Public Health Readiness for Citizen Science: Health Department Experiences.

OBJECTIVE: The aim of this study was to examine the experiences of US health departments with citizen science. DESIGN: In 2019, we conducted a national survey of 272 local health department (LHD) representatives about knowledge and attitudes, readiness, experiences, and barriers related to citizen science (response rate = 45%). SETTING: LHDs in the United States in 2019. PARTICIPANTS: LHD representatives. MAIN OUTCOME MEASURES: Knowledge and attitudes, readiness, experiences, and barriers related to citizen science. RESULTS: Sixty-two percent of respondents reported LHD experience with citizen science in areas such as health promotion, emergency preparedness, and environmental health. LHDs in large jurisdictions (78%) were more likely to report staff familiarity with citizen science than small (51%) and medium (59%) jurisdictions ( P = .01). Although 64% reported readiness for citizen science, only 32% reported readiness for community-led activities. We found that LHDs use citizen science more for community engagement activities, such as public education, than data collection activities. Respondents indicated that staff education and training in citizen science methods, funding, and partners with relevant expertise were priority needs. CONCLUSION: LHDs have leveraged citizen science for community engagement, but barriers to technical uses remain.

Practices Among Local Public Health Agencies to Support Evidence-Based Decision Making: A Qualitative Study.

OBJECTIVES: Evidence-based decision making (EBDM) capacity in local public health departments is foundational to meeting both organizational and individual competencies and fulfilling expanded roles. In addition to on-the-job training, organizational supports are needed to prepare staff; yet, less is known in this area. This qualitative study explores supportive management practices instituted as part of a training and technical assistance intervention. DESIGN: This qualitative study used a semistructured interview guide to elicit participants' descriptions and perceptions via key informant interviews. Verbatim transcripts were coded and thematic analyses were conducted. SETTING: Local public health departments in a US Midwestern state participated in the project. PARTICIPANTS: Seventeen middle managers and staff from 4 local health departments participated in remote, audio-recorded interviews. INTERVENTION: Following delivery of a 3½-day in-person training, the study team met with health department leadership teams for department selection of supportive agency policies and procedures to revise or newly create. Periodic remote meetings included collaborative problem-solving, sharing of informational resources, and encouragement. MAIN OUTCOME MEASURES: Included management practices instituted to support EBDM and impact on day-to-day work as described by the interview participants. RESULTS: Leadership and middle management practices deemed most helpful included dedicating staff; creating specific guidelines; setting expectations; and providing trainings, resources, and guidance. Health departments with a preexisting supportive organizational culture and climat e were able to move more quickly and fully to integrate supportive management practices. Workforce development included creation of locally tailored overviews for all staff members and onboarding of new staff. Staff wanted additional hands-on skill-building trainings. Several worked with partners to incorporate evidence-based processes into community health improvement plans. CONCLUSIONS: Ongoing on-the-job experiential learning is needed to integrate EBDM principles into day-to-day public health practice. Management practices established by leadership teams and middle managers can create supportive work environments for EBDM integration.

An Emergent Network for the Diffusion of Innovations Among Local Health Departments at the Onset of the COVID-19 Pandemic.

INTRODUCTION: Communication networks among professionals can be pathways for accelerating the diffusion of innovations if some local health departments (LHDs) drive the spread of knowledge. Such a network could prove valuable during public health emergencies such as the novel coronavirus disease 2019 (COVID-19) pandemic. Our objective was to determine whether LHDs in the United States were tied together in an informal network to share information and advice about innovative community health practices, programs, and policies. METHODS: In January and February 2020, we conducted an online survey of 2,303 senior LHD leaders to ask several questions about their sources of advice. We asked respondents to rank up to 3 other LHDs whose practices informed their work on new public health programs, evidence-based practices, and policies intended to improve community health. We used a social network analysis program to assess answers. RESULTS: A total of 329 LHDs responded. An emergent network appeared to operate nationally among 740 LHDs. Eleven LHDs were repeatedly nominated by peers as sources of advice or examples (ie, opinion leaders), and 24 acted as relational bridges to hold these emergent networks together (ie, boundary spanners). Although 2 LHDs played both roles, most LHDs we surveyed performed neither of these roles. CONCLUSION: Opinion leading and boundary spanning health departments can be accessed to increase the likelihood of affecting the rate of interest in and adoption of innovations. Decision makers involved in disseminating new public health practices, programs, or policies may find our results useful both for emergencies and for practice-as-usual.

The State of Rural Public Health: Enduring Needs in a New Decade.

Public health in the rural United States is a complex and underfunded enterprise. While urban-rural disparities have been a focus for researchers and policymakers alike for decades, inequalities continue to grow. Life expectancy at birth is now 1 to 2 years greater between wealthier urban and rural counties, and is as much as 5 years, on average, between wealthy and poor counties.This article explores the growth in these disparities over the past 40 years, with roots in structural, economic, and social spending differentials that have emerged or persisted over the same time period. Importantly, a focus on place-based disparities recognizes that the rural United States is not a monolith, with important geographic and cultural differences present regionally. We also focus on the challenges the rural governmental public health enterprise faces, the so-called "double disparity" of worse health outcomes and behaviors alongside modest investment in health departments compared with their nonrural peers.Finally, we offer 5 population-based "prescriptions" for supporting rural public health in the United States. These relate to greater investment and supporting rural advocacy to better address the needs of the rural United States in this new decade.

Perspectives on program mis-implementation among U.S. local public health departments.

BACKGROUND: Public health resources are limited and best used for effective programs. This study explores associations of mis-implementation in public health (ending effective programs or continuing ineffective programs) with organizational supports for evidence-based decision making among U.S. local health departments. METHODS: The national U.S. sample for this cross-sectional study was stratified by local health department jurisdiction population size. One person was invited from each randomly selected local health department: the leader in chronic disease, or the director. Of 600 selected, 579 had valid email addresses; 376 completed the survey (64.9% response). Survey items assessed frequency of and reasons for mis-implementation. Participants indicated agreement with statements on organizational supports for evidence-based decision making (7-point Likert). RESULTS: Thirty percent (30.0%) reported programs often or always ended that should have continued (inappropriate termination); organizational supports for evidence-based decision making were not associated with the frequency of programs ending. The main reason given for inappropriate termination was grant funding ended (86.0%). Fewer (16.4%) reported programs often or always continued that should have ended (inappropriate continuation). Higher perceived organizational supports for evidence-based decision making were associated with less frequent inappropriate continuation (odds ratio = 0.86, 95% confidence interval 0.79, 0.94). All organizational support factors were negatively associated with inappropriate continuation. Top reasons were sustained funding (55.6%) and support from policymakers (34.0%). CONCLUSIONS: Organizational supports for evidence-based decision making may help local health departments avoid continuing programs that should end. Creative mechanisms of support are needed to avoid inappropriate termination. Understanding what influences mis-implementation can help identify supports for de-implementation of ineffective programs so resources can go towards evidence-based programs.

How to "Start Small and Just Keep Moving Forward": Mixed Methods Results From a Stepped-Wedge Trial to Support Evidence-Based Processes in Local Health Departments.

Background: Local health departments (LHDs) in the United States are charged with preventing disease and promoting health in their respective communities. Understanding and addressing what supports LHD's need to foster a climate and culture supportive of evidence-based decision making (EBDM) processes can enhance delivery of effective practices and services. Methods: We employed a stepped-wedge trial design to test staggered delivery of implementation supports in 12 LHDs (Missouri, USA) to expand capacity for EBDM processes. The intervention was an in-person training in EBDM and continued support by the research team over 24 months (March 2018-February 2020). We used a mixed-methods approach to evaluate: (1) individuals' EBDM skills, (2) organizational supports for EBDM, and (3) administered evidence-based interventions. LHD staff completed a quantitative survey at 4 time points measuring their EBDM skills, organizational supports, and evidence-based interventions. We selected 4 LHDs with high contact and engagement during the intervention period to interview staff (n = 17) about facilitators and barriers to EBDM. We used mixed-effects linear regression to examine quantitative survey outcomes. Interviews were transcribed verbatim and coded through a dual independent process. Results: Overall, 519 LHD staff were eligible and invited to complete quantitative surveys during control periods and 593 during intervention (365 unique individuals). A total of 434 completed during control and 492 during intervention (83.6 and 83.0% response, respectively). In both trial modes, half the participants had at least a master's degree (49.7-51.7%) and most were female (82.1-83.8%). No significant intervention effects were found in EBDM skills or in implementing evidence-based interventions. Two organizational supports scores decreased in intervention vs. control periods: awareness (-0.14, 95% CI -0.26 to -0.01, p < 0.05) and climate cultivation (-0.14, 95% CI -0.27 to -0.02, p < 0.05) but improved over time among all participants. Interviewees noted staff turnover, limited time, resources and momentum as challenges to continue EBDM work. Setting expectations, programmatic reviews, and pre-existing practices were seen as facilitators. Conclusions: Challenges (e.g., turnover, resources) may disrupt LHDs' abilities to fully embed organizational processes which support EBDM. This study and related literature provides understanding on how best to support LHDs in building capacity to use and sustain evidence-based practices.

State of public health emergency response leadership training: A multitiered organizational perspective.

OBJECTIVE: To capture organizational level information on the current state of public health emergency response leadership training. DESIGN: A web-based questionnaire. PARTICIPANTS: This multitiered assessment of health departments included two distinct respondent groups: (1) Public Health Emergency Preparedness (PHEP) Cooperative Agreement recipients (n = 34) and (2) local health departments (LHDs) (n = 169) representative of different agency sizes and populations served. RESULTS: Overall, PHEP and LHD respondents expressed a clear preference for participatory learning with practical drills/exercises and participatory workshops as the preferred training delivery modes. Compared with technical and role-specific training, leadership training was less available. For both PHEP and LHD respondents, staff availability for training is most notably limited due to lack of time. For PHEP respondents, a common factor limiting agency ability to offer training is lack of mentors/instructors, whereas for LHD respondents, it is limited funding. CONCLUSIONS: Efforts should focus on increasing accessibility and the continued development of rigorous and effective training based on practical experience in all aspects of multitiered public health emergency response leadership.

Patterns and correlates of use of evidence-based interventions to control diabetes by local health departments across the USA.

OBJECTIVE: The nearly 3000 local health departments (LHDs) nationwide are the front line of public health and are positioned to implement evidence-based interventions (EBIs) for diabetes control. Yet little is currently known about use of diabetes-related EBIs among LHDs. This study used a national online survey to determine the patterns and correlates of the Centers for Disease Control and Prevention Community Guide-recommended EBIs for diabetes control in LHDs. RESEARCH DESIGN AND METHODS: A cross-sectional study was conducted to survey a stratified random sample of LHDs regarding department characteristics, respondent characteristics, evidence-based decision making within the LHD, and delivery of EBIs (directly or in collaboration) within five categories (diabetes-related, nutrition, physical activity, obesity, and tobacco). Associations between delivering EBIs and respondent and LHD characteristics and evidence-based decision making were explored using logistic regression models. RESULTS: Among 240 LHDs there was considerable variation among the EBIs delivered. Diabetes prevalence in the state was positively associated with offering the Diabetes Prevention Program (OR=1.28 (95% CI 1.02 to 1.62)), diabetes self-management education (OR=1.32 (95% CI 1.04 to 1.67)), and identifying patients and determining treatment (OR=1.27 (95% CI 1.05 to 1.54)). Although all organizational supports for evidence-based decision making factors were related in a positive direction, the only significant association was between evaluation capacity and identifying patients with diabetes and determining effective treatment (OR=1.54 (95% CI 1.08 to 2.19)). CONCLUSION: Supporting evidence-based decision making and increasing the implementation of these EBIs by more LHDs can help control diabetes nationwide.

Maintaining normalcy: a grounded theory of engaging in HIV-oriented primary medical care.

Despite advances in the medical treatment of HIV disease, marginalized populations continue to shoulder a disproportionate burden of HIV/AIDS-related morbidity and mortality. This study explored the process by which clients at HIV-oriented primary care clinics transition from being sporadic users of care to engaging as regular users of care. A model illustrating how participants were striving to maintain normalcy, manage perceptions, and develop life mastery skills contributes to an understanding of living with HIV disease in a social context. Elements of the model are sensitive to nursing interventions aimed at improving health outcomes and reducing health disparities among persons at highest risk.

Mobile direct observation treatment for tuberculosis patients: a technical feasibility pilot using mobile phones in Nairobi, Kenya.

BACKGROUND: Growth in mobile phone penetration has created new opportunities to reach and improve care to underserved, at-risk populations including those with tuberculosis (TB) or HIV/AIDS. PURPOSE: This paper summarizes a proof-of-concept pilot designed to provide remote Mobile Direct Observation of Treatment (MDOT) for TB patients. The MDOT model combines Clinic with Community DOT through the use of mobile phone video capture and transmission, alleviating the travel burden for patients and health professionals. METHODS: Three healthcare professionals along with 13 patients and their treatment supporters were recruited from the Mbagathi District Hospital in Nairobi, Kenya. Treatment supporters were asked to take daily videos of the patient swallowing their medications. Patients submitted the videos for review by the health professionals and were asked to view motivational and educational TB text (SMS) and video health messages. Surveys were conducted at intake, 15 days, and 30 days. Data were collected in 2008 and analyzed in 2009. RESULTS: All three health professionals and 11 patients completed the trial. All agreed that MDOT was a viable option, and eight patients preferred MDOT to clinic DOT or DOT through visiting Community Health Workers. CONCLUSIONS: MDOT is technically feasible. Both patients and health professionals appear empowered by the ability to communicate with each other and appear receptive to remote MDOT and health messaging over mobile. Further research should be conducted to evaluate whether MDOT (1) improves medication adherence, (2) is cost effective, and (3) can be used to improve treatment compliance for other diseases such as AIDS.

HIV medical care provider practices for reducing high-risk sexual behavior: results of a qualitative study.

A first step in ensuring that HIV-infected persons practice the safer sexual behaviors that reduce disease transmission is to make certain that they receive accurate information about the relationship between sexual risk behaviors and HIV transmission. Health care providers can play a pivotal role in preventing secondary transmission of HIV; federal agencies and professional guidelines encourage providers to counsel HIV-infected patients about safer sex practices and transmission risks, particularly since the health care encounter may be the only time that HIV-infected persons receive information about prevention and risk reduction interventions. Yet research indicates that these opportunities are often missed. Prior to implementing a prevention demonstration project in an urban HIV and STD clinic, we conducted a qualitative investigation with providers, including physicians, nurse practitioners, physician assistants, and nurses. The purpose of this investigation was to examine the current status of prevention education and counseling efforts at the clinic, examine the barriers and facilitators to providing prevention counseling, and identify key areas where providers believed that they needed additional training.

A qualitative analysis of partner selection, HIV serostatus disclosure, and sexual behaviors among HIV-positive urban men.

Using grounded theory, 18 interviews with HIV-positive urban men were conducted to understand their sexual relationships. Analysis of the verbatim transcripts revealed that regardless of age, sexual orientation or race/ethnicity, the participants were "making choices" related to their sexual relationships. Some men were "avoiding sex" whereas others were engaging in "just sex" or having sex in a relationship that was "going somewhere." However, dependent upon the type of sexual relationship, these HIV-positive urban men struggled with issues associated with "disclosure" of serostatus, the sexual "behaviors" in which they engaged, and selecting sexual "partners." Health care providers can facilitate sexual health and well-being among HIV-positive urban men by recognizing that men may be seeking sexual intimacy for different purposes, in different types of relationships, or avoiding it entirely. By exploring these decision-making processes, it is possible to facilitate sexual relationships that prevent new infections as well as manage the dissonance associated with this decision-making associated with disclosure, behaviors and their sexual partners.

Health literacy of HIV-positive individuals enrolled in an outreach intervention: results of a cross-site analysis.

This article examines health literacy among a group a HIV-positive persons at risk for receiving suboptimal health care due to histories of substance abuse, mental illness, incarceration, and unstable housing or homelessness. Participants receiving services from three outreach programs funded as part of a multisite demonstration project were screened for health literacy using the Test of Functional Health Literacy in Adults (TOFHLA) at program enrollment. The goal of this analysis was to identify demographics, risk factors, and health indicators associated with different levels of health literacy. Results indicated that although fewer than 30% of the sample scored in the marginal or inadequate range for health literacy, participants with these lower levels of health literacy were more likely to be African American or Latino/a, heterosexual, speak Spanish as their primary language, and have less than a high school education. The disparities in health literacy found in this study point to a need to assess level of health literacy and provide culturally sensitive health literacy interventions for persons with chronic diseases such as HIV. In addition to offering these services within HIV health care settings, health professionals can use other potential venues for health literacy assessment and intervention including substance abuse treatment and community-based social service, education, and training programs. Health care and support service providers also must become aware of the importance of health literacy when caring for all patients with HIV, particularly those most likely to have low health literacy.