Assessing Smoke-Free Housing Implementation Approaches to Inform Best Practices: A National Survey of Early-Adopting Public Housing Authorities.

Secondhand smoke (SHS) exposure causes chronic illness and occurs at a higher prevalence in low-income communities than the general public. In 2018, the U.S. Department of Housing and Urban Development (HUD) instituted a smoke-free housing rule for Public Housing Authorities (PHAs) to address persistent health inequities. However, the success of smoke-free housing requires evidence to inform effective implementation approaches. A mixed-methods, cross-sectional survey was conducted in a national sample of PHAs. Questions focused on housing officials' use of specific implementation strategies. Adjusted odds ratios were used to assess associations between implementation approaches and variations among PHAs (i.e., region, size, or recency of policy adoption). Qualitative analyses were conducted to assess the perceived effectiveness of implementation strategies. Resident engagement, staff training, and smoking cessation support were the most frequently used implementation strategies. Engagement with local stakeholders was cited less frequently. Enforcement actions were limited with no violations referred to housing court. Support for policy adherence was identified as a sixth implementation strategy. While most PHAs used at least some evidence-informed implementation strategies, a lack of a systematic approach may limit overall effectiveness. Further research is required to resolve implementation barriers experienced disproportionately by a subset of PHAs, and to inform a best practice implementation framework that meets the needs of a heterogeneous population.

Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action.

BACKGROUND: Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care. METHODS: We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility. FINDINGS: Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences. CONCLUSIONS: The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

Qualitative Assessment of Smoke-Free Policy Implementation in Low-Income Housing: Enhancing Resident Compliance.

PURPOSE: As public housing agencies and other low-income housing providers adopt smoke-free policies, data are needed to inform implementation approaches that support compliance. DESIGN: Focused ethnography used including qualitative interviews with staff, focus groups with residents, and property observations. SETTING: Four low-income housing properties in Massachusetts, 12 months postpolicy adoption. PARTICIPANTS: Individual interviews (n = 17) with property staff (managers, resident service coordinators, maintenance, security, and administrators) and focus groups with resident smokers (n = 28) and nonsmokers (n = 47). MEASURES: Informed by the social-ecological model: intrapersonal, interpersonal, organizational, and community factors relating to compliance were assessed. ANALYSIS: Utilized MAXQDA in a theory-driven immersion/crystallization analytic process with cycles of raw data examination and pattern identification until no new themes emerged. RESULTS: Self-reported secondhand smoke exposure (SHSe) was reduced but not eliminated. Challenges included relying on ambivalent maintenance staff and residents to report violations, staff serving as both enforcers and smoking cessation counsellors, and inability to enforce on nights and weekends. Erroneous knowledge of the policy, perception that SHSe is not harmful to neighbors, as well as believing that smokers were losing their autonomy and being unfairly singled out when other resident violations were being unaddressed, hindered policy acceptance among resident smokers. The greatest challenge to compliance was the lack of allowable outdoor smoking areas that may have reduced the burden of the policy on smokers. CONCLUSION: Smoke-free policy implementation to support compliance could be enhanced with information about SHSe for smokers and nonsmokers, cessation support from external community partners, discussion forums for maintenance staff, resident inclusion in decision-making, and framing the policy as part of a broader wellness initiative.

Building the evidence base for population-level interventions: barriers and opportunities.

Population-level interventions focused on policy, systems, and environmental change strategies are increasingly being used to affect and improve the health of populations. At the same time, emphasis on implementing evidence-based public health practices and programming is increasing, particularly at the federal level. Valuing strategies in the population health domain without the benefit of demonstrated efficacy through highly rigorous methods introduces an inherent tension between planning and acting on the best evidence available, waiting for more rigorous evidence to emerge, as well as exploring innovative ways to evaluate and model evidence-based strategies. This article describes the creation of a resource that helps public health practitioners use current evidence for strategic decision making while building the evidence base for population-level interventions. The resource addresses topics of current discussion in the field of evaluating population-level interventions, including the tension between internal and external validity, the need to include measures of health equity, and the balance between fidelity to the intervention and adaptation to the community context. The resource is intended to advance development of evidence in the field by providing practitioners, project managers, and evaluators with a practical guide for using, reviewing, and adding to the existing evidence base.