Implementation Research as Applied Science: Bridging the Research to Practice Gap.

Implementation research is intended to address challenges posed by the slow adoption of evidence-based science by the medical and health promotion practice community. A case study approach is used to illustrate and discuss the use of Quality improvement and Evaluation as an applied approach to implementation science in contrast of more classic purposes of research. Quality improvement was the implementation model used to facilitate organizational change needed to adopt the use of texting to report sexually transmitted infection test results in over a fifth of Florida's larger county health departments. Both quantitative and qualitative methods were used to evaluate implementation. All seven participating county health departments were successful in enrolling clients in texting with extensive variation (24% to 72%) in texting enrollment at the end of the 10-month study. Statistically significant outcomes for those enrolled in texting were recorded through Florida's online sexually transmitted infection reporting system in the form of increased number of people receiving early (1-4 days) treatment and reductions in delayed (≥8 days) or no treatment. This study illustrates an applied approach to implementation research which may be critical to adapt emerging evidence and technologies to the multiple and complex characteristics of the diverse populations served by health promotion institutions.

Texting Test Results Reduces the Time to Treatment for Sexually Transmitted Infections.

CONTEXT: Sexually transmitted infections (STIs) continue to be a major health problem and source of health disparities in the United States. With diminishing resources, public health agencies are challenged to limit inefficient STI practices and still maintain effective population health. OBJECTIVE: The purpose of this study was to implement a text-messaging strategy to convey STI test results and to assess whether texting positive results was associated with a shorter treatment time frame. DESIGN: Quasi-experimental design. SETTING: Six counties in Florida. PARTICIPANTS: Sexually transmitted infection clients in 6 county health departments. INTERVENTION: Clients tested for gonorrhea, chlamydia, and syphilis were given the option to receive their results by a text message or the regular notification process (phone or follow-up clinic visit). MAIN OUTCOME MEASURE: The time to treatment after a positive test result for those clients who received their results by a text message versus the regular notification process. Those who were presumptively treated were excluded from the analysis. RESULTS: Over a 10-month period, 4081 clients were offered the texting option and 47.8% agreed to participate. For the counties combined, there was a higher percentage of those who received treatment within 1 to 4 days who received their positive test results by text message (53.0%) versus those who received their results by traditional methods (42.0%). In addition, there was a lower percentage of those who either did not get treated or were treated 8 days or more who received their positive test results by text message (26.1%) versus those who received their results by traditional methods (35.2%). CONCLUSIONS: Providing a text-messaging option is a viable strategy for clinics to provide timely results to their clients, and these clients were more likely to be treated in 1 to 4 days. Important for public health quality improvement, and increased efficiency and adoption of emerging technologies.

Development of a Research Agenda Focused on Academic Health Departments.

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

Community-based pediatric palliative care for health related quality of life, hospital utilization and costs lessons learned from a pilot study.

BACKGROUND: Children with chronic complex-medical conditions comprise a small minority of children who require substantial healthcare with major implications for hospital utilization and costs in pediatrics. Community-Based Pediatric Palliative Care (CBPPC) provides a holistic approach to patient care that can improve their quality of life and lead to reduced costs of hospital care. This study's purpose was to analyze and report unpublished evaluation study results from 2007 that demonstrate the potential for CBPPC on Health Related Quality of Life (HRQoL) and hospital utilization and costs in light of the increasing national focus on the care of children with complex-medical conditions, including the Affordable Care Act's emphasis on patient-centered outcomes. METHODS: A multi-method research design used primary data collected from caregivers to determine the Program's potential impact on HRQoL, and administrative data to assess the Program's potential impact on hospital utilization and costs. Caregivers (n=53) of children enrolled in the Northeast Florida CBPPC program (Community PedsCare) through the years 2002-2007 were recruited for the Health Related Quality of Life (HRQoL) study. Children (n=48) enrolled in the Program through years 2000-2006 were included in the utilization and cost study. RESULTS: HRQoL was generally high, and hospital charges per child declined by $1203 for total hospital services (p=.34) and $1047 for diagnostic charges per quarter (p=0.13). Hospital length of stay decreased from 2.92 days per quarter to 1.22 days per quarter (p<.05). CONCLUSION: The decrease in hospital utilization and costs and the high HRQoL results indicate that CBPPC has the potential to influence important outcomes for the quality of care available for children with complex-medical conditions and their caregivers.

Cross-Jurisdictional Resource Sharing in Changing Public Health Landscape: Contributory Factors and Theoretical Explanations.

BACKGROUND: Local health departments (LHDs) are striving to meet public health needs within their jurisdictions, amidst fiscal restraints and complex dynamic environment. Resource sharing across jurisdictions is a critical opportunity for LHDs to continue to enhance effectiveness and increase efficiency. PURPOSE: This research examines the extent of cross-jurisdictional resource sharing among LHDs, the programmatic areas and organizational functions for which LHDs share resources, and LHD characteristics associated with resource sharing. METHODS: Data from the National Association of County & City Health Officials' 2013 National Profile of LHDs were used. Descriptive statistics and multinomial logistic regression were performed for the 5 implementation-oriented outcome variables of interest, with 3 levels of implementation. RESULTS: More than 54% of LHDs shared resources such as funding, staff, or equipment with 1 or more other LHDs on a continuous, recurring basis. Results from the multinomial regression analysis indicate that economies of scale (population size and metropolitan status) had significant positive influences (at P ≤ .05) on resource sharing. Engagement in accreditation, community health assessment, community health improvement planning, quality improvement, and use of the Community Guide were associated with lower levels of engagement in resource sharing. Doctoral degree of the top executive and having 1 or more local boards of health carried a positive influence on resource sharing. CONCLUSIONS: Cross-jurisdictional resource sharing is a viable and commonly used process to overcome the challenges of new and emerging public health problems within the constraints of restricted budgets. LHDs, particularly smaller LHDs with limited resources, should consider increased resource sharing to address emerging challenges.

Comparison of practice based research network based quality improvement technical assistance and evaluation to other ongoing quality improvement efforts for changes in agency culture.

BACKGROUND: Public health agencies in the USA are increasingly challenged to adopt Quality Improvement (QI) strategies to enhance performance. Many of the functional and structural barriers to effective use of QI can be found in the organizational culture of public health agencies. The purpose of this study was to assess the impact of public health practice based research network (PBRN) evaluation and technical assistance for QI interventions on the organizational culture of public health agencies in Georgia, USA. METHODS: An online survey of key informants in Georgia's districts and county health departments was used to compare perceptions of characteristics of organizational QI culture between PBRN supported QI districts and non-PBRN supported districts before and after the QI interventions. The primary outcomes of concern were number and percentage of reported increases in characteristics of QI culture as measured by key informant responses to items assessing organizational QI practices from a validated instrument on QI Collaboratives. Survey results were analyzed using Multi-level Mixed Effects Logistic Model, which accounts for clustering/nesting. RESULTS: Increases in QI organizational culture were consistent for all 10- items on a QI organizational culture survey related to: leadership support, use of data, on-going QI, and team collaboration. Statistically significant odds ratios were calculated for differences in increased QI organizational culture between PBRN-QI supported districts compared to Non-PBRN supported districts for 5 of the 10 items, after adjusting for District clustering of county health departments. CONCLUSIONS: Agency culture, considered by many QI experts as the main goal of QI, is different than use of specific QI methods, such as Plan-Do-Study-Act (PDSA) cycles or root-cause analyses. The specific use of a QI method does not necessarily reflect culture change. Attempts to measure QI culture are newly emerging. This study documented significant improvements in characteristics of organizational culture and demonstrated the potential of PBRNs to support agency QI activities.

Institutionalizing the academic health department within the context of the 3-fold academic mission.

A mature model of an academic health department (AHD) that has been institutionalized over 2 decades is described within the context of the 3-fold traditional mission of academics (teaching, research, and service/practice). This adaptive model for AHDs, based on mutual benefits that can be viewed through the lenses of both the academic health center mission and the public health functions and services, has important implications for AHD sustainability. Continued collaboration in any academic-public health partnership will depend in part on the commitments of the changing leadership. However, institutionalizing support for the academic mission enables this collaboration to transcend changing leadership styles and priorities. The collaboration of Duval County Health Department and University of Florida College of Medicine-Jacksonville is an example of a model of AHD that has endured major changes in leadership within both the academic center and the Duval County Health Department.

Using Community Engagement to Move Upstream to Address Social Determinants of Health.

ABSTRACT: Given its role as a safety net institution, the University of Florida Health (UF Health) Jacksonville has responded to the community's needs through partnerships with the community for decades. Such academic-community partnerships have a broad emphasis on population health and primary care that expands the model of care to include community engagement, which allows such partnerships to promote health and well-being and reduce health inequalities by addressing social determinants of health (SDOH).This report describes the UF Health Jacksonville and University of Florida College of Medicine - Jacksonville's creation of the Urban Health Alliance (UHA) in June 2019 due to continued poor health outcomes and inequities within the community. The mission of the UHA is to improve community health using community-focused, self-sustainable strategies and solutions to impact SDOH (i.e., more upstream interventions). Using the tenets of the collective impact model, the UHA acts as a backbone organization to achieve these objectives by empowering community partners to affect changes in policy, systems, and other structures necessary for the optimal health of the community. The UHA's work is divided across 4 pillars: services, research, education, and policy. These pillars reflect the traditional missions of academic medical centers-clinical care, research, and education-and the need to address structural changes to improve community health-namely, policy. By addressing the issues that most impact the patients and community of UF Health Jacksonville, the UHA can serve as an example of how an academic medical center can use the traditional missions to improve the community's health and move toward health equity.

A merged model of quality improvement and evaluation: maximizing return on investment.

Quality improvement (QI) and evaluation are frequently considered to be alternative approaches for monitoring and assessing program implementation and impact. The emphasis on third-party evaluation, particularly associated with summative evaluation, and the grounding of evaluation in the social and behavioral science contrast with an emphasis on the integration of QI process within programs or organizations and its origins in management science and industrial engineering. Working with a major philanthropic organization in Georgia, we illustrate how a QI model is integrated with evaluation for five asthma prevention and control sites serving poor and underserved communities in rural and urban Georgia. A primary foundation of this merged model of QI and evaluation is a refocusing of the evaluation from an intimidating report card summative evaluation by external evaluators to an internally engaged program focus on developmental evaluation. The benefits of the merged model to both QI and evaluation are discussed. The use of evaluation based logic models can help anchor a QI program in evidence-based practice and provide linkage between process and outputs with the longer term distal outcomes. Merging the QI approach with evaluation has major advantages, particularly related to enhancing the funder's return on investment. We illustrate how a Plan-Do-Study-Act model of QI can (a) be integrated with evaluation based logic models, (b) help refocus emphasis from summative to developmental evaluation, (c) enhance program ownership and engagement in evaluation activities, and (d) increase the role of evaluators in providing technical assistance and support.

Revenue sources for essential services in Florida: findings and implications for organizing and funding public health.

OBJECTIVES: The Florida Public Health Practice-Based Research Network conducted the study of Florida county health departments (CHDs) to assess relationships between self-assessed performance on essential services (ESs) and sources of funding. METHODS: Primary data were collected using an online survey based on Public Health Accreditation Board standards for ES. Bivariate and multivariate analyses were conducted to assess the relationship of sources and amounts of revenue obtained from the Florida Department of Health financial system to responses to the survey of CHD capacity for ESs. RESULTS: Self-assessed CHD performance for each ES varied extensively among the CHDs and across the 10 ESs, ranging from a high of 98% CHDs completely or almost completely meeting the standards for ES 2 (Investigating Problems and Hazards) to a low of 32% completely or almost completely meeting standards for ES 10 (Research/Evidence). Medicaid revenue and fees were positively correlated with some ESs. Per capita revenue support varied extensively among the CHDs. CONCLUSIONS: Revenue for ES is decreasing and is heavily reliant on noncategorical (discretionary) revenue. This study has important implications for continued reliance on ES as an organizing construct for public health.

Policy implications for local application of the 2009 Youth Risk Behavior Survey, Duval County, Florida.

INTRODUCTION: Youth Risk Behavior Survey (YRBS) data have rarely been analyzed at the subcounty level. The purpose of this study was to explore the feasibility of such analysis and its potential to inform local policy and resource allocation. METHODS: We administered the 2009 YRBS to 5,860 students from 46 public middle and high schools in Duval County, Florida. In addition to asking core questions, we asked a set of questions customized for local needs, including questions about zip codes. These data were used to simulate subcounty areas consistent with areas identified by behavioral, morbidity, mortality, and health disparity surveillance. We oversampled Duval County and used weighting procedures that adjusted for subcounty areas. RESULTS: Many Duval County health risk behavior rates were higher than those for Florida overall but did not vary significantly within the county. Physical activity and violence-related behaviors were exceptions that reflect major health disparities in parts of the county with a high proportion of racial/ethnic minorities. CONCLUSION: This study demonstrated that collecting subcounty data in large metropolitan areas is feasible and that analysis of these data at the local level has implications for policy. Some health risk behaviors were common across the county, indicating the need for health promotion and disease prevention programs at the school district level. Other health risk behaviors were more prevalent in specific areas of the county and may have been exacerbated by state or local policies such as restrictions on physical education. Health disparities remain a challenge throughout the country; reducing them will require more extensive data-driven problem solving at state and local levels.

Incorporating Black women's perspectives into long-acting reversible contraception implementation.

Objective: To study urban, predominantly Black women's expressed opinions and beliefs related to the use of contraceptives to better inform implementation strategies designed to increase the use of highly effective contraceptives among minoritized and low-income women. Design: Focus group interviews with women, in conjunction with a community-based organization providing programs for underserved women with a mission of improved women and infant health. Setting: Focus groups were conducted, and women were recruited from clinical sites in predominantly African American urban neighborhoods in a southeastern US city. Patients: Self-identified 18-35-year-old women recruited from clinical sites in the urban core of the city with an 80% African American population. Interventions: No interventions tested. Main Outcome Measures: Black women's opinions and concerns about contraception. Results: Key insights from the focus group results for healthcare providers include the following: the importance of framing discussions with patients within the context of the patients' goals; need to acknowledge and respect the support systems that women rely on for child birthing and childcare; recognition of the clinician's role as a trusted and respected source of information; and need to understand and be prepared to address much of the inaccurate and misleading information that can interfere with the patients' optimal choices for contraception. Conclusions: A critical component for applying the implementation science theory to increase the use of evidence-based practices, such as implementation of highly effective contraceptives, requires understanding women's perspectives of the factors influencing their decisions to use highly effective contraceptives. This study provides important insights into the following: the potential barriers inherent in minoritized women's concerns about contraceptives and how these insights can inform implementation strategies such as patient-centered counseling and education to overcome those barriers.

Comparative study of different SES neighborhood clinics for health literacy and internet access.

Background: As healthcare services are increasingly dependent on patient utilization of technology to effectively deliver services, the digital divide has the potential to exacerbate health disparities if health literacy and internet access present formidable barriers to patient use of technology. Methods: We examined the differences in health literacy and internet access between lower and upper SES neighborhood primary-care clinics in Northeast Florida. The REALM-SF for health literacy was used to assess health literacy and census survey questions were used to assess internet and technology access, during the Fall, 2020. The clinics were affiliated with a safety-net hospital in a major city in Southeastern U.S. Results: Analysis of key demographic data confirmed that the responding patients from economically disadvantaged neighborhood clinics resided in economically disadvantaged zip codes (307 responding patients lived in lower SES neighborhoods) and did have lower education levels (3% of the patients from Upper SES clinics had 11 grade or lower education, compared to 21%-29% of patients from Lower SES clinics). Patient health literacy significantly differed between clinics located in economically disadvantaged neighborhoods and clinics located in more affluent neighborhoods, with Upper SES clinics being 2.4 times more likely to have 9th grade or higher reading level. Access to internet technology was also higher in the Upper SES clinics, with 59% of respondents from Upper SES clinics versus 32%-40% from Lower SES clinics owning a computer or an IPAD. Conclusion: Results of this study have important implications for patient-engaged use of digital technology for health. Healthcare and public health clinics should be aware of the difference in health literacy and internet access when implementing technology-based services, so that advances in medicine, including precision medicine and telehealth, can be disseminated and implemented with broad populations, including disadvantaged groups.

Impact of pre-conception health care: evaluation of a social determinants focused intervention.

The purpose of this study was to evaluate the outcomes of the social determinants component of a multiple determinants model of pre- and inter-conception care. Health department vital statistics and infectious disease data on birth and factors influencing birth outcomes were analyzed for participants in a program designed to mitigate the effects of social class and stress in contrast to a matched comparison group and other relevant populations. The program showed promising results related to reducing infant mortality and reducing other high-risk factors for poor birth outcomes, including low birth weight and sexually transmitted disease. Social determinant interventions, designed to mitigate the impact of social class and stress, should be considered with efforts to reduce infant mortality, particularly the disparities associated with infant mortality. Additional research should be conducted to refine replicable social determinant focused interventions and confirm and generalize these results.

Using multiple sources of data to assess the prevalence of diabetes at the subcounty level, Duval County, Florida, 2007.

INTRODUCTION: Diabetes rates continue to grow in the United States. Effectively addressing the epidemic requires better understanding of the distribution of disease and the geographic clustering of factors that influence it. Variations in the prevalence of diabetes at the local level are largely unreported, making understanding the disparities associated with the disease more difficult. Diabetes death rates during the past 15 years in Duval County, Florida, have been disproportionately high compared with the rest of the state. METHODS: We analyzed multiple sources of secondary data related to diabetes illness and death in Duval County, including data on hospital discharge, emergency department (ED) use, and vital statistics. We accessed diabetes and diabetes-related ED use and hospitalization and death data by using codes from the International Classification of Diseases versions 9 and 10. We analyzed data from the Behavioral Risk Factor Surveillance System survey for Duval County and adapted Centers for Disease Control and Prevention weighting formulas for subcounty analysis. We used relative risk-type disease ratios and geographic information systems mapping to analyze data. RESULTS: The urban, mostly minority, low-socioeconomic area of Duval County had twice the rate of diabetes-related illness and death as other areas of the county, and the inner-city, poor area of the county had almost 3 times the rate of hospitalization and ED use for diabetes and diabetes-related conditions compared with the other areas of the county. CONCLUSION: Our analyses show that diabetes-related disparities affect not only people and their families but also the community that absorbs the costs associated with the disproportionate health care use that results from these disparities. Analyzing data at the subcounty level has implications for health care planning and public health policy development at the local level.

Crosswalking public health and health education competencies: implications for professional preparation and practice.

This article highlights similarities and differences between the public health competencies recently developed by the Association of Schools of Public Health (ASPH) and one public health specialty, health education (HE), which has used competencies in its quality assurance systems for more than 20 years. Based on a crosswalk methodology developed for this analysis, some 50 percent to 61 percent of the HE and ASPH competencies had similarities of varying degrees; 18 percent were deemed matches due to sameness in skill or content. Most similarities were found between the ASPH social and behavioral sciences competencies and the HE competencies. Significant domains of "no match" were found between the HE and ASPH competencies in the areas of Systems Thinking, Leadership, and Public Health Biology. The study results have implications for academic programs related to curricula review and revision, continuing education providers who are developing training agendas for the workforce, employers anticipating competencies in new job hires, and prospective students and practitioners who are considering a form of certification. Qualitative insights from the study related to professional culture, purpose, age, and consistency of the scope or depth of the two competency sets, as well as the crosswalk methodology itself, may be useful to those comparing other competency sets.

Implementation of possession laws and the social ecology of tobacco control.

The objective of this evaluation research was to assess the impact of programs intended to support the enforcement component of a comprehensive youth tobacco control. The research method was a survey of a randomly stratified cluster sample of law enforcement officers. Results of the evaluation showed that the enforcement behaviors of officers were increased through the state programs to support tobacco enforcement activities. The study showed that support for implementing a policy is important to achieve the objectives of a policy. The results of a study of the enforcement component of a Florida tobacco control program are reported and discussed within the ecological context of previously reported enforcement-linked decreases in youth tobacco use and funding and defunding of the Florida Tobacco Control Program.

Building health promotion capacity in developing countries: strategies from 60 years of experience in the United States.

The Galway Consensus Conference articulated key definitions, principles, values, and core domains of practice as the foundation for the diffusion of health promotion across the globe. The conference occurred in the context of an urgent need for large numbers of trained health workers in developing countries, which face multiple severe threats to the health of their people. In this article, the authors draw on the experience acquired by the health promotion profession in the United States to illustrate what might be done to build health promotion capacity in developing countries. They examine the profession's experience in the areas of accreditation and certification, research and publications, advocating for the profession, and advocating for public health policy. Finally, the authors direct a challenge to the profession in the United States to extend a hand to developing countries to assist them in expanding their capacity to prepare health promotion professionals and deliver health promotion services.

A longitudinal study of a pediatric practice-based versus an agency-based model of care coordination for children and youth with special health care needs.

BACKGROUND: Care coordination has been shown to improve the quality of care for children and youth with special health care needs (CYSHCN). However, there are different models for structuring care coordination in relation to the medical home and most Title V agencies use an agency-based model of care coordination. No studies have prospectively compared a practice-based care coordination model to a Title V agency-based care coordination model. OBJECTIVE: Report the results of a prospective cohort study comparing a practice-based nurse care coordinator model with Title V agency-based care coordination model. DESIGN/METHODS: Three pediatric practices received the intervention, placement of a nurse care coordinator onsite within the practice, along with training and quality improvement on the principles of the medical home. Three practices continued to rely on agency-based care coordination services. CYSHCN in the practices were identified, interviewed at baseline, and re-interviewed after 18 months. We interviewed 262 families/children at baseline and 144 families/children (76 in the intervention and 68 in the comparison group) at 18 months. Families rated the quality of services they received from the care coordinator and the pediatric practice, and their experience of barriers to services for their CYSHCN. RESULTS: Families in the practice-based care coordination group were more likely to report improvement in their experience with the care coordinator (P = 0.02), fewer barriers to needed services (P = 0.003), higher overall satisfaction with care coordination (P = 0.03), and better treatment by office staff (P = 0.04). CONCLUSIONS: We found that for families of CYSHCN, practice-based care coordination in the medical home led to increased satisfaction with the quality of care they received and a reduction of barriers to care. The practice-based care coordination model is utilized by a minority of State Title V agencies and should be considered as a potentially more effective model than the agency-based approach.