'We are suffering. Nothing is changing.' Black mother's experiences, communication, and support in the neonatal intensive care unit in the United States: A Qualitative Study.

OBJECTIVES: Black mothers experience markedly disproportionate maternal morbidity and mortality in the United States, with racism often cited as the root cause manifesting through several pathways. The study examined Black mothers' perceived provider communication, support needs, and overall experiences in the neonatal intensive care unit (NICU). DESIGN: This study used grounded theory embedded in the Black feminist theoretical (BFT) framework to generate new ideas grounded in the data. Data was collected through semi-structured interviews using videoconferencing, with questions related to the mother's overall NICU experiences, communication within the NICU, and perceived support needs. Data were analyzed using thematic analysis. RESULTS: Twelve mothers participated in the study; most were married (n = 10), had a cesarean birth, had a previous pregnancy complication (e.g., diabetes, hypertension), had attained a graduate degree or more (n = 9), earned an annual household income of $75,000 or more, and were between 35-44 years of age (n = 7). Three broad domains with several accompanying themes and sub-themes were identified, explicating the mother's experiences in the NICU. Specifically, factors influencing NICU hospitalization for mothers included maternal care/nursing experiences, interactions in the NICU, and the perceived support need that might attenuate negative care and birthing experiences. . CONCLUSION: The study adds to the growing literature championing Black maternal health equity and multilevel quality improvement strategies to foster equitable maternal health. Our study reinforces the need for racially congruent interventions and policy reformations to protect Black birthing people regardless of socioeconomic factors and social class using life course, holistic approaches, and intersectionality mindset. Importantly, using the BFT, this study calls for culturally sensitive research to capture the nuances associated with the multiplicity of experiences of Black people.

Insights From a Community-Based Strategy to Assess Tobacco and Vape Shop Retailers' Implementation of Tobacco 21 Law in El Paso, Texas.

In 2019, the United States Congress passed Tobacco 21 (T21) legislation that raised the minimum legal sales age for tobacco products from 18 to 21. However, although the federal legislation superseded weaker state laws that were already in place in some states, including Texas, local guidance for retailers was inconsistent. Given that retailers are ultimately responsible for policy implementation, the American Heart Association (AHA) initiated a process of assessing retailers knowledge and perceptions of the law through a survey targeting all tobacco retailers and accompanying ethnography of a subset of vape shops in El Paso, Texas. The process yielded lessons learned for assessment of community-based policy implementation including key considerations for personnel and process that are applicable to other community-based assessment processes. While AHA considered an in-person approach ideal, having an alternate online response option was necessary. In addition, a focused approach and in-depth understanding of the purpose was key to responsiveness of the retailers.

Systems-Level Evaluation of Safe Routes to School Policies in El Paso, Texas: A Modeling Study on Health and Economic Outcomes.

Safe Routes to School (SRTS) policies are linked to physical health benefits for school-age children; however, few studies have assessed long-term impacts on cardiovascular disease (CVD). This study used systems science methods to predict long-term health and economic impact of SRTS among school-age children in El Paso County, Texas. We developed an agent-based model containing 2 modules: the pedestrian injury module and the CVD module. We simulated 10 000 school-age children under 2 scenarios-SRTS policies implemented and no SRTS policies implemented-and then calculated pedestrian injuries, pedestrian injury-related deaths, coronary heart disease (CHD) and stroke events, and health care costs. When SRTS policies were implemented, the model estimated 157 fewer CHD cases and 217 fewer stroke cases per 10 000 people and reduced CVD-related health care costs ($13 788 per person). The model also predicted 129 fewer pedestrian injuries and 1.3 injury-related deaths per 10 000 people and $2417 savings in injury-related health care costs. SRTS could save an estimated $16 205 per person in health care costs. This simulation shows SRTS in El Paso County could prevent pedestrian injuries among school-age children and protect cardiovascular health in the long term. Our findings provide evidence for practitioners and policy makers to advocate for SRTS policies at the local level.

The Development of a Systems-Level Approach to Address Adolescent Access to Health Care: A Novel Confidentiality Policy Intervention.

Most evidence-based interventions in adolescent sexual and reproductive health and mental health remain largely aimed at individual-level outcomes and do not conceptualize adolescent health within a social-ecological model. Interventions to affect policy, systems, and environmental change offer potential for sustained population impact. The current initiative used an innovation framework to develop a novel systems-level approach to address adolescent access to health care. The Framework for Public Health Innovation provided an approach to develop a novel intervention. Confident Teen is a systems-level intervention that creates the opportunity, through organizational policy change, to increase adolescents' access to confidential sexual and reproductive health services through organizational policies. Gaps in adolescents' access to health care services allowed for a systems-level approach to be designed through an adolescent pregnancy prevention innovation initiative. Confidentiality is a right and critical component to their health care; therefore, a policy and conversation between provider and patient is a prioritized component of the novel intervention.

Addressing Evaluation Barriers with Early Innovation Development for Adolescent-Focused Sexual and Reproductive Health Interventions.

Most evidence-based teen pregnancy prevention programs focus on individual-level sexual health outcomes (e.g., STIs, pregnancy, teen births). To expand program and intervention approaches within teen pregnancy prevention (TPP), the Department of Health and Human Services funded two grantees, Innovative Teen Pregnancy Prevention Programs (iTP3) and Innovation Next (IN) to support and enable early innovation to advance adolescent health and prevent teen pregnancy. The pipeline to support and enable innovation in adolescent health is complex, resulting in barriers and challenges to research and evaluation of novel programs. This paper presents some of the barriers encountered by the grantees. Data for this paper was collected from key personnel and secondary data sources. Focus group participants included seven representatives (n = 7) across the two organizations. Focus group questions assessed barriers related to innovative intervention development and evaluation. Key findings include four barriers to evaluation when fostering innovative adolescent-focused pregnancy prevention interventions. These included (a) funding constraints on evaluation activities, (b) innovation readiness for rigorous testing, (c) evaluation knowledge and expertise on innovation-development teams, and (d) challenges with evaluation requirements. Novel and promising system- and technology-focused interventions with the potential to impact TPP require alternative tools and approaches for evaluation. This would allow research to focus on how systems-level change mechanisms (i.e., policy, access to care) impact sexual risk behaviors and better understand ecological and social determinants of health for the priority population. The advancement of approaches to impact adolescent health identifies the need to expand the focus of evidence-based interventions beyond the adolescent themselves and understand approaches that impact external contexts and environments related to reducing sexual and reproductive health (SRH) risk-taking.

Assessment of Action Plans as a Guide for Equity-Focused Coalition Work.

Collaborative capacity within coalitions is required to promote healthy communities and create systemic change. The purpose of this study was to evaluate the quality of three Tobacco Prevention and Control Coalitions' action plans for their likely ability to address health equity through tobacco cessation efforts. To do this, the Butterfoss State Plan Index was adapted for relevance to community-oriented coalitions, with a focus on health disparities and tobacco control. This study compares three tobacco control coalitions in Texas to quantify their efforts on addressing health disparities through a standardized measurement process. The results of this assessment indicate that there are gaps in existing coalition assessment tools, and action plan norms and requirements, specifically as it pertains to addressing health disparities in a systematic way. Through a systematic analysis of coalition action plans and supporting documents, it is clear that there is a need for more standard inclusion of disparities-focused work within action plans. Community health researchers, coalition members, and coalition funders should consider action plans to be living, iterative documents that are subject to adjustments. Systems-thinking perspective should be used to develop action plans adapted to environmental, community, policy, and other changes. Lessons learned from this study can provide an example of how to incorporate strategies for reducing health disparities within coalition action planning.

Implementation evaluation of a collective impact initiative to promote adolescent health in Oklahoma County, USA.

BACKGROUND: The teenage birth rate in the USA has considerably decreased in recent decades; however, more innovative, collaborative approaches are needed to promote adolescent health and prevent teenage pregnancy at the community level. Despite literature on the promising results of the collective impact (CI) model for health promotion, there is limited literature on the model's ability to reduce teenage pregnancies in a community. The Central Oklahoma Teen Pregnancy Prevention Collaboration is applying the CI model to foster collaboration among multiple stakeholders with the goal of increasing community and organizational capacity to improve adolescent health outcomes. This paper reports the findings from the initiative's implementation evaluation, which sought to understand whether the CI model improved collaboration among organizations and understand barriers and facilitators that affected program delivery. METHODS: Program implementers and evaluators jointly developed research questions to guide the intervention and evaluation design. The Consolidated Framework for Implementation Research (CFIR) was used to assess program components including the intervention characteristics, organization setting, community setting, facilitator characteristics, and the process of implementation. Primary sources of data included performance measures, meeting observations (n = 11), and semi-structured interviews (n = 10). The data was thematically analyzed using CFIR constructs, community capacity domains, and the five constructs of CI. RESULTS: Key findings include the need for shortened meeting times for meaningful engagement, opportunities for organizations to take on more active roles in the Collaboration, and enhanced community context expertise (i.e., those with lived experience) in all Collaboration initiatives. We identified additional elements to the core constructs of CI that are necessary for successful implementation: distinct role identification for partner organizations and incorporation of equity and inclusivity into collaboration processes and procedures. CONCLUSIONS: Results from this implementation evaluation provide valuable insights into implementation fidelity, participant experience, and implementation reach of an innovative, systems-level program. Findings demonstrate the context and requirements needed to successfully implement this innovative program approach and CI overall. Additional core elements for CI are identified and contribute to the growing body of literature on successful CI initiatives.

Network analysis of a community-wide teenage pregnancy prevention initiative.

Although US teenage birth rates substantially decreased over the past two decades, it still remains the highest in the developed world. More innovative, community-wide initiatives are needed to combat the issue. In Oklahoma County, Oklahoma, the Central Oklahoma Teen Pregnancy Prevention Collaboration is utilizing the collective impact model to convene multiple organizations with the goal of making systems-level changes related to teenage pregnancy within the community. This study used an interorganizational network analysis to evaluate the current strength of relationships between organizations in the Collaboration. An interorganizational network survey assessed collaborative relationships (e.g. information sharing and joint planning) within the network. Using R software, network diagrams were developed to depict partner relationships, and network measures, including node-, group- and network-level measures, were calculated. The network depiction (n = 23) revealed that the network core was composed of organizations from multiple sectors, and the backbone organization served as the most central organization for most centrality measures. This study provides insight into how organizational relationships can be assessed in order to increase community capacity to address teenage pregnancy. Continuous monitoring of the strength of relationships is important to ensure success in achieving goals as well as collective impact.

Delivering Tobacco Cessation Through Community Health Workers: Curriculum and Training Considerations.

Texas faces unique barriers in health status and risk behaviors such as smoking. To address tobacco use, community health workers (CHWs) are a resource for disseminating education among a population. To promote smoking cessation in Texas, there is a need for the development of a smoking cessation training program for CHWs. The National Community Health Worker Training Center used an approach with CHWs to develop a curriculum. From the curriculum development and with feedback from CHWs, 4 training courses were produced: online and in person, and in English and Spanish. The curriculum meets a need that disseminates smoking cessation strategies through peer-led, culturally relevant messages.

Ecological Approaches to Teen Pregnancy Prevention: An Examination of Evidence-Based Interventions.

Over the past 20 years, teenage birth rates in the United States have declined substantially but continue to persist among certain populations. During this time period, a series of rigorously tested teen pregnancy prevention (TPP) programs were developed, and a number of evidence-based interventions (EBIs) emerged. In April 2017, researchers reviewed EBIs in TPP and examined each program's socioecological levels of intervention, measurements approaches, and other ecological aspects. Findings indicate that the majority of TPP EBIs are aimed at the individual and/or interpersonal level of intervention. Furthermore, the programs were evaluated using the individual as the unit of analysis, regardless of what level the EBI targets. These findings represent serious gaps, specifically a lack of system-, environmental-, and policy-level EBIs. Future TP approaches should target multiple levels of social ecology, ensure measurements appropriately capture changes within these levels, and shift to a focus on a longer term population health improvement.

Critical Reflexivity of Communities on Their Experience to Improve Population Health.

Although community capacity has been prominent in the public health literature for nearly 20 years, the field has only operationalized a few dimensions. An intriguing dimension of capacity is a community's ability to critically reflect. On the basis of previous research as well as theoretical and practical insights from management and organizational learning literature, we offer a process framework for critical reflexivity practice in community. The framework draws on ideas regarding cognition and agency, praxis, as well as the transformative learning model to conceptualize how reflexivity happens as an emergent community process. The implication is that reflexivity is a community-level process of making meaning of experiences that drive a common narrative. Inclusivity and establishing consensus are paramount, and can be difficult in light of power dynamics and consideration of dissenting voices and different experiences; enlightened self-interest and creating conducive spaces for dialogue are key in this process. Strengthening communities' ability to gain and employ collective wisdom from their experience will also build their overall capacity for population health improvement.

Qualitative Analysis of Partnerships' Effect on Implementation of a Nationally Led Community-Based Initiative.

INTRODUCTION: The American Heart Association (AHA) was funded to implement a nationally led initiative to implement policy, systems, and environment (PSE) interventions in communities across the United States. In Cohort 1, 15 communities were tasked with working with local community partners to plan and implement initiatives. METHOD: Engaged as the evaluators, Texas A&M researchers conducted telephone interviews with project managers (employed by AHA) and community partners representing the 15 communities. Interviewees were asked questions pertaining to partnership planning and involvement in initiatives and overall perceptions of the impact of the program. Interviews were analyzed qualitatively using the Consolidated Framework for Implementation Research as the guiding framework. RESULTS: Thematic analysis revealed that partners were used in planning and implementing initiatives and felt that initiatives were successful in building community engagement. Some noted success in PSE changes, although this was not a major focus of respondents, regardless of it being a main indicator for the funder. DISCUSSION: Themes reveal several recommendations for those embarking on community-level work. Those recommendations include (1) build on existing priorities, (2) focus on incremental steps that build toward the bigger goal, (3) use national organizations to move more quickly, and (4) leverage resources through collaborative efforts.

Evaluation of Community-Based Policy, Systems, and Environment Interventions Targeting the Vending Machines.

The American Heart Association conducted policy, systems, and environmental (PSE) focused interventions to increase healthy vending in 8 communities. PSE interventions were assessed using the Nutrition Environment Measures Survey Vending Assessment to see changes in the food environment. Baseline and follow-up assessments were conducted with 3 settings and a total of 19 machines. PSE changes resulted in increased availability of healthy options and decreased unhealthy options. Implementation of PSE interventions targeting the food environment can be an effective method of providing increased access to healthy foods and beverages with the goal of increasing consumption to decrease chronic diseases.

Using a Community Health Development Framework to Increase Community Capacity: A Multiple Case Study.

The Physical Activity and Community Engagement Project utilized a comparative case study to understand how a theoretical framework called community health development (CHD) influences community capacity. Three rural communities (cases) developed interventions using a CHD framework. Researchers collected qualitative evidence measuring capacity and the CHD process for more than 3 years. Patterns identified seven capacity constructs relevant to CHD, including community history, civic participation, leadership, skills, resources, social and interorganizational networks, and critical reflection. Community health development focuses on population health improvement and strengthening community capacity. As such, it helps communities address local priorities and equips them to address future issues.

Using Community-Based Participatory Research to Disseminate a Mass Media Campaign Into Rural Communities.

The authors present the results of a media documentary, Weight of the Nation, disseminated in rural communities in the Brazos Valley region of east central Texas. Researchers relied on a community-based participatory research strategy to assure community participation in the implementation and evaluation of the media documentary in rural communities. To measure the short-term effects of the documentary, the research team used a mixed-methods approach of quantitative panel data from a pre/post survey, qualitative meeting notes, and observations from facilitated discussion groups. Results showed short-term increases in behavioral intention, as well as an increase in self and collective efficacy of participants to make healthy changes at individual and community levels to reduce obesity. The findings suggest that Weight of the Nation is a catalyst for increasing awareness about obesity and initiating changes in intention and efficacy perceptions.

Evaluating Policy, Systems, and Environmental Change Interventions: Lessons Learned From CDC's Prevention Research Centers.

INTRODUCTION: The field of public health is increasingly implementing initiatives intended to make policies, systems, and environments (PSEs) more supportive of healthy behaviors, even though the evidence for many of these strategies is only emerging. Our objective was 3-fold: 1) to describe evaluations of PSE-change programs in which the evaluators followed the steps of the Centers for Disease Control and Prevention's (CDC's) Framework for Program Evaluation in Public Health, 2) to share the resulting lessons learned, and 3) to assist future evaluators of PSE-change programs with their evaluation design decisions. METHODS: Seven Prevention Research Centers (PRCs) applied CDC's framework to evaluate their own PSE-change initiatives. The PRCs followed each step of the framework: 1) engage stakeholders, 2) describe program, 3) focus evaluation design, 4) gather credible evidence, 5) justify conclusions, and 6) ensure use and share lessons learned. RESULTS: Evaluation stakeholders represented a range of sectors, including public health departments, partner organizations, and community members. Public health departments were the primary stakeholders for 4 of the 7 evaluations. Four PRCs used logic models to describe the initiatives being evaluated. Their evaluations typically included both process and outcome questions and used mixed methods. Evaluation findings most commonly focused on contextual factors influencing change (process) and the adoption or implementation of PSE-change strategies (outcome). Evaluators shared lessons learned through various channels to reach local stakeholders and broader public health audiences. CONCLUSION: Framework for Program Evaluation in Public Health is applicable to evaluations of PSE-change initiatives. Using this framework to guide such evaluations builds practice-based evidence for strategies that are increasingly being used to promote healthful behaviors.

Evaluation of a multi-site health services psychology training program for telehealth and integrated behavioral health.

Introduction: Training future providers in telehealth and integrated care models can improve access and outcomes, especially among rural and underserved populations. The (blinded) project implemented behavioral health training for health service psychology doctoral students with three partner organizations. Trainees received both experiential and didactic training in telehealth and integrated behavioral health. Telehealth was utilized for remote warm hand-offs, hybrid shared appointments, therapy sessions, coordination with providers, and supervision. Program elements included opportunities for consultations with experts in other disciplines, supportive mentorship, exposure to various parts of a healthcare system, and interactions with diverse clients. Methods: The (blinded) training program evaluated trainee outcomes using fourteen interviews and three focus groups. Interviews and focus groups examined aspects of the program that contributed to trainees' knowledge, skills, and attitudes. Results: Evaluation results revealed increased levels of trainee confidence, autonomy and independence. Training reportedly enabled improved ability to collaborate and communicate with other professions, increased flexibility and adaptability, and openness to others' ideas. Trainees reported the program's use of telehealth enhanced awareness of their own skills and team members' perspectives of technology in care delivery. Discussion: Descriptions of the three care models, lessons learned, and qualitative results about trainee outcomes can be translated into best practices for workforce development and enhance psychology trainees' self-awareness and ability to incorporate others' viewpoints about technology and treatment approaches into healthcare.