an online survey based on Public Health Accreditation Board standards for ES. Bivariate and multivariate analyses were conducted to assess the relationship of sources and amounts of revenue obtained from the Florida Department of Health financial system to responses to the survey of CHD capacity for ESs. Self-assessed CHD performance for each ES varied extensively among the CHDs and across the 10 ESs, ranging from a high of 98% CHDs completely or almost completely meeting the standards for ES 2 (Investigating Problems and Hazards) to a low of 32% completely or almost completely meeting standards for ES 10 (Research/Evidence). Medicaid revenue and fees were positively correlated with some ESs. Per capita revenue support varied extensively among the CHDs. Revenue for ES is decreasing and is heavily reliant on noncategorical (discretionary) revenue. This study has important implications for continued reliance on ES as an organizing construct for public health.

Stimulating Public Health Improvement in Complex and Constrained Delivery Systems: Findings from the Public Health PBRNs

The Robert Wood Johnson Foundation’s Public Health Practice-Based Research Networks Program sponsored a series of studies to examine how public health decision-makers are responding to accreditation, quality improvement, and public reporting initiatives amid the ongoing fiscal pressures. Overall, the evidence to date indicates that these initiatives represent promising strategies for strengthening evidence-based decision-making and expanding the delivery of evidence-tested programs and policies in local public health settings. Continued, comparative research and evaluation activities are needed to provide more definitive evidence about which combination of strategies work best, for which population groups, in which community and organizational settings, and why.

Expanding Delivery System Research in Public Health Settings

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. 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. 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. 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 Health Departments and Specific Maternal and Child Health Expenditures

As a part of the Public Health Activities and Service Tracking study and in collaboration with partners in 2 Public Health Practice-Based Research Network states, we examined relationships between local health department (LHD) maternal and child health (MCH) expenditures and local needs. We used a multivariate pooled time-series design to estimate ecologic associations between expenditures in 3 MCH-specific service areas and related measures of need from 2005 to 2010 while controlling for other factors. Retrospective expenditure data from LHDs and for 3 MCH services represented annual investments in (1) Special Supplemental Nutrition for Women, Infants, and Children (WIC), (2) family planning, and (3) a composite of Maternal, Infant, Child, and Adolescent (MICA) service. Expenditure data from all LHDs in Florida and Washington were then combined with "need" and control variables. Our sample consisted of the 102 LHDs in Florida and Washington and the county (or multicounty) jurisdictions they serve. Expenditures for WIC and for our composite of MICA services were strongly associated with need among LHDs in the sample states. For WIC, this association was positive, and for MICA services, this association was negative. Family planning expenditures were weakly associated, in a positive direction. Findings demonstrate wide variations across programs and LHDs in relation to need and may underscore differences in how programs are funded. Programs with financial disbursements based on guidelines that factor in local needs may be better able to provide service as local needs grow than programs with less needs-based funding allocations.

Recent Advances in Public Health Systems Research in the United States

Recognizing the public's health is the outcome of dynamic, adaptive, and complex systems of agencies; infrastructure, relationships, and interactions that dictate how to improve health outcomes; and reducing health risks in a population is based on systems thinking and evidence. New methods such as network analysis and public health practice-based research networks demonstrate the potential for new insight to our understanding of how systems and infrastructure influence population health. We examine advances in public health systems research since 1988 and discuss the relevance of this type of research to public health practice. We assess the current infrastructure for conducting public health systems research, suggest how the research infrastructure can be improved, and conclude with a discussion of how health reform in the United States will require research focused on understanding the adaptive complexity inherent in public health and health care systems and strengthening the systems research infrastructure.