Enterprise Evaluation: A New Opportunity for Public Health Policy.

Standard evaluation practice in public health remains limited to evaluative measures linked to individual projects, even if multiple interrelated projects are working toward a common impact. Enterprise evaluation seeks to fill this policy gap by focusing on cross-sector coordination and ongoing reflection in evaluation. We provide an overview of the enterprise evaluation framework and its 3 stages: collective creation, individual data collection, and collective analysis. We illustrate the application of enterprise evaluation to the Gulf Region Health Outreach Program, 4 integrated projects that aimed to strengthen health care in Louisiana, Mississippi, Alabama, and the Florida Panhandle after the Deepwater Horizon oil spill. Shared commitment to sustainability and strong leadership were critical to Gulf Region Health Outreach Program's success in enterprise evaluation. Enterprise evaluation provides an important opportunity for funding agencies and public health initiatives to evaluate the impact of interrelated projects in a more holistic and multiscalar manner than traditional siloed approaches to evaluation.

Qualitative Methodologies as an Intervention: Beyond Program Planning and Implementation.

The Primary Care Capacity Project (PCCP), implemented by the Louisiana Public Health Institute, systematically and rigorously applied qualitative methodologies beyond simple interviews and focus groups to develop the project areas of focus, evaluate clinical transformation interventions in selected heath centers along the Gulf Coast, and provide data and support to foster ongoing quality improvement approaches. Qualitative methodologies were utilized for formative, implementation, and summative evaluation. During the early formative stages of PCCP, community prioritization meetings were conducted in Louisiana, Mississippi, Alabama, and Florida, in which key stakeholders were asked to brainstorm and prioritize major health issues and recommendations in their communities. Findings from these meetings were then used to inform PCCP clinic funding and other community priorities. During project implementation, dyadic interviews were facilitated around specific PCCP areas of focus. These dyadic interviews were valuable in that they uncovered stories, successes, and challenges of clinical transformation. Moreover, they promoted peer-to-peer learning among diverse health centers. The relationships between interview participants are likely to continue past the grant period and further promote innovation and efficiency. Finally case studies were conducted to inform actionable recommendations tailored to each health center. These data also provided value add back to the health centers as they used the information to guide programming and quality improvement efforts. Qualitative methods are critical tools for public health practitioners to support project planning and improvement as well as community change.

Engagement Strategies to Advance Community-Centered Primary Care.

The Louisiana Public Health Institute designed and implemented the Primary Care Capacity Project (PCCP) with the purpose of expanding access to high-quality, integrated, and sustainable community-based primary care, including linkages to behavioral health services, as well as environmental and occupational health services. With a primary focus to invest in community health centers across 17 Gulf Coast counties and parishes, PCCP engaged stakeholders, including 4 primary care organizations, over 20 federally qualified health centers, public health institutes, health information exchanges, national experts, academic organizations, and health departments along with their relevant community partners. This article examines the strategies PCCP used to engage stakeholders and partners throughout the project in order to strengthen sustainable primary care systems. The PCCP team fostered trusted partnerships with a wide range of stakeholders to not only understand the need of the communities but to also identify ways to complement and not duplicate already existing efforts. Specifically, community prioritization convenings, peer-to-peer learning through the Regional Care Collaborative, and dyadic interviews were instrumental in linking stakeholders and maximizing capacity-building efforts. Health partners across the 4 states are now better positioned to collaborate on future regional opportunities including continued knowledge transfer through special interest groups, ongoing engagement with an annual regional convening, continued efforts to advance emergency management and resiliency, and potential development of group purchasing and other shared services. The PCCP experience suggests that in disaster-prone areas the sustainability of integrated primary care and behavioral health services is enhanced when cross-jurisdiction collaborations are established.

Texting for Health: An Evaluation of a Population Approach to Type 2 Diabetes Risk Reduction With a Personalized Message.

txt4health is an innovative, 14-week, interactive, population-based mobile health program for individuals at risk of type 2 diabetes, developed under the Beacon Community Program in the Greater New Orleans, La., area. A comprehensive social marketing campaign sought to enroll hard-to-reach, at-risk populations using a combination of mass media and face-to-face engagement in faith-based and retail environments. Little is known about the effectiveness of social marketing for mobile technology application in the general population. A systematic evaluation of the campaign identified successes and barriers to implementing a population-based mobile health program. Face-to-face engagement helped increase program enrollment after the initial launch; otherwise, enrollment leveled off over time. Results show positive trends in reaching target populations and in the use of mobile phones to record personal health information and set goals for reducing the risk of type 2 diabetes. The lessons from the txt4health campaign can help inform the development and programmatic strategies to provide a person-level intervention using a population-level approach for individuals at risk for diabetes as well as aid in chronic disease management.

Workplace exposure to secondhand smoke among non-smoking hospitality employees.

INTRODUCTION: This article examines salivary cotinine concentrations to characterize secondhand smoke (SHS) exposure among non-smoking hospitality employees (bar and casino employees and musicians who perform in bars) who are exposed to SHS in the workplace. METHODS: A pre-post test study design was implemented to assess SHS exposure in the workplace. The convenience sample of 41 non-smoking hospitality employees included 10 controls (non-smoking hospitality employees not exposed to SHS in the workplace). RESULTS: The findings demonstrate that post-shift saliva cotinine levels of hospitality employees who are exposed to SHS in the workplace are significantly higher than controls who work in smoke-free venues. Findings also suggested a statistically significant increase between pre- and post-shift saliva cotinine levels of hospitality employees who are exposed in the workplace. No statistically significant difference was noted across labor categories, suggesting that all exposed employees are at increased risk. CONCLUSION: The study results indicate that non-smoking hospitality employees exposed to SHS in the workplace have significantly higher cotinine concentration levels compared with their counterparts who work in smoke-free venues. Findings from other studies suggest that these increased cotinine levels are harmful to health. Given the potential impact on the health of exposed employees, this study further supports the efforts of tobacco prevention and control programs in advocating for comprehensive smoke-free air policies to protect bar and casino employees.

Sexual risk behaviors among youth heads of household in Gikongoro, south province of Rwanda.

BACKGROUND: As a result of the 1994 genocide and AIDS, Rwanda has a crisis of orphans. In 2005, the Ministry of Local Governance and Social Affairs of Rwanda has reported one million vulnerable children. Many of these are not only orphans but also youth heads of households (YHH). The purpose of this study was to: (a) identify risk behaviors that expose YHH to HIV infection, (b) determine gender-specific high risk profiles and, (c) determine predictors of sexual onset. METHODS: A household survey was conducted among 692 YHH, aged 12-24, all beneficiaries of a World Vision basic needs program in Gikongoro, Rwanda, from January to March 2004. Participants were interviewed using a structured questionnaire. Data was collected on socio-demographic variables, HIV/AIDS prevention knowledge and sexual risk behaviors. Bivariate analyses of the study variables were performed to examine differences between males and females. A logistic regression analysis was conducted to analyze factors that were independently associated with the debut of having sex. RESULTS: Forty-one percent of respondents reported sexual onset before age 15. Males were more likely to start earlier than females (50.4% versus 26.7%) but females reported more sexual onset with an older partner. Fifty-eight percent of females had their first intercourse with a partner who was four or more years older than themselves. While sexual activity was low (1.75 mean lifetime sexual partner, 0.45 mean sexual partner last twelve months), sexual experience was related to less social connectedness and use of drugs. Having a close friend also appeared to be protective for sexual debut. The analysis also found that although YHH were aware of some prevention measures against HIV/AIDS, there was low (19.8%) knowledge of the "ABC" prevention program promoted by the government. In addition, despite 85% of respondents knowing someone who had died of AIDS, only 31% perceived themselves at risk of HIV infection, and there was very low (13.2%) condom use among the sexually experienced. CONCLUSIONS: Results suggest the urgent need of HIV prevention programs tailored to YHH that provide knowledge, enhance negotiations skills, and increase the perception of HIV infection risk among YHH in Rwanda.

The influence of orphan care and other household shocks on health status over time: a longitudinal study of children's caregivers in rural Malawi.

In the context of rising rates of orphanhood in AIDS-affected settings, very little is understood about implications for caregiver well-being given increasing and intensifying responsibilities for the care of orphaned children. Emotional distress and self-reported health status as well as shifts in household orphan care, wealth, food security and recent illness and death among household members were measured among a panel of 1219 caregivers in rural Malawi between 2007 and 2009. Logistic regression was used to identify predictors of improved and diminished caregiver health and emotional distress. Results suggest that becoming an orphan caregiver is associated with a shift from good to poor health status (adjusted odds ratio [AOR]=2.29, 95% confidence interval [CI]=1.16-4.54), and that elevated levels of distress and poor health both persist over time in comparison with care for non-orphans only. Once engaged in orphan care, taking on additional orphans is associated with increased emotional distress in relation to not caring for orphans (AOR=3.16, 95% CI=1.30-7.73) as well as in relation to maintaining the same number of orphans in care over time (AOR=2.84, 95% CI=1.04-7.70). In addition, findings illustrate the strong influence of household wealth and food security on caregiver well-being. Food insecurity and poverty that persist or develop over time are associated with increasing distress. Conversely, maintenance or improvement in food security and household wealth are associated with decreases in distress. Providing all aspects of household maintenance and care for children, primary caregivers are key to the extended family solution for orphaned and vulnerable children. Bolstering the foundation of rural African families to ensure care and protection of these children involves targeting support to orphan caregivers but must also include addressing the issues of poverty and food insecurity that pose a wider threat to caregiving capacity.

Development and acceptability of an educational video about a smoking cessation quitline for use in adult outpatient mental healthcare.

Tobacco use is a leading preventable cause of early mortality and is prevalent among adults with mental health diagnoses, especially in the southern USA. Increasing cessation resources in outpatient mental health care and targeting individuals most receptive to changing their behavior may improve cessation. Drawing on the transtheoretical model, our goals were to develop an educational video about the Louisiana Tobacco Quitline and evaluate its acceptability. We designed the video with knowledge derived from Louisiana-specific data (2016 Louisiana Adult Tobacco Survey, N = 6,469) and stakeholder feedback. Bivariate associations between demographic/tobacco-use characteristics and participants' stage of quitting (preparation phase vs. nonpreparation phase) were conducted, which informed design elements of the video. Four stakeholder advisory board meetings involving current smokers, mental health clinicians, and public health advocates convened to provide iterative feedback on the intervention. Our stakeholder advisory board (n = 10) and external stakeholders (n = 20) evaluated intervention acceptability. We found that 17.9% of Louisiana adults were current smokers, with 46.9% of them in the preparation phase of quitting. Using insights from data and stakeholders, we succeeded in producing a 2-min video about the Louisiana Tobacco Quitline which incorporated three themes identified as important by stakeholders: positivity, relatability, and approachability. Supporting acceptability, 96.7% of stakeholders rated the video as helpful and engaging. This study demonstrates the acceptability of combining theory, existing data, and iterative stakeholder feedback to develop a quitline educational video. Future research should examine whether the video can be used to reduce tobacco use.

Reducing HIV-related stigma: lessons learned from Horizons research and programs.

Since the early years of the human immunodeficiency virus (HIV) epidemic, stigma has been understood to be a major barrier to successful HIV prevention, care, and treatment. This article highlights findings from more than 10 studies in Asia, Africa, and Latin America-conducted from 1997 through 2007 as part of the Horizons program-that have contributed to clarifying the relationship between stigma and HIV, determining how best to measure stigma among varied populations, and designing and evaluating the impact of stigma reduction-focused program strategies. Studies showed significant associations between HIV-related stigma and less use of voluntary counseling and testing, less willingness to disclose test results, and incorrect knowledge about transmission. Programmatic lessons learned included how to assist institutions with recognizing stigma, the importance of confronting both fears of contagion and negative social judgments, and how best to engage people living with HIV in programs. The portfolio of work reveals the potential and importance of directly addressing stigma reduction in HIV programs.

Improving the lives of vulnerable children: implications of Horizons research among orphans and other children affected by AIDS.

From 1997 through 2007, the Horizons program conducted research to inform the care and support of children who had been orphaned and rendered vulnerable by acquired immunodeficiency syndrome in sub-Saharan Africa. Horizons conducted studies in Kenya, Malawi, Rwanda, South Africa, Uganda, Zambia, and Zimbabwe. Research included both diagnostic studies exploring the circumstances of families and communities affected by human immunodeficiency virus (HIV) and evaluations of pioneering intervention strategies. Interventions found to be supportive of families included succession planning for families with an HIV-positive parent, training and supporting youth as caregivers, and youth mentorship for child-headed households. Horizons researchers developed tools to assess the psychosocial well-being of children affected by HIV and outlined key ethical guidelines for conducting research among children. The design, implementation, and evaluation of community-based interventions for orphans and vulnerable children continue to be a key gap in the evidence base.

Changes in risk behavior among HIV-positive patients during their first year of antiretroviral therapy in Cape Town South Africa.

We explore changes in sexual risk behaviour over the first year of antiretroviral therapy (ART) among a cohort of patients in Cape Town South Africa initiating treatment in five public facilities in 2006 and again 1 year later (Time 1 and Time 2). Contemporaneous measures of unprotected sex were also obtained from 2 cross-sectional samples of HIV-positive patients waiting to start ART attending the same facilities. Unprotected sex at last sex among patients on ART decreased significantly from a baseline of 44.7-23.2% one year later, regardless of partner status. After controlling for confounding factors, the observed decrease in unprotected sex among the ART cohort was highly significant in relation to the 2 cross-sectional samples of patients at Time 1 and Time 2 waiting to initiate ART. Findings suggest it is critical to start positive prevention to decrease risky sexual behavior prior to the start of ART within this setting.

Using the emergency department to investigate smoking in young adults.

PURPOSE: Smoking in young adults identifies the population at risk for future tobacco-related disease. We investigated smoking in a young adult population and within high-risk groups using emergency department (ED) data in a metropolitan area. METHODS: Using the electronic health record, we performed a retrospective study of smoking in adults aged 18-30 years presenting to the ED. RESULTS: Smoking status was available for 55,777 subjects (90.9% of the total ED cohort); 60.8% were women, 55.0% were black, 35.3% were white, and 8.1% were Hispanic; 34.4% were uninsured. Most smokers used cigarettes (95.1%). Prevalence of current smoking was 21.7% for women and 42.5% for men. The electronic health record contains data about diagnosis and social history that can be used to investigate smoking status for high-risk populations. Smoking prevalence was highest for substance use disorder (58.0%), psychiatric illness (41.3%) and alcohol use (39.1%), and lowest for pregnancy (13.5%). In multivariable analyses, male gender, white race, lack of health insurance, alcohol use, and illicit drug use were independently associated with smoking. Smoking risk among alcohol and drug users varied by gender, race, and/or age. CONCLUSIONS: The ED provides access to a large, demographically diverse population, and supports investigation of smoking risk in young adults.

Barriers to the community support of orphans and vulnerable youth in Rwanda.

A consistent theme in the literature on interventions for orphans and vulnerable children is the need for community-based care. However, a number of socio-cultural factors may impede community response. In this study, mixed methods are used to elucidate community-level barriers to care for orphans and vulnerable youth in Rwanda. Data from a large survey of youth heads of household on perceptions of marginalization from the community and the factors predicting that marginalization are considered in light of additional data from a survey of adults who volunteered to mentor these youth and focus groups with both community adults and youth heads of household. Results highlight how orphans' impoverished condition, cause of parents' death, and community perceptions of orphan behavior play a role in the marginalization of orphaned youth in Rwanda. Evidence is also offered to show that targeting humanitarian assistance to vulnerable youth may inadvertently lessen the level of community support they receive and contribute to their marginalization. The implications of these data for community-based program approaches are discussed.

Infants and young children living in youth-headed households in Rwanda: Implications of emerging data.

The HIV/AIDS epidemic has already produced millions of orphans in Africa and the peak of the orphan epidemic has not yet been reached. One emerging social trend associated with premature parental death is the formation of households headed by youth aged 13-24. In Rwanda, specific sociocultural factors have supported the formation of youth-headed households (YHH) in the wake of both the 1994 genocide and the ongoing HIV/AIDS epidemic. There is no published data on the health and socioemotional functioning of children under 5 living in YHH. Survey data from 692 YHH in one region of Rwanda yielded a subsample of 89 homes which contained one or more children under 5 (n=104). These data reveal that a majority of young children living in YHH's is in fair or poor health. Heads of household themselves report high levels of depressive symptoms and social isolation; reports of emotional distress among the youngest children in the homes are associated with reports of higher symptomatology among heads of household. Findings are interpreted in light of the sociocultural context of Rwanda and the implications of the data for intervention are considered.

Estimating the costs of supporting safety-net transformation into patient-centered medical homes in post-Katrina New Orleans.

There is a need to understand the costs associated with supporting, implementing, and maintaining the system redesign of small and medium-sized safety-net clinics. The authors aimed to understand the characteristics of clinics that transformed into patient-centered medical homes and the incremental cost for transformation.The sample was 74 clinics in Greater New Orleans that received funds from the Primary Care Access and Stabilization Grant program between 2007 and 2010 to support their transformation. The study period was divided into baseline (September 21, 2007-March 21, 2008), transformation (March 22, 2008-March 21, 2009), and maintenance (March 22, 2009-September 20, 2010) periods, and data were collected at 6-month intervals. Baseline characteristics for the clinics that transformed were compared to those that did not. Fixed-effect models were conducted for cost estimation, controlling for baseline differences, using propensity score weights.Half of the 74 primary care clinics achieved transformation by the end of the study period. The clinics that transformed had higher total cost, more clinic visits, and a larger female patient proportion at baseline. The estimated incremental cost for clinics that underwent transformation was $37.61 per visit per 6 months, and overall it cost $24.86 per visit per 6 months in grant funds to support a clinic's transformation.Larger-sized clinics and those with a higher female proportion were more likely to transform. The Primary Care Access and Stabilization Grant program provided approximately $24.86 per visit over the 2 and 1/2 years. This estimated incremental cost could be used to guide policy recommendations to support primary care transformation in the United States.

Developing a Community-Based Participatory Research Curriculum to Support Environmental Health Research Partnerships: An Initiative of the GROWH Community Outreach and Dissemination Core.

BACKGROUND: The Transdisciplinary Research Consortium for Gulf Resilience on Women's Health (GROWH) addresses reproductive health disparities in the Gulf Coast by linking communities and scientists through community-engaged research. Funded by the National Institutes of Environmental Health Sciences, GROWH's Community Outreach and Dissemination Core (CODC) seeks to utilize community-based participatory research (CBPR) and other community-centered outreach strategies to strengthen resilience in vulnerable Gulf Coast populations. The CODC is an academic-community partnership comprised of Tulane University, Mary Queen of Vietnam Community Development Corporation, Bayou Interfaith Shared Community Organizing, and the Louisiana Public Health Institute (LPHI). METHODS: Alongside its CODC partners, LPHI collaboratively developed, piloted and evaluated an innovative CBPR curriculum. In addition to helping with curriculum design, the CODC's community and academic partners participated in the pilot. The curriculum was designed to impart applied, practical knowledge to community-based organizations and academic researchers on the successful formulation, execution and sustaining of CBPR projects and partnerships within the context of environmental health research. RESULTS: The curriculum resulted in increased knowledge about CBPR methods among both community and academic partners as well as improved relationships within the GROWH CODC partnership. CONCLUSION: The efforts of the GROWH partnership and curriculum were successful. This curriculum may serve as an anchor for future GROWH efforts including: competency development, translation of the curriculum into education and training products, community development of a CBPR curriculum for academic partners, community practice of CBPR, and future environmental health work.

Conflict and HIV: A framework for risk assessment to prevent HIV in conflict-affected settings in Africa.

In sub-Saharan Africa, HIV/AIDS and violent conflict interact to shape population health and development in dramatic ways. HIV/AIDS can create conditions conducive to conflict. Conflict can affect the epidemiology of HIV/AIDS. Conflict is generally understood to accelerate HIV transmission, but this view is simplistic and disregards complex interrelationships between factors that can inhibit and accelerate the spread of HIV in conflict and post conflict settings, respectively. This paper provides a framework for understanding these factors and discusses their implications for policy formulation and program planning in conflict-affected settings.

Interventions to reduce HIV/AIDS stigma: what have we learned?

This article reviews 22 studies that test a variety of interventions to decrease AIDS stigma in developed and developing countries. This article assesses published studies that met stringent evaluation criteria in order to draw lessons for future development of interventions to combat stigma. The target group, setting, type of intervention, measures, and scale of these studies varied tremendously. The majority (14) of the studies aimed to increase tolerance of persons living with HIV/AIDS (PLHA) among the general population. The remaining studies tested interventions to increase willingness to treat PLHA among health care providers or improve coping strategies for dealing with AIDS stigma among PLHA or at-risk groups. Results suggest some stigma reduction interventions appear to work, at least on a small scale and in the short term, but many gaps remain especially in relation to scale and duration of impact and in terms of gendered impact of stigma reduction interventions.

How a Beacon Community Program in New Orleans Helped Create a Better Health Care System by Building Relationships before Technology.

INTRODUCTION: In the aftermath of Hurricane Katrina, much of New Orleans' healthcare infrastructure was destroyed. Initial federal funding after the storm expanded primary care services and helped set up medical homes for New Orleans' large uninsured and underinsured population. Following that, the Beacon Community in New Orleans, charged with improving health care through the use of technology, decided the best way to accomplish those goals was to build community partnerships and introduce technology improvements based on their input and on their terms. The purpose of this paper is to describe how those partnerships were wrought, including the innovative use of a conceptual framework, and how they are being sustained; how different technologies were and are being introduced; and what the results have been so far. METHODS: Past successful community experiences, as well as a proven conceptual framework, were used to help establish community partnerships and governance structures, as well as to demonstrate their linkages. This paper represents a compilation of reports and information from key Beacon leaders, staff and providers and their firsthand experiences in setting up those structures, as well as their conclusions. RESULTS: The community partnerships proved extremely successful in not only devising successful ways to introduce new technology into healthcare settings, but in sustaining those changes by creating a governance structure that has enough fluidity to adapt to changing circumstances. CONCLUSIONS: Building and developing community partnerships takes time and effort; however, these relationships are necessary and essential to introducing and sustaining new technologies in a healthcare setting and should be a first step for any organization looking to accomplish such goals.