The Effects of Neonatal Abstinence Syndrome on Language Delay from Birth to 10 Years.

PURPOSE: To examine the longitudinal effects of a history of neonatal abstinence syndrome (NAS) on language development over the first 10 years of life. DESIGN AND METHODS: This study used a retrospective, longitudinal design. The data were analyzed using generalized linear mixed models (GLMM) to examine the effects of NAS on language delay over time while controlling for demographic, prenatal, and household factors. RESULTS: There was a significant difference in the pattern of language delays over time between the NAS and non-NAS groups. At the age of 5 (est: -1.788, p < .001), children with a history of NAS had a decreased log odds of developing language delays than those without NAS. Conversely, compared with age 1, at the age of 10 (est: 1.098 p < .001), children with a history of NAS had an increased log odds of developing language delays than those without NAS. CONCLUSIONS: Children with a history of NAS had significantly different rates of language delays over time. Children with a history of NAS had significantly higher rates of language delays at 10 years than children without NAS. PRACTICE IMPLICATIONS: There is a need to increase developmental surveillance, along with referrals for specialized services, for children with a history of NAS through middle childhood.

The Association Between Evidence-Based Decision Making and Accreditation of State Health Departments.

OBJECTIVE: To assess the association between evidence-based decision making, including implementation of evidence-based interventions (EBIs), with accreditation of state health departments through the Public Health Accreditation Board (PHAB). DESIGN: This was a cross-sectional, electronic survey of state health department practitioners. We utilized a survey instrument focused on evidence-based public health, de-implementation, and sustainability of public health programs. Survey questions were organized into 6 domains: (1) demographic information; (2) individual-level skills; (3) decision making on programs ending; (4) decision making on programs continuing; (5) organization/agency capacity; and (6) external influences. PARTICIPANTS: The targeted practitioners were randomly selected from the 3000-person membership of National Association of Chronic Disease Directors and program manager lists from key Centers for Disease Control and Prevention-supported programs in cancer and cancer risk factors. The final target audience for the survey totaled 1329 practitioners, representing all 50 states. MAIN OUTCOME MEASURE(S): The main outcome measures included the strength of association between a state's PHAB accreditation status and variables related to evidence-based public health and use of EBIs that fell within the individual participant skills, organization/agency capacity, and external influences domains. RESULTS: We received 643 valid responses (response rate = 48.4%), representing all 50 states, with 35 states being PHAB accredited. There was a statistically significant association between PHAB accreditation and state health department use of quality improvement processes (P = .002), leadership plans to implement EBIs (P = .009), and leadership reactions to EBI implementation issues (P = .004). Respondents from PHAB-accredited states were significantly more likely than participants from nonaccredited states to report greater engagement with legislators and governors regarding EBIs and 14% less likely to report the inappropriate termination of programs in their work unit (P = .05). CONCLUSIONS: The importance of accreditation relates to both internally focused functions and externally focused activities, especially regarding policy-related impact.

Evidence-Based Public Health Provided Through Local Health Departments: Importance of Academic-Practice Partnerships.

OBJECTIVES: To determine the extent to which US local health departments (LHDs) are engaged in evidence-based public health and whether this is influenced by the presence of an academic health department (AHD) partnership. METHODS: We surveyed a cross-sectional stratified random sample of 579 LHDs in 2017. We ascertained the extent of support for evidence-based decision-making and the use of evidence-based interventions in several chronic disease programs and whether the LHD participated in a formal, informal, or no AHD partnership. RESULTS: We received 376 valid responses (response rate 64.9%). There were 192 (51.6%) LHDs with a formal, 80 (21.6%) with an informal, and 99 (26.7%) with no AHD partnership. Participants with formal AHD partnerships reported higher perceived organizational supports for evidence-based decision-making and interventions compared with either informal or no AHD partnerships. The odds of providing 1 or more chronic disease evidence-based intervention were significantly higher in LHDs with formal AHD partnerships compared with LHDs with no AHD partnerships (adjusted odds ratio = 2.3; 95% confidence interval = 1.3, 4.0). CONCLUSIONS: Formal academic-practice partnerships can be important means for advancing evidence-based decision-making and for implementing evidence-based programs and policies.

Implications of Tennessee's Opioid Legislation for Neonatal Abstinence Syndrome.

Opioid use during pregnancy is on the rise in the United States. Neonatal abstinence syndrome (NAS), also known as newborn drug withdrawal, is a public health epidemic. Between 2004 and 2014, Tennessee experienced a fivefold increase in NAS hospitalizations, from 1.5 to 8.0 per 1,000 live births. Soaring increases in the number of newborns with NAS nationwide have caught the attention of many federal and state lawmakers, especially given the unknown burdens associated with medical and social services needed by those affected over time. Tennessee opioid-related regulations and laws enacted between 2000 and 2018 were systematically reviewed and analyzed to identify each law's purpose; effects on families and individuals; pros and cons in terms of social, practical, and legal factors; and implications for nursing practice. Our findings were that Tennessee's laws are intended to decrease the number of opioids prescribed, ensure access to continued prenatal care and substance abuse management for mothers with substance use disorders, and reduce the ease of obtaining opioids. We also found that Tennessee lawmakers have enacted laws and regulations aimed at decreasing the abuse of opioids, but not reducing the incidence of NAS. As new laws are considered, it is critical that health care providers and lawmakers work together to ensure that the developed and enacted laws strike a balance between safely managing the care of both pregnant women and their newborns without producing negative outcomes.

Public Health Agency Accreditation Among Rural Local Health Departments: Influencers and Barriers.

OBJECTIVE: Health department accreditation is a crucial strategy for strengthening public health infrastructure. The purpose of this study was to investigate local health department (LHD) characteristics that are associated with accreditation-seeking behavior. This study sought to ascertain the effects of rurality on the likelihood of seeking accreditation through the Public Health Accreditation Board (PHAB). DESIGN: Cross-sectional study using secondary data from the 2013 National Association of County & City Health Officials (NACCHO) National Profile of Local Health Departments Study (Profile Study). SETTING: United States. PARTICIPANTS: LHDs (n = 490) that responded to the 2013 NACCHO Profile Survey. MAIN OUTCOME MEASURES: LHDs decision to seek PHAB accreditation. RESULTS: Significantly more accreditation-seeking LHDs were located in urban areas (87.0%) than in micropolition (8.9%) or rural areas (4.1%) (P < .001). LHDs residing in urban communities were 16.6 times (95% confidence interval [CI], 5.3-52.3) and micropolitan LHDs were 3.4 times (95% CI, 1.1-11.3) more likely to seek PHAB accreditation than rural LHDs (RLHDs). LHDs that had completed an agency-wide strategic plan were 8.5 times (95% CI, 4.0-17.9), LHDs with a local board of health were 3.3 times (95% CI, 1.5-7.0), and LHDs governed by their state health department were 12.9 times (95% CI, 3.3-50.0) more likely to seek accreditation. The most commonly cited barrier was time and effort required for accreditation application exceeded benefits (73.5%). CONCLUSION: The strongest predictor for seeking PHAB accreditation was serving an urban jurisdiction. Micropolitan LHDs were more likely to seek accreditation than smaller RLHDs, which are typically understaffed and underfunded. Major barriers identified by the RLHDs included fees being too high and the time and effort needed for accreditation exceeded their perceived benefits. RLHDs will need additional financial and technical support to achieve accreditation. Even with additional funds, clear messaging of the benefits of accreditation tailored to RLHDs will be needed.

Macro Trends and the Future of Public Health Practice.

Public health practice in the twenty-first century is in a state of significant flux. Several macro trends are impacting the current practice of governmental public health and will likely have effects for many years to come. These macro trends are described as forces of change, which are changes that affect the context in which the community and its public health system operate. This article focuses on seven such forces of change: the Patient Protection and Affordable Care Act, public health agency accreditation, climate change, health in all policies, social media and informatics, demographic transitions, and globalized travel. Following the description of each of these, this article then turns to possible approaches to measuring, tracking, and understanding the impact of these forces of change on public health practice, including the use of evidence-based public health, practice-based research, and policy surveillance.

The Public Health Practitioner of the Future.

The requisite capacities and capabilities of the public health practitioner of the future are being driven by multiple forces of change, including public health agency accreditation, climate change, health in all policies, social media and informatics, demographic transitions, globalized travel, and the repercussions of the Affordable Care Act. We describe five critical capacities and capabilities that public health practitioners can build on to successfully prepare for and respond to these forces of change: systems thinking and systems methods, communication capacities, an entrepreneurial orientation, transformational ethics, and policy analysis and response. Equipping the public health practitioner with the requisite capabilities and capacities will require new content and methods for those in public health academia, as well as a recommitment to lifelong learning on the part of the practitioner, within an increasingly uncertain and polarized political environment.

Development of a Research Agenda Focused on Academic Health Departments.

An academic health department (AHD) is a formal partnership between an academic institution and a governmental public health agency. Case studies have described the value of individual AHDs in the areas of student engagement, practice-based research, workforce development, and service. With growing interest in AHDs and the increasing importance of academic-practice linkages in both academic programs' and public health agencies' accreditation processes, articulating a research agenda focused on the AHD model can be useful for stimulating the research and practice fields to further develop the evidence base for AHDs. We provide a research agenda, developed through an iterative process involving academicians, practitioners, and others interested in academic-practice linkages.

A Population Health Driver Diagram to Address Neonatal Abstinence Syndrome.

This article describes the process for developing a population health driver diagram to address a priority health issue in East Tennessee: neonatal abstinence syndrome (NAS). Population health driver diagrams are used in quality improvement processes for determining and aligning actions that a community can take to achieve a specified outcome. The Tennessee Department of Health contracted with the University of Tennessee's Department of Public Health to conduct a community participatory process to contribute to a statewide health improvement plan. Colleagues in local public health practice identified NAS as the leading perinatal health issue, and community engagement was achieved by involving community health councils. Qualitative and quantitative data were collected, analyzed, and provided to these councils. A region-wide stakeholders' meeting resulted in the development of a population health driver diagram to address NAS. We describe this process and provide lessons learned that can be valuable in other settings. Population health diagrams have important implications for practice because of their use as a framework for community action, especially in the context of a community health assessment.

Characteristics of Academic Health Departments: Initial Findings From a Cross-Sectional Survey.

Academic Health Departments (AHDs) represent collaborative relationships between public health academia and practice. The purpose of this study was to gain a better understanding of AHD characteristics, to document the extent of collaboration between organizations in an AHD, and to explore the benefits of AHDs. An electronic survey on the AHD was sent to members of the AHD Learning Community--a virtual learning community with 338 members. There were 110 valid responses to the survey, with 65 indicating they were currently in an AHD partnership. Thirty-two percent of AHDs had been established for more than 10 years; 64% were engaged in joint research activities; and, while 92% of respondents placed a high value on improving the competencies of students, almost half placed a high value on improving the competencies of faculty. This study can be a springboard for further research on the impact of AHDs on practice, academia, and ultimately community health.

A Logic Model for Evaluating the Academic Health Department.

Academic Health Departments (AHDs) are collaborative partnerships between academic programs and practice settings. While case studies have informed our understanding of the development and activities of AHDs, there has been no formal published evaluation of AHDs, either singularly or collectively. Developing a framework for evaluating AHDs has potential to further aid our understanding of how these relationships may matter. In this article, we present a general theory of change, in the form of a logic model, for how AHDs impact public health at the community level. We then present a specific example of how the logic model has been customized for a specific AHD. Finally, we end with potential research questions on the AHD based on these concepts. We conclude that logic models are valuable tools, which can be used to assess the value and ultimate impact of the AHD.

Pediatricians and the Oral Health Needs of Children: One Potential Means for Reducing Oral Healthcare Inequities.

OBJECTIVES: Children in poverty have limited access to oral healthcare. One approach to reduce such health inequities is to expand the involvement of primary care physicians in the provision of oral healthcare. The purpose of this study was to assess pediatricians' knowledge, attitudes, and professional experiences regarding oral health in children, and to determine their willingness to incorporate preventive dental education and procedures into their practices. METHODS: We conducted a survey of pediatricians in Tennessee to assess their knowledge, attitudes, and professional experiences regarding oral health, and to determine their willingness to incorporate preventive dental education and procedures into their practices. RESULTS: Of the 450 providers randomly selected for survey distribution, 107 returned completed surveys (response rate, 23.8%). The majority of respondents reported that they are likely to examine children's teeth during well-child care visits, but only a minority use preventive techniques such as application of fluoride varnish. Pediatricians receive very little education on oral health during medical school and residency programs. CONCLUSIONS: Expanding oral healthcare access through primary care physicians will require adequate training in medical school, residency, and in continuing education courses.

The Academic Health Department: the process of maturation.

The Academic Health Department (AHD) involves an arrangement between a governmental health agency and an academic institution, which provides mutual benefits in teaching, service, research, and practice. From its initial development in the mid-1980s as the public health equivalent of the relationship between a teaching hospital and a medical school, the AHD concept has evolved to include multiple levels of governmental public health agencies (local, state, and federal) as well as multiple academic institutions (public health, medicine, and primary care medical residencies). Throughout the decade of the 2000s, multiple influences have impacted both the quality and quantity of AHDs, leading to an expansion of AHDs through the Council on Linkages' AHD Learning Community. The value of the AHD--as described from prior studies as well as the AHD case examples in this current special issue--is evident in its impact on the quality of educational experiences and workforce development, agency and academic accreditation, practice-based research, and the potential to influence health reform.

Forming an academic health department: a case example.

The disconnect between public health practice and its academic base has major implications for training and hiring the future public health workforce, for practice-based research, and ultimately for improving the public's health. To bridge this disconnect, the University of Tennessee Department of Public Health and the Knox County Health Department established an academic health department in early 2011 through a memorandum of understanding. This action followed a long history of informal collaborations, built on mutual trust. The memorandum of understanding identified the scope of academic health department activities, clarified responsibilities of each organization, and created a shared coordinator position. Accomplishments during the first 18 months include improving the efficiency and effectiveness of student field placements; establishing collaborative learning sessions delivered jointly by University of Tennessee Department of Public Health faculty and Knox County Health Department staff; and exploring opportunities for practice-based research. The shared coordinator position and an active steering committee are considered fundamental to achieving sustainable academic-practice linkages.

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

OBJECTIVES: We assessed the use of administrative-evidence based practices (A-EBPs) among managers of programs in chronic diseases, environmental health, and infectious diseases from a sample of local health departments (LHDs) in the United States. DESIGN: Program managers completed a survey consisting of 6 sections (biographical data, use of A-EBPs, diffusion attributes, use of resources, and barriers to, and competencies in, evidence-based public health), with a total of 66 questions. PARTICIPANTS: The survey was sent electronically to 168 program managers in chronic diseases, 179 in environmental health, and 175 in infectious diseases, representing 228 LHDs. The survey had previously been completed by 517 LHD directors. MEASURES: The use of A-EBPs was scored for 19 individual A-EBPs, across the 5 A-EBP domains, and for all domains combined. Individual characteristics were derived from the survey responses, with additional data on LHDs drawn from linked National Association of County & City Health Officials Profile survey data. Results for program managers were compared across the 3 types of programs and to responses from the previous survey of LHD directors. The scores were ordered and categorized into tertiles. Unconditional logistic regression models were used to calculate odds ratios and 95% confidence intervals, comparing individual and agency characteristics for those with the highest third of A-EBPs scores with those with the lowest third. RESULTS: The 332 total responses from program managers represented 196 individual LHDs. Program managers differed (across the 3 programs, and compared with LHD directors) in demographic characteristics, education, and experience. The use of A-EBPs varied widely across specific practices and individuals, but the pattern of responses from directors and program managers was very similar for the majority of A-EBPs. 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 evidence-based public health.

Local health department and academic institution linkages for community health assessment and improvement processes: a national overview and local case study.

Community health improvement processes that yield community health assessments (CHAs) and community health improvement plans (CHIPs) provide data and a process to determine key community priorities and take action and are ideally collaborative endeavors. Nationally, increased focus on CHAs and CHIPs highlights the role that Academic Health Departments or other local health department (LHD)-academic linkages can play in completing CHAs and CHIPs. Drawn from the experiences of 5 LHD-academic partnerships that participated in a national demonstration and a detailed account of the experience of one, this article presents how such linkages can support CHA and CHIP work, ways to anticipate and overcome challenges, and the tangible benefits that may be realized for both the LHD and the academic partner. Community health improvement processes are ripe opportunities for LHD-academic linkages and can be fruitful and mutually beneficial partnerships to be used in completing CHAs and CHIPs to measurably improve the public's health.