Evidence-Based Decisionmaking for Community Health Programs

Evidence-Based. Decisionmaking for Community. Health Programs. TION AT BROUCI. – Catherine A. Jackson. Kathryn Pitkin. Raynard Kington.
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Performance measurement in public health has most frequently focused on the agency and characteristics of the agency director, based most often on responses from a single individual, i. While LHD directors and program managers report similar levels of performance in many of the A-EBPs, there are differences in both performance and individual characteristics which have important implications for improving competencies in EBPH. It is not surprising to find differences in performance of A-EBPs and individual characteristics across the three programs areas of chronic disease, environmental health, and infectious diseases — such differences reflect not only the differences in program content, but the history and organizational milieu of these programs.

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Chronic disease programs are among the newer major programs to be established at state and local health department levels, and the data on time in current position and overall experience in public health among CD managers in this study may reflect this history. Meissner et al described internal and external factors that contribute to success in controlling cancer in the public health setting, which included leadership, use of data, training, and the importance of linkages and coalitions for developing, implementing, and maintaining community-based programs.

In contrast to CD programs, ID programs are among the oldest and most well-established programs in public health, reflecting the initial focus of most governmental public health agencies in controlling epidemics of diseases such as yellow fever, smallpox, and tuberculosis. The training of program managers overall compared to LHD directors further highlights these differences, as It is possible that some of the variation observed - e.

The recommendations in the Guide to Community Preventive Services 7 pertain in large part to chronic diseases. Because of this, it may be that program managers in ID and EH rely more on best practices guidelines within their disciplines. There was a notable difference in governance structure as a predictor of the performance of A-EBPs for LHD directors compared to program managers.

For LHD directors, working in a state-governed LHD was a greater predictor of performance, while working in locally-governed LHDs was a greater predictor for program managers. One can only speculate that for program managers, local autonomy provides an organizational climate more conducive to program-level leadership, while state-governed LHDs may have higher requirements and expectations for LHD directors than locally-governed LHDs.

Historically, studies have come to different conclusions in examining correlates of higher overall performance, with some reporting higher performance scores for LHDs which are part of a centralized, state-governed public health system, while others have reported higher performance scores for LHDs in decentralized governance relationships. The differences in educational background, experience, and performance of A-EBPs between LHD directors compared to program managers, as well as across the three different types of programs, have direct relevance to training and improving competencies in EBPH.

Nurses, epidemiologists, and sanitarians, for example, differ in their specific focus on evidence — individual, population, organizational; their skill sets are different; and, the context of practice — clinical, population-focused, regulatory — is different. These findings, combined with more detailed data on performance of A-EBPs by LHD directors 9 , bring a special focus to nursing in public health.

Whether these differences reflect different capacities of LHDs simply on the basis of size, whether there is a different focus and skill set among LHD directors who are nurses, or whether small LHDs have a special history and affinity for having nurses as directors is not clear. The importance of nursing as a major entry point for future public health professionals has been recognized by the Institute of Medicine in its reports on Who will keep the public healthy? Leading Change, Advancing Health 42 , with several recommendations on education and leadership development, e.

This renewed emphasis on nursing and public health, given the differences noted above for small LHDs, lends itself well to practice-based research which can be actionable. While differences in leadership practices and performance by both directors and program managers have been well described in the general literature on leadership 43 , there is very little published information specific to public health. In a current project on setting budgets and priorities, Leider et al report important differences when comparing practices among state health department directors, deputy directors, and program managers in environmental health, emergency preparedness, and maternal and child health.

The present study adds to these studies regarding the importance of considering whom to target for survey response, particularly for studies that focus on performance, as perspectives may differ according to who responds. There are notable limitations to this study. First, all data are self-reported, and there were no attempts to verify the accuracy of responses. Second, the responses may have been biased towards larger LHDs, as the larger the agency the more likely it is to have program managers for all three programs studied. In conclusion, performance of A-EBPs varies between LHD directors and program managers, as well as across different public health program areas.

Understanding the differences in educational background, experience, and organizational culture for program managers is a necessary step to improving competencies in EBPH. A common path to improving such competencies may be one means to reduce the silo-reinforcing nature of public health funding. This has important implications for quality improvement —related initiatives such as national voluntary public health accreditation, with standards focused on workforce development and evidence-based public health, but especially for the standards focused on administration and management.

The identification of A-EBPs provides a stronger evidence-based platform for revising standards and measures for administrative practices, and this current study provides real-world evidence of how different capacities in achieving A-EBPs exist across different types of programs and levels of leadership. This can be useful not only to those involved in administering accreditation, but also for public health agencies which are preparing for accreditation. This study was supported in part by Robert Wood Johnson Foundation's grant no.

We also thank members of our research team: National Center for Biotechnology Information , U. J Public Health Manag Pract. Author manuscript; available in PMC Jan 6. Brownson , PhD 2, 3. Harris 2 Prevention Research Center in St. Brownson 2 Prevention Research Center in St. See other articles in PMC that cite the published article. Design Program managers completed a survey consisting of six sections biographical data, use of A-EBPs, diffusion attributes, use of resources, and barriers to, and competencies in, evidence-based public health EBPH with a total of 66 questions.

Results The total responses from program managers represented individual LHDs. Conclusions Understanding the differences in educational background, experience, organizational culture, and performance of A-EBPs between program managers and LHD directors is a necessary step to improving competencies in EBPH. Introduction Public health programs and policies have largely been credited with gains in longevity and quality of life in the previous century, with notable achievements in the reduction of morbidity and mortality from vaccine preventable diseases, tobacco use, and motor vehicle accidents.

Results The individual characteristics of program managers and LHD directors are provided in table 1. Open in a separate window. Table 2 Predictors of administrative evidence-based practices among directors and program managers in local health departments, United State, Discussion Performance measurement in public health has most frequently focused on the agency and characteristics of the agency director, based most often on responses from a single individual, i.

Ten great public health achievements--United States, Public health in the twentieth century: Annual Review of Public Health. Government Printing Office; Mar, Impact of the economic recession on local health departments. Am J Prev Med. The Guide to Community Preventive Services: What Works to Promote Health?

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Am J Public Health. Public health delivery systems: Evidence-based medicine beyond the bedside: J Eval Clin Pract. Barriers to evidence-based decision making in public health: The effect of disseminating evidence-based interventions that promote physical activity to health departments. We used 2-level multilevel regression models to account for the hierarchical structure of the data. We modeled information about the LHDs at level 1 and information about the 47 states at level 2. Each model included a random intercept for each state. All analyses incorporated statistical weights to account for sampling of LHDs that completed the module 2 supplemental survey and for variation in nonresponses as a function of LHD size LHDs that served larger populations were more likely to respond to the profile survey than LHDs that served smaller populations.

We conducted analyses in using MPlus 7. Before adding any predictor variables, we tested an empty model with EBDM as the outcome to calculate the intraclass correlation, which was 0. LHDs that had experienced a budget cut from the previous year used more EBDM practices than those whose budget had stayed the same, had increased, or was unknown, and LHDs that provided a larger number of clinical services used more EBDM practices. None of the other predictor variables were statistically significant.

All values are adjusted for other variables in the model. LHDs that had a top executive with a public health degree; LHDs that employed epidemiologists, health educators, and emergency preparedness staff; LHDs in which the staff had participated in a training session for health impact assessments in the past year; and LHDs with more employees all used significantly more EBDM practices than other LHDs Table 3.

Across models, LHDs located in states that had a centralized public health governance structure used significantly fewer EBDM practices than those in states with a decentralized governance. The study findings suggest several directions for future research and practice. First, the low use of certain strategies is striking, particularly the application of research findings only A majority of LHDs Because all these strategies are considered key to EBDM for population health improvement, 4,5,7,8,10,15,49—52 researchers should pursue why some strategies get little use and what is needed to enhance uptake.

Our finding that LHDs led by executives with public health degrees used more EBDM practices than other LHDs stands in contrast with other studies that have found a negative association between having a public health degreed director and LHD performance. In this study, having a medical or nursing degree did not predict the use of EBDM practices. Bekemeier and Jones 29 found that nurse-led LHDs used a greater breadth of population-focused primary prevention activities than did non—nurse-led LHDs, but they were less likely to conduct community health assessment and planning 2 of the practices in our EBDM measure.

Their study also did not investigate the unique impact of the director having a public health degree. This finding may reflect the diversity of education and training among LHD executives or the relatively recent focus on EBDM in public health practice and training programs. Third, beyond characteristics of the executive, employing other key LHD staff was also important. LHDs that employed people in the roles of epidemiologist, health educator, or preparedness coordinator used more EBDM practices.

Together, these positions are assigned activities that correspond to critical EBDM practices in our index as well as to core health education and epidemiology competencies. For example, the epidemiologists employed by LHDs may have completed a BS or MPH in epidemiology, a short course, on-the-job training, or none of these.

Even if degreed health educators fill health education positions, some training programs focus on individual-level change, in keeping with a patient education role, and others focus on changing programs, systems, and policies. In future research, it will be important to explore the qualifications, skills, and importance of personnel in these key positions as well as the most effective level and mix of staffing for public health service delivery.

LHDs with a larger per capita workforce may have been able to hire personnel who had skills tailored to these roles or had more time for EBDM. Notably, there were more workforce than resource predictors, suggesting that how resources are used is critical. Fourth, the results from the resources model suggest that spending more money i. LHDs with fewer resources may concentrate on necessary and expected clinical services rather than engage in EBDM processes that could lead to programs that would be too costly to support. Losing employees through layoffs or attrition was not associated with the number of EBDM practices used, possibly because some LHDs that lost personnel became more strategic in how they used their resources.

In the resources model, EBDM was positively associated with the breadth of clinical services, suggesting that there is not necessarily a trade-off between these. Because the NACCHO data do not allow tracking expenditures to specific public health activities, the possibilities we suggest should be viewed with caution. The large percentage of missing resource data may have obscured some relationships. To do this, it will be necessary to institute financial accounting systems that support overall financial and program management i.

Fifth, although Brownson et al.

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These differing results, however, may reflect differences in measurement because the Brownson measure encompassed a wider breadth of practices and the perceived value and access to EBDM skills, but not the use of them. Taken together, studies suggest that some types of LHD performance may be handled better in decentralized states, 55 some in mixed or shared states, 21,59 and some in centralized states.

Together, these findings suggest that LHDs may invest more in public health when they have the autonomy and local support to do so, whether through spending measures or through the use of EBDM practices that focus on the local jurisdiction. By contrast, with the evidence suggesting that decentralization is important for EBDM, the presence of local oversight in the form of a local board of health did not lead to more EBDM practices, even when testing for different types of board responsibilities e. It is likely that even boards with policymaking authority vary in their oversight and activism, and this difference could mask any associations.

Sixth, our findings regarding jurisdiction size were consistent with those of other studies that have also found jurisdiction size to be 1 of the strongest predictors of LHD performance. Hyde and Shortell 67 noted that the inefficiencies resulting from small LHDs have resulted in calls for consolidation since the mids, but research to suggest the effectiveness of this strategy is still limited.

An implication from this study is that LHDs should be encouraged to be strategic in their hiring and training processes and consider hiring directors with a public health degree as well as epidemiologists and health educators. With expected retirements in the governmental public health system, there may be opportunities for LHDs to make these strategic hires. It is also important to ensure that public health schools and programs provide a pipeline of workers for employment in governmental health and that funding enables LHDs to recruit these workers.

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

Much of the current public health workforce does not have public health training, 24 and many LHDs do not have the occupational roles that we found to be important for EBDM; however, other resources exist for LHDs. EBDM training courses and tools have been developed and disseminated, 4,6,11,15,36,69 and new research is emerging on the use of evidence-based administrative practices. State centers for health statistics may also provide local or regional data. Training efforts could promote the use of the community guide and the application of research to organizational and community practices.

Taking advantage of these resources is needed but not sufficient in the translation and dissemination process. Dissemination would best be facilitated through LHDs with similar staffing and funding levels, and implementation might be enhanced through partnerships with the LHDs in the largest jurisdictions. Practice-based research networks are another effective mechanism for facilitating research translation in practice.

LHDs in smaller jurisdictions face more challenges. LHDs could develop resource-sharing agreements through which specialized personnel e. This study had a number of limitations. The cross-sectional data did not allow us to determine the temporal order of relationships or test causal relationships between our independent and dependent variables.

For example, it is possible that LHDs using more EBDM practices see the need for and hire the specific personnel identified in our study rather than the reverse. The secondary data set limited the extent to which we could explore every predictor of public health system performance. In some cases, particularly in large LHDs, the person who completed the survey may not have known about all LHD activities.

Our outcome measure also had limitations. The survey questions we used only addressed the front end of EBDM because the data set did not include items on the use of interventions, evaluation, and dissemination. A more informative measure would assess the quantity or extent of a practice as well as the quality of the practice. Also, our measure of EBDM weighted all activities except epidemiology and surveillance equally; however, it is possible that some activities are more important indicators of EBDM, and the EBDM practices most needed in any LHD may vary considerably depending on available resources and the context of the local community.

Finally, this study did not determine whether combinations of EBDM practices were more important than others. Using data from routinely available data sets, we developed an EBDM measure focused on population health practices and identified the extent to which a nationally representative sample of LHDs use EBDM practices. Moreover, we identified modifiable factors at state and local levels that promote the use of these practices. Finally, our measure of EBDM requires further validation, as well as testing of its association with the use of evidence-based programs and various population health outcomes.

Nevertheless, this study has important practical and policy implications because it clearly highlights the underutilization of EBDM practices in LHDs. This research was funded by the Robert Wood Johnson Foundation grant ; we thank the Robert Wood Johnson Foundation for the support for this research. We appreciate the very helpful advice of 3 anonymous reviewers. This research was approved as exempt by the institutional review board of the University of North Carolina at Greensboro. National Center for Biotechnology Information , U.

Am J Public Health. Published online April. Rulison , PhD, Jeffrey D. Labban , PhD, Gulzar H. Lovelace and Kelly L. At the time of the study, Robert E. Correspondence should be sent to Kay A. Reprints can be ordered at http: Accepted September 5, This article has been cited by other articles in PMC. Abstract We examined variation in the use of evidence-based decision-making EBDM practices across local health departments LHDs in the United States and the extent to which this variation was predicted by resources, personnel, and governance. The key processes of EBDM are making decisions using the best available scientific evidence, systematically using data and information systems, applying program-planning frameworks that often have a foundation in behavioral science theory , engaging the community in assessment and decision making, conducting sound evaluation, and disseminating what is learned.

Open in a separate window. Predictor Variables Contextual variables. Statistical Analyses We used 2-level multilevel regression models to account for the hierarchical structure of the data. No or unknown participation Acknowledgments This research was funded by the Robert Wood Johnson Foundation grant ; we thank the Robert Wood Johnson Foundation for the support for this research.

Human Participant Protection This research was approved as exempt by the institutional review board of the University of North Carolina at Greensboro. Committee on Assuring the Health of the Public in the 21st Century. Institute of Medicine; US Health in International Perspective: Shorter Lives, Poorer Health.

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

National Academies Press; The Strategy of Preventive Medicine. Oxford University Press; Developing and using the Guide to Community Preventive Services: Annu Rev Public Health. Evidence-based interventions to promote physical activity: Am J Prev Med.

Centers for Disease Control and Prevention.