Building a New Generation of Public Health Leaders Forged in a Public Health Crisis.

The COVID-19 pandemic presented wide-ranging leadership challenges to public health leaders and public health organizations. In its wake, as the necessity of reconstructing public health and modernizing the Centers for Disease Control and Prevention (CDC) is considered, we reviewed reports from the Commonwealth Fund and the CDC and other leadership-focused literature to identify common themes for a new generation of public health leaders. We posit that this new generation must have the ability to communicate (build and maintain trust and accountability); forge, facilitate, and promote partnerships; connect public health and health care systems; build information systems that provide accessible, actionable data; engage in systems and strategic thinking and action; center equity and inclusivity and understand structural racism as a fundamental driver and creator of health inequities; and achieve and maintain resilience and self-care. For each of the 7 abilities, we offer a description, assess what COVID-19 taught us about the necessity of the ability for public health leaders, and offer suggestions for developing (or honing) one's skill set, mindset, and tool set in this regard. (Am J Public Health. 2024;114(6):626-632. https://doi.org/10.2105/AJPH.2024.307633).

The Value and Impacts of Academic Public Health Departments.

The academic health department (AHD) is a partnership between an academic institution and a governmental health agency. These partnerships are meant to provide mutual benefits that include opportunities for student field placements and internships, practice-informed curriculum, and practice-based research. The term academic health department dates back only to 2000, although there are several examples of academic-practice partnerships prior to that date. In addition to AHDs that have been established over the past two decades, other forms of academic-practice engagement provide similar mutual benefits, such as prevention research centers and public health training centers. Current research on AHDs explores how these partnerships matter regarding the outputs, outcomes, and impacts of the units that comprise them. This review also considers the most recent perspectives on how AHDs have responded to the COVID-19 pandemic and how they might advance public health's efforts to address structural racism and promote health equity.

Experiences of United States Graduates at the Latin American Medical School in Cuba: A Road Less Traveled.

OBJECTIVES: Determine if United States graduates of the Latin American Medical School in Cuba: 1) provide primary health care to disadvantaged populations; 2) complete licensing exams and obtain residencies; and 3) accrue additional debt during their medical education. METHODS: A Qualtrics secure web-based survey was provided to 158 graduates via email, completed anonymously. Responses were compiled and descriptive statistics generated. RESULTS: Fifty-six valid surveys were returned, for a response rate of 35.4%. Chi-square analysis showed no statistically significant differences between survey respondents and the sampling frame. Most graduates are people of color; 68% work in clinical medicine; of these, 90% are in primary care, with 100% serving disadvantaged populations. Most accrued no further educational loan debt. CONCLUSIONS: United States graduates of the Latin American Medical School work in primary care with disadvantaged populations. Graduates accrue little additional student loan debt.

Understanding the Differences in COVID-19 Case Fatality Rates Observed Across Alabama Counties.

To understand county-level variation in case fatality rates of COVID-19, a statewide analysis of COVID-19 incidence and fatality data was performed, using publicly available incidence and case fatality rate data of COVID-19 for all 67 Alabama counties and mapped with health disparities at the county level. A specific adaptation of the Shewhart p-chart, called a funnel chart, was used to compare case fatality rates. Important differences in case fatality rates across the counties did not appear to be reflective of differences in testing or incidence rates. Instead, a higher prevalence of comorbidities and vulnerabilities was observed in high fatality rate counties, while showing no differences in access to acute care. Funnel charts reliably identify counties with unexpected high and low COVID-19 case fatality rates. Social determinants of health are strongly associated with such differences. These data may assist in public health decisions including vaccination strategies, especially in southern states with similar demographics.

COVID-19's Impact on the African American Community: A Stakeholder Engagement Approach to Increase Public Awareness Through Virtual Town Halls.

COVID-19 has created a rapidly evolving public health crisis disproportionately impacting African Americans due to persistent inequities. The changing COVID-19 guidelines have resulted in concerns expressed by the American public, including unique concerns expressed by African Americans. To increase COVID-19-related awareness and dialogue among the African American community, the University of Alabama at Birmingham School of Public Health and the Housing Association of the Birmingham District convened a virtual town hall. This process of stakeholder engagement underscored the importance of cross-disciplinary expertise and collaboration and of community education and outreach by trusted sources.

Implications of Tennessee's Opioid Legislation for Neonatal Abstinence Syndrome.

Opioid use during pregnancy is on the rise in the United States. Neonatal abstinence syndrome (NAS), also known as newborn drug withdrawal, is a public health epidemic. Between 2004 and 2014, Tennessee experienced a fivefold increase in NAS hospitalizations, from 1.5 to 8.0 per 1,000 live births. Soaring increases in the number of newborns with NAS nationwide have caught the attention of many federal and state lawmakers, especially given the unknown burdens associated with medical and social services needed by those affected over time. Tennessee opioid-related regulations and laws enacted between 2000 and 2018 were systematically reviewed and analyzed to identify each law's purpose; effects on families and individuals; pros and cons in terms of social, practical, and legal factors; and implications for nursing practice. Our findings were that Tennessee's laws are intended to decrease the number of opioids prescribed, ensure access to continued prenatal care and substance abuse management for mothers with substance use disorders, and reduce the ease of obtaining opioids. We also found that Tennessee lawmakers have enacted laws and regulations aimed at decreasing the abuse of opioids, but not reducing the incidence of NAS. As new laws are considered, it is critical that health care providers and lawmakers work together to ensure that the developed and enacted laws strike a balance between safely managing the care of both pregnant women and their newborns without producing negative outcomes.

Mid-level Practitioners in Oral Health: Tennessee Dental Professional's Attitudes and Perceptions of the Dental Therapist Workforce Model.

OBJECTIVES: To determine Tennessee dentists' knowledge and attitudes about the Dental Therapist Workforce Model (DTWM), as one means of expanding access to oral health care. METHODS: We surveyed 1,047 general dentists in Tennessee to determine their attitudes and perceptions of the DTWM. We used descriptive statistics such as frequency distributions for demographic variables. For additional analyses, we used analysis of variance and chi-square. RESULTS: We received 418 completed responses, for a response rate of 40%. While dentists believed they had a responsibility to provide care to the underserved, and that the DTWM would help improve access, the majority had a negative opinion of the impact dental therapists will have on dentistry, in regard to both clinical care quality and patient perceptions of dentists. CONCLUSIONS: This study provides baseline data on the DTWM in Tennessee, and can be a reference for similar states that may begin evaluating the model.

Macro Trends and the Future of Public Health Practice.

Public health practice in the twenty-first century is in a state of significant flux. Several macro trends are impacting the current practice of governmental public health and will likely have effects for many years to come. These macro trends are described as forces of change, which are changes that affect the context in which the community and its public health system operate. This article focuses on seven such forces of change: the Patient Protection and Affordable Care Act, public health agency accreditation, climate change, health in all policies, social media and informatics, demographic transitions, and globalized travel. Following the description of each of these, this article then turns to possible approaches to measuring, tracking, and understanding the impact of these forces of change on public health practice, including the use of evidence-based public health, practice-based research, and policy surveillance.

Do racial inequities in infant mortality correspond to variations in societal conditions? A study of state-level income inequality in the U.S., 1992-2007.

BACKGROUND: Prior studies have examined the association between income inequality and overall infant mortality rates (IMR). We examine effects of income inequality on racial inequities in IMR over the period 1992-2007 in the U.S. METHODS: Race-specific state IMR data were obtained from 1992 to 2007, from which absolute and relative IMR inequities were calculated. Fixed and random effects models, adjusted for state-level median income, percent poverty, percent high school graduates, and unemployment rate, were used to determine contemporaneous and lagged state-level associations between income inequality and racial IMR inequities. RESULTS: Racial IMR inequities varied significantly across the U.S. Contemporaneous income inequality was negatively associated with white IMR only. Two-year lagged income inequality was negatively associated with black IMR and had the most pronounced effect on racial inequities in IMR. DISCUSSION: Future studies should consider lagged effects of income inequality on IMR and other health outcomes, and should examine other potential societal conditions that may account for state-level variations in racial IMR inequities.

Does higher income inequality adversely influence infant mortality rates? Reconciling descriptive patterns and recent research findings.

As the struggle continues to explain the relatively high rates of infant mortality (IMR) exhibited in the United States, a renewed emphasis is being placed on the role of possible 'contextual' determinants. Cross-sectional and short time-series studies have found that higher income inequality is associated with higher IMR at the state level. Yet, descriptively, the longer-term trends in income inequality and in IMR seem to call such results into question. To assess whether, over the period 1990-2007, state-level income inequality is associated with state-level IMR; to examine whether the overall effect of income inequality on IMR over this period varies by state; to test whether the association between income inequality and IMR varies across this time period. IMR data--number of deaths per 1000 live births in a given state and year--were obtained from the U.S. Centers for Disease Control Wonder database. Income inequality was measured using the Gini coefficient, which varies from zero (complete equality) to 100 (complete inequality). Covariates included state-level poverty rate, median income, and proportion of high school graduates. Fixed and random effects regressions were conducted to test hypotheses. Fixed effects models suggested that, overall, during the period 1990-2007, income inequality was inversely associated with IMR (ß = -0.07, SE (0.01)). Random effects models suggested that when the relationship was allowed to vary at the state-level, it remained inverse (ß = -0.05, SE (0.01)). However, an interaction between income inequality and time suggested that, as time increased, the effect of income inequality had an increasingly positive association with total IMR (ß = 0.009, SE (0.002)). The influence of state income inequality on IMR is dependent on time, which may proxy for time-dependent aspects of societal context.

Pediatricians and the Oral Health Needs of Children: One Potential Means for Reducing Oral Healthcare Inequities.

OBJECTIVES: Children in poverty have limited access to oral healthcare. One approach to reduce such health inequities is to expand the involvement of primary care physicians in the provision of oral healthcare. The purpose of this study was to assess pediatricians' knowledge, attitudes, and professional experiences regarding oral health in children, and to determine their willingness to incorporate preventive dental education and procedures into their practices. METHODS: We conducted a survey of pediatricians in Tennessee to assess their knowledge, attitudes, and professional experiences regarding oral health, and to determine their willingness to incorporate preventive dental education and procedures into their practices. RESULTS: Of the 450 providers randomly selected for survey distribution, 107 returned completed surveys (response rate, 23.8%). The majority of respondents reported that they are likely to examine children's teeth during well-child care visits, but only a minority use preventive techniques such as application of fluoride varnish. Pediatricians receive very little education on oral health during medical school and residency programs. CONCLUSIONS: Expanding oral healthcare access through primary care physicians will require adequate training in medical school, residency, and in continuing education courses.

The diffusion of evidence-based decision making among local health department practitioners in the United States.

OBJECTIVES: Evidence-based decision making (EBDM) is the process, in local health departments (LHDs) and other settings, of translating the best available scientific evidence into practice. Local health departments are more likely to be successful if they use evidence-based strategies. However, EBDM and use of evidence-based strategies by LHDs are not widespread. Drawing on diffusion of innovations theory, we sought to understand how LHD directors and program managers perceive the relative advantage, compatibility, simplicity, and testability of EBDM. DESIGN, SETTING, AND PARTICIPANTS: Directors and managers of programs in chronic disease, environmental health, and infectious disease from LHDs nationwide completed a survey including demographic information and questions about diffusion attributes (advantage, compatibility, simplicity, and testability) related to EBDM. Bivariate inferential tests were used to compare responses between directors and managers and to examine associations between participant characteristics and diffusion attributes. RESULTS: Relative advantage and compatibility scores were high for directors and managers, whereas simplicity and testability scores were lower. Although health department directors and managers of programs in chronic disease generally had higher scores than other groups, there were few significant or large differences between directors and managers across the diffusion attributes. Larger jurisdiction population size was associated with higher relative advantage and compatibility scores for both directors and managers. CONCLUSIONS: Overall, directors and managers were in strong agreement on the relative advantage of an LHD using EBDM, with directors in stronger agreement than managers. Perceived relative advantage has been demonstrated to be the most important factor in the rate of innovation adoption, suggesting an opportunity for directors to speed EBDM adoption. However, lower average scores across all groups for simplicity and testability may be hindering EBDM adoption. Recommended strategies for increasing perceived EBDM simplicity and testability are provided.

Capacity building for evidence-based decision making in local health departments: scaling up an effective training approach.

BACKGROUND: There are few studies describing how to scale up effective capacity-building approaches for public health practitioners. This study tested local-level evidence-based decision making (EBDM) capacity-building efforts in four U.S. states (Michigan, North Carolina, Ohio, and Washington) with a quasi-experimental design. METHODS: Partners within the four states delivered a previously established Evidence-Based Public Health (EBPH) training curriculum to local health department (LHD) staff. They worked with the research team to modify the curriculum with local data and examples while remaining attentive to course fidelity. Pre- and post-assessments of course participants (n=82) and an external control group (n=214) measured importance, availability (i.e., how available a skill is when needed, either within the skillset of the respondent or among others in the agency), and gaps in ten EBDM competencies. Simple and multiple linear regression models assessed the differences between pre- and post-assessment scores. Course participants also assessed the impact of the course on their work. RESULTS: Course participants reported greater increases in the availability, and decreases in the gaps, in EBDM competencies at post-test, relative to the control group. In adjusted models, significant differences (p<0.05) were found in 'action planning,' 'evaluation design,' 'communicating research to policymakers,' 'quantifying issues (using descriptive epidemiology),' and 'economic evaluation.' Nearly 45% of participants indicated that EBDM increased within their agency since the training. Course benefits included becoming better leaders and making scientifically informed decisions. CONCLUSIONS: This study demonstrates the potential for improving EBDM capacity among LHD practitioners using a train-the-trainer approach involving diverse partners. This approach allowed for local tailoring of strategies and extended the reach of the EBPH course.

The pattern of association between U.S. economic indicators and infant mortality rates at the state level.

This cross-sectional ecological study examines the pattern of association of state income and income inequality (measured by Gini coefficient) with state infant mortality rates (IMRs) in the U.S. Scatter plots and correlation coefficients were used to examine bivariate associations and bubble plots to examine three-way relationships. Infant mortality rate was positively associated with Gini (R=0.397, p=.004) and negatively with income (R=-0.482, p <.001). However using Black and White IMRs, the associations with Gini were non-significant, but with income remained significant. The bubble plot of Gini versus White IMR (income represented by bubble size) showed increasing IMR as Gini increases and income decreases, except for a subgroup of high-gini, high-income states with low IMRs. State income appears to be a stronger and more consistent predictor of U.S. IMRs for both Black and White races and can explain the pattern of association of White IMR with state Gini coefficient.

Local health departments and the 2008 recession: characteristics of resiliency.

BACKGROUND: The 2008 recession had a significant impact on local health departments (LHDs), with more than half of such agencies experiencing job losses and program cuts. PURPOSE: To identify potential modifiable factors that can protect LHDs from job losses and budget cuts during future economic crises. METHODS: This retrospective cohort study used data from 2005 and 2010 surveys of LHDs. The outcome of interest was financial resiliency for maintaining budgets during the recession and was based on the ratio of observed to predicted expenditures (O/E) per capita for 2010. Logistic regression was used to model the resiliency of the LHD with independent variables grouped around domains of organization, revenues, and services, with stratification by size of the LHD jurisdiction. Data were analyzed in 2013. RESULTS: Of the 987 LHDs in the final data set, 328 (33.2%) were categorized as resilient and 659 (66.8%) as non-resilient. Overall, resilient LHDs received a higher percentage of revenues from non-local sources compared to non-resilient LHDs (p<0.05) and had a more diversified service mix, with significantly (p<0.05) more treatment, population, and regulatory services. In the final regression models, findings differed substantially across the stratifications of LHD jurisdictional population size, with no single independent or control variable significantly associated with resiliency across all population categories. CONCLUSIONS: Funding streams and service mix may be modifiable characteristics, suggesting possible means for LHDs to weather future economic stress; however, these characteristics may be unique to the size of the population served.