Using Collective Impact to Develop a Community-Led Initiative for Improving Black Infant Mortality.

The United States has one of the highest infant mortality rates among developed countries. When stratified by race, disparities are more evident: Black infant mortality rates are 2.5 times higher than non-Hispanic white infants. Structural, systemic racism is a contributing cause for these racial disparities. Multisector collaborations focused on a common agenda, often referred to as collective impact, have been used for infant mortality reduction interventions. In addition, community-based participatory approaches have been applied to incorporate those with lived experience related to adverse pregnancy outcomes. This article critically describes the transition of an infant mortality collective impact initiative from being led by a multisector organizational group to being community led over a 5-year period, 2015-2020. A 34-member community leaders group was developed and determined four priorities and corresponding strategies for the initiative. Findings show that community participatory approaches are a way to address racial equity for public health initiatives.

Community Health Worker Impact on Knowledge, Antenatal Care, And Birth Outcomes: A Systematic Review.

OBJECTIVES: Community health worker (CHW) interventions have been shown to be effective in areas of maternal and child health (MCH), mostly in relation to infant and neonatal mortality. The specific aims of this review were to expand outcomes to include improving knowledge related to pregnancy and infant health and the receipt of antenatal care (ANC), along with birth outcomes. We also summarized the role, characteristics and activities of CHWs in interventions conducted in settings with demonstrated improvements in key MCH outcomes. METHODS: Articles were retrieved from: PubMed, CINAHL, Global Health, Scopus, Web of Science, and the Cochrane Library from January 2008 through 2018. We included evaluation studies that utilized CHWs as all or part of an intervention to improve outcomes, were printed in English, and published in peer-reviewed journals. RESULTS: Initial electronic database search identified 816 studies and 123 studies met inclusion criteria for full text review. The quality assessment resulted in 0 strong-, 19 moderate-, and 25 weak-rated studies. In most interventions, CHWs were a component of a larger intervention. The majority of the studies (n = 10) found that a CHW intervention can have a positive impact on outcomes. CHW interventions showed improvements in knowledge and ANC. When combined with clinical services, the interventions positively impacted birth outcomes. Most conducted home visits and utilized CHW that were members of the community. CONCLUSIONS FOR PRACTICE: CHWs serve an important role as health educators conducting home visits as a member of the community they serve. They should also continue to collaborate with clinical providers to address MCH outcomes.

Evidence of Effectiveness of a Home Visitation Program on Infant Weight Gain and Breastfeeding.

OBJECTIVES: Adequate weight gain is important to reduce the risk of infant morbidity and mortality. Breastfeeding is also important to prevent infant morbidity. Home visitation programs have been used for many years to prevent infant and child morbidity and maltreatment. Nurses for Newborns is a home visitation model with the goals of preventing infant mortality and maltreatment. This study evaluated the impact of the Nurses for newborns program on infant weight gain and breastfeeding. METHODS: We used a retrospective case-control propensity matched model to evaluate outcomes. We received secondary data from Vanderbilt Research Derivative Group and Tennessee Office of Health Statistics to conduct the analysis. Data were accessed for infants born in 2013, 2014 and 2015 and limited to those with at least four NFN visits and no more than 2 days in the NICU. We conducted chi square analysis and logistic regression to test our hypotheses. RESULTS: NFN infants were two times more likely to triple their birth weight in the first year. NFN infants were also two times more likely to be breast fed at 2 weeks, but this finding was not statistically significant. CONCLUSIONS FOR PRACTICE: Home visitation models can be effective in encouraging adequate weight gain in the first year of life. In addition, home visitors can encourage women to breastfeed. Significance Home visitation models can prevent infant morbidity and mortality. Few studies, however, have demonstrated that infant weight gain, an important factor in the health of infants, can be enhanced using this approach. In addition, home visitation can positively impact breastfeeding, another important factor in preventing infant morbidity. Findings from this study suggest that the NFN model of home visitation can improve weight gain and breastfeeding, indicating the impact of this model.

An Unexpected, Yet Welcomed Outcome of the St. Louis Healthy Start Program.

Introduction Racial disparities in birth outcomes are a significant problem in the U.S. The St. Louis Healthy Start (SLHS) program, funded for 14 years, had a goal of reducing disparate rates of poor birth outcomes in three disadvantaged communities in the St. Louis area. The Making Change Happen Leadership Academy (MCHLA) was an unanticipated community-driven effort that grew out of SLHS and continues today. The primary goal of the MCHLA is to empower women to gain mastery over their lives and use their power to improve birth outcomes in their communities. Methods Qualitative interviews were conducted with MCHLA participants to determine the impact of participation in the MCHLA on their leadership skills and attitudes. Results Participants reported positive attitudes about themselves including increased confidence and improved parenting skills. Through active participation in project work, they noted increased professional and advocacy skills and recognition of the importance of their voice. As leaders, they recognized the importance of giving and receiving emotional, tangible, and information social support. The small sample prevents us from confidently reporting that findings directly relate to the MCHLA. Discussion Leaders exist in all communities. Public health practitioners may help enhance and develop leaders with tangible support. We need to encourage more MCHLA type programs while systematically evaluating their impact on empowerment in underserved women.

Evaluating a train-the-trainer approach for improving capacity for evidence-based decision making in public health.

BACKGROUND: Evidence-based public health gives public health practitioners the tools they need to make choices based on the best and most current evidence. An evidence-based public health training course developed in 1997 by the Prevention Research Center in St. Louis has been taught by a transdisciplinary team multiple times with positive results. In order to scale up evidence-based practices, a train-the-trainer initiative was launched in 2010. METHODS: This study examines the outcomes achieved among participants of courses led by trained state-level faculty. Participants from trainee-led courses in four states (Indiana, Colorado, Nebraska, and Kansas) over three years were asked to complete an online survey. Attempts were made to contact 317 past participants. One-hundred forty-four (50.9 %) reachable participants were included in analysis. Outcomes measured include frequency of use of materials, resources, and other skills or tools from the course; reasons for not using the materials and resources; and benefits from attending the course. Survey responses were tabulated and compared using Chi-square tests. RESULTS: Among the most commonly reported benefits, 88 % of respondents agreed that they acquired knowledge about a new subject, 85 % saw applications for the knowledge to their work, and 78 % agreed the course also improved abilities to make scientifically informed decisions at work. The most commonly reported reasons for not using course content as much as intended included not having enough time to implement evidence-based approaches (42 %); other staff/peers lack training (34 %); and not enough funding for continued training (34 %). The study findings suggest that utilization of course materials and teachings remains relatively high across practitioner groups, whether they were taught by the original trainers or by state-based trainers. CONCLUSIONS: The findings of this study suggest that train-the-trainer is an effective method for broadly disseminating evidence-based public health principles. Train-the-trainer is less costly than the traditional method and allows for courses to be tailored to local issues, thus making it a viable approach to dissemination and scale up of new public health practices.

A method for building evaluation competency among community-based organizations.

Community-based organizations often lack the capacity (e.g., time, staff, skills) to effectively evaluate programs, policies, and environmental changes. Providing evaluation technical assistance and training can be an effective and feasible way to build individual evaluation competency. The purpose of this article is to present a practical approach and related tools that can be used by evaluators and others (e.g., academic partners, funders) providing assistance to build evaluation skills in community organizations. The approach described was developed in collaboration with local universities and a regional health foundation to provide intensive technical support to 19 community-based organizations awarded funding to implement obesity prevention projects. Technical assistance processes and tools were designed to be tailored to organizations' capacity and needs and can be used as templates by others who provide technical assistance. Evaluators, funders, and academic partners can use lessons learned from this experience to help shape and implement evaluation technical assistance approaches with community-based organizations.

The impact of SLHS program on perinatal indicators.

The federal Healthy Start program began 20 years ago, yet outcome evaluations lack sufficient rigor to draw conclusions on program impact. We evaluated the impact of the Healthy Start program on birth outcomes, prenatal care, and public services utilization. Birth record data for the St. Louis Healthy Start Program (SLHS) and non-SLHS controls (matched using a propensity score technique) were assessed for differences. Propensity score matching techniques matched SLHS to non-SLHS clients on potentially confounding variables for births from years 2006 to 2008. Traditional multivariable logistic regression on the full, unmatched sample was also conducted for comparison. Matching eliminated any prior statistical differences between groups on covariates. 168 controls and 84 SLHS participants remained in the final matched analysis group. Both analysis techniques were similar on all outcomes, revealing significant group differences for low birth weight (matched OR = 0.28, p = 0.023) and prematurity (matched OR = 0.25, p = 0.012) but not for prenatal care (matched OR = 0.76, p = 0.414), or public services utilization (matched OR = 3.31, p = 0.121). Early results for this Healthy Start project are positive in key areas directly impacting infant mortality. However, continued analysis of this program for sustained impact in these areas and ultimately, a reduction in infant mortality is needed. Additionally, more rigorous experimental and quasi-experimental evaluation designs are needed to assess the impact of other Healthy Start programs around the country.

A tool for rating chronic disease prevention and public health interventions.

Bridging the gap between research and practice requires more than evaluating the effectiveness of interventions in controlled studies. To bridge this gap, evidence needs to be defined in different ways, and opportunities need to be provided for practice-based evidence to be replicated and disseminated. Community-based interventions are often not conducted or evaluated in controlled settings, yet they provide more real-world context and have the potential to have a greater effect on population health than findings from controlled studies that are limited in generalizability. The purpose of this article is to describe an approach to identify community-based programs and interventions that have the potential for replication and dissemination. In our study, such interventions met criteria in 3 primary domains: innovativeness, effectiveness, and sustainability. The criteria and tool developed were applied to 2 obesity-prevention programs to demonstrate the usefulness of the tool for identifying potential programs for replication and dissemination, contributing to practice-based evidence. Funders, practitioners, and researchers can apply these criteria to identify programs, environmental changes, or policies that may be replicated and disseminated.

The moderating role of depression in the association between hypertension during pregnancy and birth outcomes.

OBJECTIVE: Investigate how hypertension during pregnancy (HDP) and depression during pregnancy (DDP) independently and jointly affect infant birth outcomes. METHODS: This population-based, retrospective cohort study included a sample of 68,052 women who participated in PRAMS 2016-2018 survey. Poisson regression was used for adjusted relative risks (aRRs). RESULTS: Compared to women without HDP and DDP, aRRs for PTB and LBW among women with both HDP and DDP are 2.04 (95% CI 1.73, 2.42) and 2.84 (95% CI 2.27, 3.56), respectively, albeit lower than the expected joint effect of risk. CONCLUSION: DDP may modify the association between HDP and PTB, LBW.

The Longitudinal Impact of Maternal Depression and Neighborhood Social Context on Adolescent Mental Health.

Purpose: Maternal depression and neighborhood characteristics are known to be associated both with each other and with adolescent mental health outcomes. These exposures are also subject to change throughout the life of a child. This study sought to identify multi-trajectories of maternal depression (MD) and self-reported neighborhood collective efficacy (NCE) over a 12-year period and determine whether these trajectories are differentially associated with adolescent mental health. Methods: Data from the Fragile Families and Child Wellbeing study, a longitudinal cohort study of new parents and their children, were used. Maternal depression (MD) and self-reported NCE when the child was 3, 5, 9, and 15 years of age were the primary exposures of interest. Adolescent depression and anxiety symptomology when the child was 15 years of age were the primary outcomes. Primary analyses were conducted using multi-trajectory modeling and linear regressions. Results: Five multi-trajectories were identified, two of which were characterized by no MD but either high or low NCE, and three of which were characterized by similarly moderate levels of NCE but either increasing, decreasing, or consistently high MD. Children of mothers with increasing or consistently high depressive symptomology and moderate NCE had significantly higher depression and anxiety scores compared to children of mothers with no depressive symptomology and high NCE. Conclusion: Adolescents with consistent and proximal exposure to MD are most likely to suffer from adverse mental health and should be provided with appropriate support systems to mitigate these outcomes.

Lessons learned from a decade of focused recruitment and training to develop minority public health professionals.

From 1999 to 2009, the Eliminating Health Disparities Pre-doctoral Fellowship Program provided specialized education and mentoring to African American graduate students in public health. Fellows received a public health degree, coursework in understanding and eliminating health disparities, experiential learning, mentored research, and professional network building with African American role models. We describe successful strategies for recruiting and training fellows and make 5 recommendations for those seeking to increase workforce diversity in public health: (1) build a community of minority students, not a string of individual recruits; (2) reward mentoring; (3) provide a diverse set of role models and mentors; (4) dedicate staffing to assure a student-centered approach; and, (5) commit to training students with varying levels of academic refinement.

Barriers and facilitators of African American participation in Alzheimer disease biomarker research.

African Americans experience a greater risk of Alzheimer disease (AD), but are underrepresented in AD research. Our study examined barriers and facilitators of AD research participation among African Americans. Investigators conducted 11 focus groups with African American participants (n=70) who discussed barriers and facilitators to AD research participation including lumbar puncture studies. The moderator and comoderator independently reviewed the transcripts, identified themes, and coded transcripts for analysis. Participants were predominately female (73%) with a mean age of 52 years (range 21 to 86 y). Concerns and attitudes were consistent across education, socioeconomic status, and sex. Mistrust was a fundamental reason for nonparticipation. Additional barriers included insufficient information dissemination in the African American community, inconvenience, and reputation of the researcher and research institution. Barriers to participation in AD biomarker studies were fear of the unknown and adverse effects. Altruism and relevance of research projects to the individual, family members, or the African American community facilitate participation. Increased participation results from relationships with the community that extend beyond immediate research interests, dissemination of research findings, and emphasis on relevance of proposed studies. Pervasive barriers impede African American participation in AD research but can be overcome through a sustained presence in the community.

Construct validity of the core competencies for public health professionals.

Measuring the competency of the public health workforce is critical to improving the functioning of the public health system. This study investigated the construct validity and reliability of the Core Competencies for Public Health Professionals, as promulgated by the Council on Linkages Between Academia and Public Health (COL). Principal component analysis, correlation and reliability analysis and known-groups comparisons were utilized. Results suggest omitting six items and moving six items to arrive at a 65 item, eight factor solution that corresponds with the eight COL domains. Additional evidence of construct validity was provided by known-groups comparisons that effectively discriminated between respondents known to differ on job type, education and practice experience. This study provides substantial support for the validity of the Core Competencies as a tool for assessing the competency of professionals in the public health workforce while suggesting some revisions to improve the measurement properties of the competency set.

Psychosocial determinants of intention to screen for Alzheimer's disease.

BACKGROUND: There is little information about how receptive older adults are to discuss memory problems with healthcare providers. Here we test the psychosocial factors explaining older adults' intention to undergo screening for Alzheimer disease (AD). METHODS: A population-based, random-digit dialing strategy surveyed 1,039 older adults. The Behavioral Model of Health Services Use was used as a conceptual framework for a questionnaire testing constructs from several behavioral theories. Structural equation modeling assessed the relationship of latent variables to each construct with goodness-of-fit indices. RESULTS: The study had an 82% response rate and 72% completer rate. The respondents' mean age was 62.7 +/- 10.2 years (range, 50 to 97 years). The sample was 67% women, 86% were white, and less than 40% had personal experience with AD. Respondents were nondemented (Short Blessed scores, 1.7 +/- 2.2). Predictors of intention to screen included perceived benefits (gamma = .35), knowledge of dementia (gamma = .26), self-efficacy (gamma = .23), preventive health behaviors (gamma = .17), and perceived susceptibility (gamma = .14). Knowledge was positively correlated with perceived benefits (phi = .29) and susceptibility (phi = .20). Preventive behaviors (phi = .20) were positively correlated with perceived benefits. Self-efficacy correlated positively with preventive behaviors (phi = .24) and perceived benefits (phi = .37) and negatively with perceived susceptibility (phi = -.11). Goodness-of-fit indices suggested a good fit of this model (root mean square error of approximation, .037; comparative fit index, 0.98; relative fit index; .96). DISCUSSION: Older adults who have knowledge of dementia and perceive benefit from diagnosis and treatment are more likely to exhibit willingness and confidence to be tested for cognitive problems. Individuals with high self-efficacy, perceived susceptibility, and positive preventive health behaviors are also more likely to exhibit intention. These constructs can now be used to develop interventions to evaluate cognitive health in the elderly.

Bridging research and practice through competency-based public health education.

Reducing the gap between research and practice is gaining much needed attention. Schools of public health can play a role by ensuring that students are taught the necessary knowledge and skills to translate research into practice and to effectively disseminate research and other public health information. Competency-based education is one mechanism by which this can occur. In this article, we introduce a set of competencies specific to translation and dissemination. We describe the process used to develop the set as well as the ways in which we have begun to use these competencies for curriculum review and development. In this way, other schools and training programs in public health can begin to design curricula that will prepare their students to reduce the gap between research and practice. Graduate students will thus be effectively prepared to respond to the changing demands of the field of public health.

Factors influencing organ donation decisions by African Americans: a review of the literature.

The purpose of this article is to review the literature from 1980 to 2005 regarding organ donation decision making by African Americans for themselves and their loved ones and recommend improvements in subsequent studies. Using the behavioral model of health services utilization as an organizing framework, the review procedure consists of a (1) search of health and medical literature using several key words and eight indexes, (2) selection of articles based on specific criteria, and (3) review of each article with regard to the population and sample used, study design, dependent variables addressed, and its findings. The review indicates that predisposing, enabling, and need factors each influence African Americans' organ donation decision making. Retrospective chart reviews provide a good design for future multivariate analyses of the many factors influencing African American decision making. Interventions to influence decision making should emphasize both community education and the process of organ procurement.

Flipping Classrooms in a School of Public Health.

Alternative course formats are gaining increasing attention in higher education. The literature provides a number of examples and studies of flipped classrooms in the medical sciences and liberal arts and sciences. However, fewer than five papers on flipped classes in graduate public health courses have been published, and none in health management. Because graduate public health education is competency based, it seems that a flipped approach with its applied nature would be an appropriate form of teaching public health courses. This paper describes three successfully flipped courses taught in a school of public health. We provide a rationale for flipping, description of each course, and lessons learned. Once some of the challenges are overcome, we believe flipping courses can provide an alternative approach that enhances active learning in applied, public health, and health management courses.

A qualitative assessment of factors that influence emergency medical services partnerships in prehospital research.

OBJECTIVES: Recent efforts to increase emergency medical services (EMS) prehospital research productivity by focusing on reducing systems-related barriers to research participation have had limited effect. The objective of this study was to explore the barriers and motivators to participating in research at the agency and provider levels and to solicit suggestions for improving the success of prehospital research projects. METHODS: The authors conducted a qualitative exploratory study of EMS personnel using focus group and focused interview methodology. EMS personnel affiliated with the Pediatric Emergency Care Applied Research Network (PECARN) hospitals were selected for participation using a purposive sampling plan. Exploratory questioning identified identified factors that influence participation in research and suggestions for ensuring successful research partnerships. Through iterative coding and analysis, the factors and suggestions that emerged from the data were organized into a behavioral change planning model. RESULTS: Fourteen focus groups were conducted, involving 88 EMS prehospital providers from 11 agencies. Thirty-five in-depth interviews with EMS administrators and researchers were also conducted. This sample was representative of prehospital personnel servicing the PECARN catchment area and was sufficient for analytical saturation. From the transcripts, the authors identified 17 barriers and 12 motivators to EMS personnel participation in research. Central to these data were patient safety, clarity of research purpose, benefits, liability, professionalism, research training, communication with the research team, reputation, administrators' support, and organizational culture. Interviewees also made 29 suggestions for increasing EMS personnel participation in research. During data analysis, the PRECEDE/PROCEED planning model was chosen for behavioral change to organize the data. Important to this model, factors and suggestions were mapped into those that predispose (knowledge, attitudes, and beliefs), reinforce (social support and norms), and/or enable (organizational) the participation in prehospital research. CONCLUSIONS: This study identified factors that influence the participation of EMS personnel in research and gathered suggestions for improvement. These findings were organized into the PRECEDE/PROCEED planning model that may help researchers successfully plan, implement, and complete prehospital research projects. The authors provide guidance to improve the research process including directly involving EMS providers throughout, a strong theme that emerged from the data. Future work is needed to determine the validity of this model and to assess if these findings are generalizable across prehospital settings other than those affiliated with PECARN.