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.

Scaling Up Evidence-Based Public Health Training.

Evidence-based public health (EBPH) is the process of integrating science-based interventions with community preferences. Training in EBPH improves the knowledge and skills of public health practitioners. To reach a wider audience, we conducted scale-up efforts including a train-the-trainer version of the EBPH course to build states' capacity to train additional staff. In this essay, we describe formats for course delivery and local adaptations to content, and we review success factors and barriers for state-based replication of the EBPH training course. Findings were based on our experiences and interviews. EBPH training was delivered in varied blended formats as well as in person and in distance courses, each with advantages and disadvantages. Adaptations were made to meet the needs of learners. Success factors included having committed and competent coordinators and trainers, organizational incentives, leadership support, funding, internal and external collaborators, the infrastructure to support training, and models to learn from. Barriers reported included insufficient staff or trainer capacity; time constraints for organizers, trainers, and participants; and lack of sustained funding. We hope our experience and findings will be a guide for states that are committed to building and sustaining capacity through continued EBPH training. Our lessons may also apply more generally to other workforce development training efforts.

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.

Long-Term Evaluation of a Course on Evidence-Based Public Health in the U.S. and Europe.

The evidence-based public health course equips public health professionals with skills and tools for applying evidence-based frameworks and processes in public health practice. To date, training has included participants from all the 50 U.S. states, 2 U.S. territories, and multiple other countries besides the U.S. This study pooled follow-up efforts (5 surveys, with 723 course participants, 2005-2019) to explore the benefits, application, and barriers to applying the evidence-based public health course content. All analyses were completed in 2020. The most common benefits (reported by >80% of all participants) were identifying ways to apply knowledge in their work, acquiring new knowledge, and becoming a better leader who promotes evidence-based approaches. Participants most frequently applied course content to searching the scientific literature (72.9%) and least frequently to writing grants (42.7%). Lack of funds for continued training (35.3%), not having enough time to implement evidence-based public health approaches (33.8%), and not having coworkers trained in evidence-based public health (33.1%) were common barriers to applying the content from the course. Mean scores were calculated for benefits, application, and barriers to explore subgroup differences. European participants generally reported higher benefits from the course (mean difference=0.12, 95% CI=0.00, 0.23) and higher frequency of application of the course content to their job (mean difference=0.17, 95% CI=0.06, 0.28) than U.S. participants. Participants from later cohorts (2012-2019) reported more overall barriers to applying course content in their work (mean difference=0.15, 95% CI=0.05, 0.24). The evidence-based public health course represents an important strategy for increasing the capacity (individual skills) for evidence-based processes within public health practice. Organization-level methods are also needed to scale up and sustain capacity-building efforts.

Adjusting the Equity Lens: Gaps in Addressing Health Equity in State Chronic Disease Prevention.

Purpose: Chronic diseases cause a significant proportion of mortality and morbidity in the United States, although risk factors and prevalence rates vary by population subgroups. State chronic disease prevention practitioners are positioned to address these issues, yet little is known about how health equity is being incorporated into their work. The purpose of this study was to explore perceptions of health equity in a sample of state chronic disease practitioners. Methods: Participants were selected in conjunction with a related evaluation of the National Association of Chronic Disease Directors (NACDD) capacity-building and evidence-based efforts. Four states were chosen for study based on variance in capacity. Directors in each of the states were interviewed and using snowball sampling, 8-12 practitioner interviews were conducted in each state, digitally audio recorded and transcribed. Using a comparative coding technique, themes and analyses were developed. Results: Comments from the practitioners fell into three main and inter-related categories. First, they discussed the varying degrees of integration of health equity in their work. The second theme was collaboration and the importance of working within and outside of departments, as well as with the community. The third theme related to measurement and the need for better data that can be used to garner support and measure impact. Conclusion: Chronic disease practitioners can play an important role in achieving health equity. Integrating this work more fully into chronic disease prevention and health promotion, developing strategic partnerships, tracking efforts, and measuring impact will improve practice and ultimately population health.

Development and validation of an instrument to measure resources and support for chronic illness self-management: a model using diabetes.

PURPOSE: Few comprehensive and practical instruments exist to measure the receipt of self-management support for chronic illness. An instrument was developed to measure resources and support for self-management (RSSM) for the survey component of the evaluation of the Robert Wood Johnson Foundation's Diabetes Initiative. It includes items to measure an ecological range of RSSM. This article describes the development and validation of the instrument, focusing on individuals' reported access to RSSM from providers and from nonclinical, social, and community sources. METHODS: Cross-sectional analyses of the second wave of a survey of participants in the Diabetes Initiative (68% response rate, n = 957) were used. RESULTS: Confirmatory factor analyses supported grouping the 17 items into 5 subscales, measuring key aspects of RSSM: individualized assessment, collaborative goal setting, enhancing skills, ongoing follow-up and support, and community resources (comparative fit index = 0.97, Tucker-Lewis fit index = 0.99, and root means square error of approximation = 0.06). The overall scale and 5 subscales were internally consistent (Cronbach alpha >or= .70) and were significantly, positively related to diabetes self-management behaviors, supporting their construct validity. CONCLUSIONS: This instrument shows promise for measuring RSSM. Although it was developed for diabetes programs, its ecological orientation and link to the broad framework of chronic care suggest broader application.

The public health role in the primary prevention of diabetes: recommendations from the chronic disease directors' project.

AIM: The article reports on the recommendations from the Diabetes Primary Prevention Project that was initiated and funded by the Division of Diabetes Translation, Centers for Disease Control and Prevention, and developed by the National Association of Chronic Disease Directors. METHOD: Essential components of statewide programs are delineated for effective interventions for diabetes primary prevention. The recommendations were derived from a structured process that is detailed on the basis of a cross-comparison of state-level diabetes prevention initiatives in six states where such programs were most developed. RESULTS: The recommendations focus on state-level partnerships, statewide program planning, required resources, policies, benchmarks for progress, and data collection. CONCLUSION: Illustrations are provided regarding how the project influenced the six participating states in further developing their programs for the primary prevention of diabetes.

Characteristics of organizational resources and supports for self management in primary care.

PURPOSE: The purpose of this article is to describe components of organizational support for self-management in primary care and provide illustrations of each of these components from the Diabetes Initiative's Advancing Diabetes Self Management (ADSM) projects. METHODS: Elements of organizational resources and supports for diabetes self-management in primary care were developed from the experience of the ADSM projects and in collaboration with Diabetes Initiative staff and experts. RESULTS: Eight elements of organizational support for self-management were identified: (1) the establishment of patient care teams, (2) continuity of care, (3) coordination of referrals, (4) documentation of self-management support, (5) ongoing quality improvement, (6) patient input, (7) staff training and education, and (8) integration of self-management into primary care. CONCLUSION: Establishing a comprehensive system of care for people with diabetes is enabled by an infrastructure of organizational resources and supports for self-management in primary care settings. These components of organizational support provide guidance for integrating diabetes self-management services into primary care settings.

Patient-centered goal setting as a tool to improve diabetes self-management.

PURPOSE: The purpose of this article is to describe the process of collaborative goal setting as a means to improve diabetes self-management in primary care. METHODS: The Self-Management Goal Cycle framework illustrates a model of care for patients with diabetes. The Big Bad Sugar War is an approach to patient counseling that includes background, barriers, successes, willingness to change, action plan, and reinforcement. RESULTS: Planned visits occur when a medical assistant performs routine health checks and laboratory tests prior to traditional individual appointments. Mini-group medical visits occur when a provider and medical assistant meet with 3 patients at one time. Open office group visits occur when 7 to 12 patients attend 2-hour sessions staffed by a provider. DISCUSSION: Collaborative goal setting is a valuable tool for improving self-management skills among patients with diabetes. By implementing goal setting techniques, members of the patient care team are better equipped to help patients manage their chronic conditions by making them valued partners of the health care team.

Integration of a promotora-led self-management program into a system of care.

PURPOSE: The purpose of this article is to describe the integration of a promotora-led self-management component into a system of care and assess the influence of this program on indicators of metabolic control over time. METHODS: Gateway Community Health Center is a federally qualified health center in Laredo, Texas, that serves a predominantly Hispanic population. Gateway integrated self-management support into care for people with diabetes by incorporating promotora-led self-management services into the clinic structure, operations, and patient visits. The self-management program included education, goal setting, depression screening with symptom follow-up, and support groups after course end. Indicators of metabolic control, HbA1c, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides were compared at baseline and at 12 months. RESULTS: The integration of promotora-led self-management services into the system of care allowed for continual improvements of self-management services in response to patient needs. Patients enrolled in the self-management course showed improved indicators of metabolic control that were sustained over time, and they reported a high level of goal achievement. CONCLUSIONS: The integration of the promotora-led self-management program into diabetes care at Gateway generated a system of referral, follow-up, feedback, and documentation that produced consistently high-quality clinical care.

Starting a diabetes self-management program in a free clinic.

PURPOSE: The purpose of this project is to develop and implement a system of care for people with type 2 diabetes in a free clinic setting. METHODS: This project was conducted in the Homestead/Florida City community at the Open Door Health Center (a free clinic for the uninsured poor). Through a grant from the Robert Wood Johnson Foundation Diabetes Initiative, organizational and programmatic changes were made to improve care for patients with type 2 diabetes. Program participation and clinical data, incorporation of healthy practices and programs in other community organizations, and the success of collaborations were evaluated to judge program success. RESULTS: Critical factors for providing health care for persons with type 2 diabetes in a free clinic setting were identified. These included reviewing and organizing medical records of patients with diabetes, developing a system that made efficient use of limited staff resources, finding an educational approach appropriate for the population served (ie, Popular Education), involving patients in self-management support roles by providing them the opportunity and training to become peer mentors, and developing strong community partnerships to complement and reinforce self-management. CONCLUSION: Creation of a successful system of care for patients with diabetes in a free clinic setting is possible through innovative collaboration and creative program design.

Move More Diabetes: using Lay Health Educators to support physical activity in a community-based chronic disease self-management program.

PURPOSE: The purpose of this article is to describe Move More Diabetes (MMD), which is used by Lay Health Educators (LHEs) to promote physical activity and improve diabetes self-management among individuals with type 2 diabetes. METHODS: Move More Diabetes used social marketing strategies to choose and segment the target audience, develop messages, and determine message delivery. Based on market research results, MMD chose natural peer support from LHEs as the main intervention strategy. RESULTS: Move More Diabetes built a sustainable volunteer network of 35 LHEs who recorded 1500 contacts with enrollees from 2004 to 2006. Participation improved when the program was not specific for diabetes. CONCLUSION: The MMD program demonstrated benefits of partnership and natural peer support and the utility of social marketing in planning and implementing a community-based chronic disease self-management and physical activity promotion program. This low-cost program can serve as a model for other rural communities interested in increasing physical activity to address chronic disease.

Use of the transtheoretical model to enhance resources and supports for diabetes self management: lessons from the Robert Wood Johnson Foundation Diabetes Initiative.

PURPOSE: The purpose of this article is to describe how Resources and Supports for Self Management (RSSM) and strategies of the transtheoretical model (TTM) intersect to produce a comprehensive approach resulting in cutting-edge diabetes programs. METHODS: Specific components of RSSM, especially individualized assessment, collaborative goal setting, and enhancing skills, are reviewed in terms of contributions to the TTM. RESULTS: Specific examples from the Diabetes Initiative of using TTM constructs from 5 projects are shown to illustrate the first 3 RSSM constructs: individualized assessment, collaborative goal setting, and skill building. CONCLUSION: Diabetes Initiative grantees have demonstrated that the TTM enhances RSSM and facilitates the adoption of good diabetes self-management behaviors.

Ongoing follow-up and support for chronic disease management in the Robert Wood Johnson Foundation Diabetes Initiative.

PURPOSE: The purpose of this article is to identify approaches to providing ongoing follow-up and support for diabetes self-management based on the experience of 14 self-management projects of the Diabetes Initiative of the Robert Wood Johnson Foundation. METHODS: This study is a collaboration with grantees of the Diabetes Initiative of the Robert Wood Johnson Foundation, a program focused on diabetes self-management in primary care and community settings. Grantees and national program staff identified key functions that ongoing follow-up and support need to fill and key features of programs that do so. RESULTS: Key functions of ongoing follow-up and support include monitoring of status and self-management, encouragement and facilitation of regular clinical care, encouragement and motivation of self-management, and facilitating skills for coping with changes in circumstances or emergent problems. Key features of ongoing follow-up and support to fill these functions are being available on demand; being proactive in maintaining contact and preventing individuals from "falling between the cracks"; having personal, motivational, and consistent key messages; not being limited to diabetes; and being inclusive of a wide range of resources and settings. CONCLUSIONS: Initial characterization of key features of ongoing follow-up and support has been accomplished. This should facilitate research to clarify how it may best be provided and systematic approaches to doing so. These should lead to health service and policy initiatives supporting this critical dimension of programs to promote self-management and lifelong healthy living patterns.

Teaching how, not what: the contributions of community health workers to diabetes self-management.

PURPOSE: The purpose of this study is to describe ways in which community health workers (CHWs) are used in various clinic and community settings to support diabetes self-management. METHODS: Descriptive quantitative data were collected from logs completed by CHWs. Logs described mode, place, type, duration, and focus of individual contact between the CHW and the patient. Qualitative data were collected from semistructured interviews with patients. Interviews were conducted on site from June to August 2006. Interviewees included a purposeful sample of 47 patients who perceived being helped by CHWs. RESULTS: CHWs reported providing assistance and teaching or practicing skills as the focus of most of the 1859 individual contacts. The assistance CHWs reported providing was most often in the form of encouragement/motivation. During interviews, patients shared that CHWs were helpful in demonstrating how to incorporate diabetes self-management (DSM) into their daily lives. The information patients shared also provided insight into what they perceived as encouragement/motivation from the CHWs. Quotes from interviews provide specific examples of how support from CHWs was different from that received from family and health care team members. CONCLUSIONS: Both CHWs and patients perceived assistance being provided in similar ways, with consistent emphasis on encouragement/motivation. Interviews with the patients revealed that a personal connection along with availability and provision of key resources and supports for self-management made the CHW-patient interaction successful for DSM. Examples provide insight into the valuable contributions of CHWs to DSM. This insight should encourage guidelines that make CHWs a routine, standard part of the diabetes care team.

Perspectives on self-management from the Diabetes Initiative of the Robert Wood Johnson Foundation.

PURPOSE AND METHOD: Review and highlight findings from the projects of the Diabetes Initiative of the Robert Wood Johnson Foundation described in this special supplemental issue. RESULTS: The broad framework for self-management around which these programs were developed, "Resources and Supports for Self Management," includes individualized assessment, collaborative goal setting, building skills for self-management, ongoing follow-up and support, community resources, and continuity of quality clinical care. Lessons learned include the central role of community health workers in self-management, the importance of ongoing follow-up and support to sustain self-management, varied program approaches to depression and negative emotion, the importance of organizational infrastructure to support self-management programs, and the contributions of clinic-community partnerships. Several emergent themes include the value of providing choices among "good practices" as opposed to one best practice, the role of the physician as part of the self-management team, and the importance of broad efforts in promoting dissemination of self-management programs. Finally, self-management will benefit from replacing categorical distinctions, like good and bad control, proven and unproven treatment, with thinking in terms of key dimensions, like level of control and continued quality improvement. CONCLUSIONS: Diabetes Initiative projects have shown that diabetes self-management can be promoted in the "real worlds" of community agencies and primary care settings serving diverse and disadvantaged populations.

The Robert Wood Johnson Foundation Diabetes Initiative: demonstration projects emphasizing self-management.

PURPOSE: The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings. METHODS: The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States. This report describes the Initiative, its ecological perspective on self-management, and implications for program development, sustainability, and dissemination. RESULTS: Ecological perspectives stress varied levels of influence ranging from individuals to communities and policies. Based on this, the Initiative has identified key resources and supports for self-management (individualized assessment, collaborative goal setting, enhancing skills, follow-up and support, community resources, and continuity of quality clinical care). Lessons learned include the central roles of community health workers, integration of healthy coping and attention to negative emotion and depression in self-management, community partnerships, approaches to ongoing follow-up and support, organizational factors in sustaining programs, and the utility of a collaborative learning network for program development. Sustainability stresses organizational and policy supports for the program. Dissemination of lessons learned will stress collaboration among interested parties, stimulating consumer understanding and demand for self-management services as central to diabetes care. CONCLUSIONS: The Diabetes Initiative demonstrates that effective self-management programs and supports can be implemented in real-world clinical and community settings, providing models of worthwhile, sustainable programs.

A quality improvement tool to assess self-management support in primary care.

BACKGROUND: Self management is an essential, central component of effective care for diabetes and other chronic illnesses, yet very few instruments exist to assess delivery or consistency of self-management support. The Assessment of Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS) tool assesses both organizational infrastructure and delivery of self-management support services. METHODS: The PCRS was developed by the Robert Wood Johnson Foundation Diabetes Initiative and underwent several stages of development, including three pilot tests, review by experts, and implementation by a national quality improvement (QI) program. RESULTS: The development and testing of the instrument resulted in the current 16-item measure. Use of the PCRS in a QI collaborative with 20 diverse health care teams across the United States demonstrated that the instrument is helpful in assessing areas for improvement. DISCUSSION: Initial experience suggests that the PCRS is a user-friendly self-assessment tool that primary care teams can use to assess their current capacity to support and implement consistent patient-centered self management. The initial evaluation indicates that the PCRS has acceptable psychometric properties and is applicable across different types of primary care teams and chronic illness conditions.

Application of the transtheoretical model to health education for older adults.

The application of theory to practice can be challenging. This article describes the experiences of one organization in applying the Transtheoretical Model (TTM) to a health promotion program for older adults, Health Stages. The concepts of the model, especially stage of change, were successfully used for program planning, curriculum development, and program evaluation. A Programming Grid was developed to guide curriculum development and evaluate if programs were reaching out to people at all stages of readiness to make healthy changes. Other TTM constructs, including self-efficacy, decisional balance, and processes of change were incorporated into the Health Stages curriculum. Evaluation showed that the pilot sites increased their offering of action- and maintenance-oriented programs, filling in the gaps in current programming. Older adults were receptive and interested in the model. The TTM enhanced the program by providing a framework for design and a method for reaching a wider audience of older adults with important health information.