A Strategy for Strengthening: Implementation of the Capabilities Opportunities Assessment Tool for the Public Health Workforce.

CONTEXT: Strengthening the national public health infrastructure is crucial to ensure provision of necessary public health services in all jurisdictions. Public health agencies and their governing bodies need an evidence-based understanding of workforces' capabilities to operationalize this effort. PROGRAM: The Capabilities Opportunities Assessment Tool for the Public Health Workforce (COAT-PH) is an assessment of workforce foundational capabilities (FCs), based on the Foundational Public Health Services (FPHS) framework. The COAT-PH provides data on employees' capabilities to health departments to help them improve and operationalize the FPHS. IMPLEMENTATION: This article describes the development and pilot testing of the COAT-PH in a convenience sample of 8 health departments in Texas of various sizes and accreditation statuses. Participating leadership teams were provided easily interpretable reports to deliver clear evidence of division and organization-level workforce capability gaps and strengths. Follow-up semistructured interviews were conducted with leaders to capture insights into the tool and the usefulness of the findings. EVALUATION: Eighty-eight percent of pilot health departments reported successfully appraising employee capability deficits, and 83% of small and medium health departments successfully assessed division or organizational FC strengths and gaps. All participating departments identified ways they could use their findings in future improvement efforts. Instrument psychometrics included the Cronbach α of internal reliability using a small test-retest sample (n = 6) of 0.956. Item test-retest reliability using Cohen's κ revealed 89% of items demonstrated at least slight reliability and 43% demonstrated moderate to substantial reliability. Content validity was established through review by 15 subject matter experts in the field of public health. DISCUSSION: To provide the FPHS, health department leadership teams need a strong, prepared workforce and an effective method to demonstrate employee capabilities and provide evidence of health department workforce strengths and gaps to their governing bodies in the form of data that are clear and easy to understand. Early results demonstrated the usefulness of the COAT-PH in this effort.

Teaching nursing within a population health context: From concept to exemplars.

As researchers in the health sciences improve their understanding of the underlying causes of poor health to include non-medical factors, nursing practice must expand and adapt to enable nurses to effectively contribute to population health improvement. The concept of population health has been incorporated into the current American Association of Colleges of Nursing (AACN) The Essentials: Core Competencies for Professional Nursing Education (2021) as a set of competencies for nurses at entry and advanced levels. This article provides a description of these competencies, and exemplars of how to include them meaningfully in nursing curricula at the entry level.

Measuring Bachelor of Science in Nursing competencies in public/population health.

Nurses have a long history of practice in public health. More recently basic population health knowledge and skills are being required across all nursing practice settings. To prepare nurses for this practice nursing education has long included public or community health nursing (PHN) content and skills as part of prelicensure education at the baccalaureate level and above. However, little work has been done to document student competency in these areas. Competency-based education is a process whereby students are held accountable for the mastery of knowledge and skills deemed critical for an area of study. The AACN Public/Population Health Workgroup addressed the challenge of measuring baccalaureate student nursing competencies in population health by developing an unfolding case study, with embedded questions assessing selected competencies. Lacking established population health competencies in nursing curriculum at the time of this work but wanting to assess students' basic competencies across the care continuum, the Workgroup selected relevant competencies from the Council of Public Health Nursing Organizations (formerly called the Quad Council) Competencies for Public Health Nurses. Utilizing these selected competencies, the Workgroup devised the unfolding case study and piloted it with 275 baccalaureate nursing education programs across the country. The findings from the Pilot demonstrated nursing student competency achievement and how this achievement changed as students progressed through the curriculum. The authors report implications and recommendations for competency measurement in population health based on the results of the pilot.

Behind Closed Doors: A Thematic Analysis of Diabetes Community Health Worker Home Visit Content.

The present work studies how community health workers (CHWs) perform the role of educator and how this relates to the implementation of other CHW roles, skills, and qualities. Prior studies on this topic have relied on interviews or focus groups rather than analysis of CHW interactions. We conducted a thematic analysis of 24 transcripts of conversations occurring between CHWs and participants during home visits as part of the Mexican American Trial of Community Health Workers, a randomized controlled trial that improved clinical outcomes among low-income Mexican American adults with type 2 diabetes. Three themes describing interactions related to diabetes self-management education accounted for about half of encounter content. The other half of encounter content was dedicated to interactions not explicitly related to diabetes described by 4 subthemes. In a successful CHW intervention, focused educational content was balanced with other interactions. Interactions not explicitly related to diabetes may have provided space for the implementation of core CHW roles, skills, and qualities other than educator, particularly those related to relationship building. It is important that interventions provide CHWs with sufficient time and flexibility to develop strong relationships with participants.

A critical gap: Advanced practice nurses focused on the public's health.

BACKGROUND: The COVID-19 pandemic has highlighted the need for nurse leaders who "embrace the interconnection" between medicine and public health. The inequitable impact of COVID-19 on people of color demonstrates the importance of applying expertise from nursing practice and public health systems to work with communities and other professions on complex health issues. Yet, despite a clear need for improved population health, educational programs designed to produce Advanced Public Health Nurses, with skills to address complex system changes, have become increasingly scarce. PURPOSE: We put forward the perspective that the nation needs more advanced practice nurses prepared for leadership roles focused on the health of whole populations, marginalized communities, and the systems and policies that promote their health. DISCUSSION: We argue that opportunities should be expanded for nurses to attain education for these roles through increased investments in the Doctor of Nursing Practice model to prepare nurses for advanced public health specialty practice.

Applying the Chronic Care Model to Improve Patient Activation at a Nurse-Managed Student-Run Free Clinic for Medically Underserved People.

This article describes a practice change intended to improve patient activation, also described as self-care management, in a sample of uninsured and underinsured patients with one or more chronic diseases who received care at a nurse-managed student-run free clinic project. Chronic diseases are the leading causes of death and disability in the United States. Individuals with chronic illnesses may be uninsured or underinsured and often do not receive adequate medical management, resulting in complications and unnecessary hospitalizations. Lack of knowledge related to self-care has been identified as one risk factor associated with poor health outcomes in medically underserved populations. Student-run free clinics have emerged to provide care to groups that would otherwise not receive health care while simultaneously providing experiential learning for healthcare students. Guided by the Chronic Care Model, an intervention was designed to improve patients' self-care management and chronic disease care delivery offered by the family nurse practitioner and baccalaureate nursing students. The evaluation plan for the Patient Activation Intervention utilized a pretest-posttest design. The Patient Activation Measure tool was administered at the beginning and end of the intervention. Additional outcomes were evaluated using a chart audit tool. A total of 19 unique patients, representing 42 free clinic visits, were evaluated during the intervention period. The mean Patient Activation Measure score was 60.95 (standard deviation ± 12.03) and was indicative of a good foundational understanding of chronic illness and working toward self-management. Chi-square and Fischer's exact test statistics demonstrated a statistically significant (p < .05) difference in the documentation of medication reconciliation, patient-centered goals, and self-management education from baseline to post intervention follow-up appointments. The evidence-based Patient Activation Intervention demonstrated promise as an effective method to increase patient's self-care management and improve patient-centered outcomes for underserved patients when delivered at a nurse-managed student-run free clinic.

Using a Community Preventive Services Task Force Recommendation to Prevent and Reduce Intimate Partner Violence and Sexual Violence.

Intimate partner violence (IPV) and sexual violence (SV) are preventable public health problems affecting millions in the United States. The Community Preventive Services Task Force (CPSTF), an independent panel of experts that develops evidence-based recommendations based on rigorous systematic reviews, recommends interventions that aim to prevent or reduce IPV and SV among youth aged 12-24 years. Decision makers can use these findings to select interventions appropriate for their populations, identify additional areas for research, and justify funding requests.

Evidence of Public Health Nursing Effectiveness: A Realist Review.

OBJECTIVES: The purpose of this realist review was to examine PHN interventions and their outcomes during the period preceding the Affordable Care Act (1990-2010), to determine what types of interventions demonstrated effectiveness, and whether these were related to target population or setting. DESIGN AND SAMPLE: The review focused on PHN interventions with data support documented over 20 years. A search of the published literature using CINHAL, PubMed, and ancestry methods resulted in 64 articles meeting the search criteria. The researchers reviewed each article for the relevant variables; achieved consensus for each variable; and summarized results using descriptive statistics. RESULTS: Documented PHN interventions targeted vulnerable populations. Interventions included health education, behavior change, and screening. There was evidence of effectiveness of PHN interventions in a number of studies; however, the study limitations and variety of intervention types make overall conclusions about PHN effectiveness challenging. CONCLUSIONS: Despite the long history of PHN working in communities to promote and maintain the health of vulnerable populations, practice outcomes have not been well documented. Further work is needed to: strengthen the methods for documenting effectiveness of PHN practice; focus on promising PHN interventions via multisite studies; and translate evidence-based PHN interventions to practice settings.

Mexican American trial of community health workers: a randomized controlled trial of a community health worker intervention for Mexican Americans with type 2 diabetes mellitus.

OBJECTIVES: We assessed whether community health workers (CHWs) could improve glycemic control among Mexican Americans with diabetes. METHODS: We recruited 144 Mexican Americans with type 2 diabetes between January 2006 and September 2008 into the single-blinded, randomized controlled Mexican American Trial of Community Health Workers (MATCH) and followed them for 2 years. Participants were assigned to either a CHW intervention, delivering self-management training through 36 home visits over 2 years, or a bilingual control newsletter delivering the same information on the same schedule. RESULTS: Intervention participants showed significantly lower hemoglobin A1c levels than control participants at both year 1 Δ = -0.55; P = .021) and year 2 (Δ = -0.69; P = .005). We observed no effect on blood pressure control, glucose self-monitoring, or adherence to medications or diet. Intervention participants increased physical activity from a mean of 1.63 days per week at baseline to 2.64 days per week after 2 years. CONCLUSIONS: A self-management intervention delivered by CHWs resulted in sustained improvements in glycemic control over 2 years among Mexican Americans with diabetes. MATCH adds to the growing body of evidence supporting the use of CHWs to reduce diabetes-related health disparities.

Home asthma triggers: barriers to asthma control in Chicago Puerto Rican children.

We sought objectively to measure, summarize, and contextualize the asthma triggers found in the homes of urban high-risk Puerto Rican children and adolescents with asthma in Chicago. Data were from the baseline home assessments of Project CURA. Research assistants interviewed caregivers, conducted a home visual inspection, and collected saliva samples for cotinine analysis. A trigger behavior summary score was created. The housing inspected was old with multiple units and obvious structural deficiencies. Many allergic and irritant triggers were observed. Having a controller medicine or private insurance was associated with lower trigger behavior summary scores; caregiver depression, caregiver perceived stress, and child negative life events were associated with high trigger scores. The final multivariate model retained had a controller medicine, private insurance, and caregiver perceived stress. The data from this high-risk cohort identified modifiable areas where environmental interventions could reduce morbidity in Puerto Rican children and adolescents.

The Quad Council practice competencies for public health nursing.

This article describes the most recent efforts by the Quad Council of Public Health Nursing organizations to review and revise the competencies for PHN practice, and highlights the implications of these competencies for practice, education, and research. The Quad Council is a coalition of four nursing organizations with a focus on public health nursing and includes the Association of Community Health Nursing Educators; the Association of Public Health Nursing (known prior to July 1, 2012 as the Association of State and Territorial Directors of Nursing); the Public Health Nursing section of the American Public Health Association; and the Council on Economics and Practice of the American Nurses' Association. The Quad Council competencies are based on the Council on Linkages competencies for public health professionals and were designed to ensure that public health nursing fits in the domain of public health science and practice.

Embracing a competency-based specialty curriculum for community-based nursing roles.

The Quad Council competencies for public health nursing (PHN) provide guidance in developing curricula at both the generalist and specialist level. However, these competencies are based on nursing roles in traditional public health agencies and community/public health is defined more broadly than official agency practice. The question arises as to whether community-based specialties require largely the same knowledge and skill set as PHN. The purpose of the competency cross-mapping project reported here was to (a) assess the intersection of the Quad Council competencies with four community-based specialties and (b) ensure the appropriateness of a Quad Council-based curriculum to prepare graduates across these four specialties (home health, occupational health, environmental health, and school nursing). This article details the multistep cross-mapping process, including validation with practice leaders. Results indicate strong alignment of community-based specialty competencies with Quad Council competencies. Community-based specialty-specific content that did not align well is identified, along with examples of didactic and clinical strategies to address gaps. This work indicates that a Quad Council-based curriculum is appropriate to prepare graduates in community-based specialties when attention to the specialty-specific competencies in the clinical setting is included. This work guides the development of a doctorate of nursing practice curriculum in PHN, encompassing the four additional community-based specialties.

The Mexican-American Trial of Community Health workers (MATCH): design and baseline characteristics of a randomized controlled trial testing a culturally tailored community diabetes self-management intervention.

OBJECTIVES: Community Health Workers (CHWs) have been recommended to reduce diabetes disparities, but few robust trials of this approach have been conducted. Limitations of prior studies include: unspecified a priori outcomes; lack of blinded outcome assessments; high participant attrition rates; and lack of attention to intervention fidelity. These limitations reflect challenges in balancing methodologic rigor with the needs of vulnerable populations. The Mexican-American Trial of Community Health workers (MATCH) was a blinded randomized controlled trial testing CHW efficacy in improving physiologic outcomes and self-management behaviors among Mexican-Americans with type 2 diabetes. This paper describes methods used to overcome limitations of prior studies. RESEARCH DESIGN AND METHODS: The primary aim was to determine if a CHW intervention would result in significant reductions in Hemoglobin A1c and rates of uncontrolled blood pressure. 144 Mexican-Americans with diabetes were randomized. The intervention consisted of self-management training delivered by CHWs over a 24-month period; the comparison population received identical information via bilingual newsletter. Blinded research assistants completed assessments at baseline, 12 months, and 24 months post-randomization. RESULTS: The MATCH cohort was characterized by low acculturation and socioeconomic status. Study participants had low rates of medication adherence and glucose monitoring. 70% had poor glycemic control with A1c levels over 7.0, and 57.3% had blood pressures worse than ADA target levels (<130/80). CONCLUSIONS: MATCH preserved community sensitivity and methodologic rigor. The study's attention to intervention fidelity, behavioral attention control, blinded outcomes assessment, and strategies to enhance participant retention can be replicated by researchers testing culturally-tailored CHW interventions.

Recruitment of Mexican American adults for an intensive diabetes intervention trial.

OBJECTIVE: Effective behavioral diabetes interventions for Mexican Americans are needed. Our study focused on efforts to recruit Mexican American adults for a trial testing a diabetes community health worker (CHW) self-management intervention. DESIGN: Behavioral randomized controlled trial, community-based participatory research approach. SETTING: Chicago. PARTICIPANTS: Mexican American adults with type 2 diabetes. OUTCOME MEASURES: Screening and randomization. METHODS: Initial eligibility criteria included Mexican heritage, treatment with oral diabetes medication, residence in designated zip codes, planned residence in the area for two years, and enrollment in a specific insurance plan. RESULTS: Recruitment through the insurer resulted in only one randomized participant. Eligibility criteria were relaxed and subsequent efforts included bilingual advertisements, presentations at churches and community events, postings in clinics, partnerships with community providers, and CHW outreach. Zip codes were expanded multiple times and insurance criteria removed. CHW outreach resulted in 53% of randomized participants. CONCLUSIONS: Despite strong ties with the target community, culturally appropriate recruitment strategies involving community representation, and a large pool of potential participants, significant challenges were encountered in recruitment for this diabetes intervention trial. Researchers identified three key barriers to participation: study intensity and duration, lack of financial incentives, and challenges in establishing trust. For future research to be successful, investigators need to recognize these barriers, offer adequate incentives to compensate for intervention intensity, and establish strong trust through community partnerships and the incorporation of community members in the recruitment process.

Project MATCH: training for a promotora intervention.

PURPOSE: Adequate training and support are critical for community health workers (promotoras de salud in Spanish) to work effectively. Current literature on promotora training is limited by a focus on promotoras' knowledge and satisfaction immediately after training. The relevance of training to subsequent work performance and the need for ongoing training are rarely addressed. This article describes the training and evaluation components of a promotora intervention focused on diabetes self-management. Training Methods Project MATCH (the Mexican American Trial of Community Health Workers) is a clinical trial designed to test the effectiveness of an intensive, promotora-based intervention to improve disease self-management for Mexican Americans with diabetes. The MATCH investigators designed a multicomponent promotora training program that provided both initial and ongoing training. The investigators used multiple methods to determine promotoras' knowledge levels, initial competency in intervention delivery, and changes in this competency over time. Evaluation Methods and Results The evaluation results show that although the initial training provided a solid knowledge and skills base for the promotoras, the ongoing training was critical in helping them deal with both intervention-related and personal challenges. CONCLUSIONS: The experiences of the MATCH study suggest that in addition to strong initial training, promotora interventions benefit from ongoing training and evaluation to ensure success.

Community/public health nursing practice leaders' views of the doctorate of nursing practice.

OBJECTIVES: This paper presents thoughts of practice leaders in the community/public health nursing (C/PHN) specialty on advanced nursing practice (ANP) and the necessary educational preparation for such practice. DESIGN AND SAMPLE: Practice leaders were engaged in conversations specifically focused on the Doctor of Nursing Practice (DNP) as preparation for ANP in their specialties, and asked to consider the benefits of, and challenges to, this educational program. MEASURES AND RESULTS: The resulting remarks were then assessed for themes by the interviewers and these are presented along with thoughts on the future of education for ANP. CONCLUSION: Overall, there was much agreement among the practice leaders interviewed about the importance of a broad skill set for ANP in the specialty. However, the practice leaders interviewed here also identified the practical challenges involved in educating nurses at the DNP level in the C/PHN specialty, as well as some concerns about the definitions of ANP for the future.

Creating diversity in a baccalaureate nursing program: a case study.

Minority groups in the United States experience disparity in the health care services they receive and in their health related outcomes. Minority healthcare providers are more likely to serve minority under-served populations, thus addressing this healthcare disparity in an effective culturally competent manner (Robert Wood Johnson 2005; Sullivan, 2004). The purpose of the project was to increase the number of racial and ethnic minority students who are successfully recruited and admitted to the nursing program at Hope College in Holland, Michigan. The project involved the identification of perceived barriers to increased minority participation in nursing at the college, review of the literature to identify evidence-based interventions, and implementation of selected interventions to overcome the identified barriers. Implementation and evaluation are still on-going but showing early success.

Options for sustaining school-based health centers.

Several methods exist for financing and sustaining operations of school-based health centers (SBHCs). Promising sources of funds include private grants, federal grants, and state funding. Recently, federal regulation changes mandated that federal funding specifically for SBHCs go only to SBHCs affiliated with a Federally Qualified Health Center (FQHC). Becoming a FQHC allows a SBHC to bill Medicaid at a higher rate, be notified about federal grants, and access the federal drug-pricing program. However, FQHCs must bill for services, including a sliding-fee scale based on ability to pay; develop a governance board with a majority of consumer members; provide a set of designated primary care services; and serve all people regardless of ability to pay. Private grants impose fewer restrictions and usually provide start-up and demonstration funds for specific program needs. Such funds are generally time limited, so new programs need to be incorporated into the operational budget of the center. State funding proves relatively stable, but fiscal challenges in some states made these funds less available. Using a variety of funding sources will enable ongoing provision of health care to students. Overall, SBHCs should consider infrastructure development that allows a variety of funding options, including formalizing existing partnership commitments, engaging in a needs assessment and strategic planning process, developing the infrastructure for FQHC status, and implementing a billing system for client services.