Understanding Health Equity in Public Health Practice in the United States.

CONTEXT: Understanding the extent to which equity-focused work is occurring in public health departments (eg, in chronic disease programs) can identify areas of success and what is needed to move the needle on health equity. OBJECTIVE: The study objective was to characterize the patterns and correlates of equity-related practices in US state and territorial public health practice. DESIGN: The design was a multimethod (quantitative and qualitative), cross-sectional study. SETTING: The setting included US state and territorial public health departments. PARTICIPANTS: Chronic disease prevention practitioners (N = 600) completed self-report surveys in July 2022 through August 2022 (analyzed in September 2022 through December 2022). MAIN OUTCOME MEASURES: Health equity data were obtained across 4 domains: (1) staff skills, (2) work unit practices, (3) organizational priorities and values, and (4) partnerships and networks. RESULTS: There was a wide range in self-reported performance across the health equity variables. The highest values (those agreeing and strongly agreeing) were related to staff skills (eg, the ability to describe the causes of inequities [82%]). Low agreement was reported for multiple items, indicating the lack of systems for tracking progress on health equity (32%), the lack of hiring of staff members who represent disadvantaged communities (33%), and limited use of principles for community engagement (eg, sharing decision-making authority with partners [34%]). Qualitative data provided tangible examples showing how practitioners and their agencies are turning an array of health equity concepts into actions. CONCLUSIONS: There is urgency in addressing health equity and our data suggest considerable room for enhancing health equity practices in state and territorial public health. To support these activities, our findings provide some of the first information on areas of progress, gaps in practice, and where to target technical assistance, capacity building efforts, and accreditation planning.

Core Competencies for Chronic Disease Prevention Practice.

Chronic disease prevention practice is an important specialization within public health and health care that connects chronic conditions, causes, prevention tactics, and population-based health promotion modalities. Required competencies for successful chronic disease prevention and health promotion encompass leadership, epidemiology, program practice, and evaluation, among others. In 2007, the National Association of Chronic Disease Directors (NACDD) developed and codified the Core Chronic Disease Prevention Competencies (Competencies), a standard set of competencies for professionals in chronic disease prevention and control. NACDD also devised support tools to assist individuals and managers in increasing capacity and opportunities for member growth, thereby benefitting the agencies they serve. In revisiting the Competencies in 2015 through 2018, the NACDD Professional Development Committee reviewed uses, conducted member surveys, polled NACDD councils, and produced recommendations. The goal of this process was to recognize rapid changes in the environments, practices, and characteristics that affect chronic disease prevention, both at the population level and for individual groups at risk during the past 10 years. In addition, opportunities existed to benefit from the changes in technology that have increased demands on health professionals, who as a result have had to adapt to these changes. We worked with the NACDD Learning and Professional Development Committee and reviewed learning offerings, other related competency sets, and tools for performance assessment. The results of the review include a final set of Competencies and subcompetencies, a guide to using the competencies, and a fully integrated interactive assessment tool used by individuals, managers, and teams. Going forward, NACDD's strategic focus includes a regular review of the Competencies and building chronic disease learning assets.

A case study examination of structure and function in a state health department chronic disease unit.

OBJECTIVES: I explored the structural and operational practices of the chronic disease prevention and control unit of a state health department and proposed a conceptual model of structure, function, and effectiveness for future study. METHODS: My exploratory case study examined 7 elements of organizational structure and practice. My interviews with staff and external stakeholders of a single chronic disease unit yielded quantitative and qualitative data that I coded by perspective, process, relationship, and activity. I analyzed these for patterns and emerging themes. RESULTS: Chi-square analysis revealed significant correlations among collaboration with goal ambiguity, political support, and responsiveness, and evidence-based decisions with goal ambiguity and responsiveness. CONCLUSIONS: Although my study design did not permit conclusions about causality, my findings suggested that some elements of the model might facilitate effectiveness for chronic disease units and should be studied further. My findings might have important implications for identifying levers around which capacity can be built that may strengthen effectiveness.

Partnerships to expand worksite wellness programs - A qualitative analysis of state and local health department perspectives.

Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the U. S. Because the central mission of state and local health departments (HDs) is to protect, promote, and improve population health, these agencies are well-positioned to address risk behaviors for chronic disease. HD-employer partnerships could enhance worksite wellness programming, but few studies have explored this topic. Building upon previously published findings, the purpose of this qualitative study was to describe the context and environment for HDs' delivery of worksite wellness programs, including interest, barriers, facilitators, and decision-making processes. We conducted 12 interviews with directors of state chronic disease programs, 21 interviews with local directors, and three focus groups with local staff. We performed a thematic analysis of the data. Key themes include the following: (1) worksite wellness programs delivered by HDs were diverse in topic and scope and delivered both internally (at the HD for their agency) and externally (for other employers); (2) decisions made about chronic disease prevention were largely driven by funding priorities, with federal, state, and local entities playing roles in the decision-making process; and (3) HDs expressed potential interest in worksite wellness program delivery, dependent upon staff capacity, available funding, and employer buy-in. Our results suggest that funding should be increased for and reallocated towards chronic disease prevention, including worksite wellness. To overcome HD barriers to program delivery, key funders and stakeholders should prioritize and communicate the importance of worksite wellness.

Practitioner perspectives on building capacity for evidence-based public health in state health departments in the United States: a qualitative case study.

BACKGROUND: Public health agencies are responsible for implementing effective, evidence-based public health programs and policies to reduce the burden of chronic diseases. Evidence-based public health can be facilitated by modifiable administrative evidence-based practices (A-EBPs) (e.g., workforce development, organizational climate), yet little is known about how practitioners view A-EBPs. Thus, the purpose of this qualitative study was to understand state health department practitioners' perceptions about how A-EBPs are implemented and what facilitators and barriers exist to using A-EBPs. METHODS: Chronic disease prevention and health promotion program staff who were members of the National Association of Chronic Disease Directors were recruited to participate in telephone interviews using a snowball sampling technique. Interviews were transcribed verbatim, and transcripts were analyzed using a common codebook and the a priori method in NVivo. RESULTS: Twenty seven interviews were conducted with practitioners in four states (5-8 interviews per state). All practitioners felt that their work unit culture is positive and that leadership encouraged and expected staff to use evidence-based processes. Participants discussed the provision of trainings and technical assistance as key to workforce development and how leaders communicate their expectations. Access to evidence, partnerships, and funding restrictions were the most commonly discussed barriers to the use of A-EBPs and EBDM. CONCLUSIONS: Results of this study highlight practitioners' perspectives on promoting evidence-based public health in their departments. Findings can inform the development and refinement of resources to improve A-EBP use and organizational and leadership capacity of state health departments.

Development of public health priorities for end-of-life initiatives.

OBJECTIVE: Recently, end-of-life (EOL) issues have captured the attention of the public health community. This study reports a project to help state health departments better understand their potential role in addressing EOL issues and develop initial priorities for EOL activities. METHODS: The project involved two studies. Study 1 (October 2002 to September 2003) involved a concept mapping process to solicit and organize recommendations from key stakeholders. Concept mapping integrates qualitative group processes with multivariate statistical analysis to represent the ideas of stakeholders visually through maps. A key-informant approach was used to identify stakeholder participants with expertise in aging, cancer, public health, and EOL. In two meetings, stakeholders used the maps to develop short-, intermediate-, and long-term recommendations for EOL initiatives. Study 2 (October 2003 to September 2004) involved a modified Delphi process with three iterations to prioritize recommendations for initial action from among a group of short-term recommendations. RESULTS: Study 1 resulted in 103 recommendations for EOL initiatives across nine domains. Study 2 resulted in consensus on five initial recommendations from three domains: identifying an EOL point of contact in state health departments, collecting and analyzing data about EOL, incorporating EOL principles into state comprehensive cancer control plans, educating the public about hospice and palliative care, and educating the public about the importance of advance directives. CONCLUSIONS: Diverse perspectives of key public health stakeholders resulted in a series of short- and longer-term recommendations for EOL action. These recommendations can guide future efforts by state health departments and other public health agencies to address EOL issues.