The intersection of systems thinking and structural empowerment in the work of public health dietitians.

BACKGROUND: Public health dietitians navigate complex professional landscapes amid dwindling resources, organisational disruptions and limited advancement opportunities. Cultivating systems thinking and structural empowerment competencies may enable this workforce to address multifaceted public health challenges more effectively. This study explored the extent to which public health dietitians apply systems thinking and perceive access to structural empowerment and the relationship between these constructs. METHODS: A quantitative online survey incorporating the systems thinking scale (STS) and conditions for work effectiveness questionnaire-II (CWEQ-II) was conducted among US public health dietitians who worked in governmental public health. Data were collected from September 2022 to October 2022. Descriptive and inferential statistical analyses were conducted. RESULTS: Among 216 respondents, 98% demonstrated moderate-to-high systems thinking competency (mean STS score = 60.3 ± 8.74, range 28-78). Over 88% reported moderate-to-high perceived structural empowerment (mean CWEQ-II score = 18.3 ± 0.96, range 8-29). Higher systems thinking scores were associated with greater decision-making authority (p = 0.01) but not budget oversight. Higher structural empowerment scores correlated with increased job responsibilities and decision-making authority (p < 0.001). A significant positive correlation existed between systems thinking and structural empowerment (r = 0.24, p < 0.001). Public health dietitians exhibited substantial systems thinking capabilities and perceived access to organisational power structures. CONCLUSIONS: This study offers baseline understanding of systems thinking and structural empowerment among public health dietitians. The positive interplay between these constructs underscores their potential to drive systems-level change and influence population health outcomes. Integrating systems thinking and structural empowerment into dietetic education and professional development may enhance the workforce's preparedness for navigating complexities.

Enhancing Adaptability: Exploring Structural Empowerment and Systems Thinking Among State Governmental Public Health Nutritionists.

This study explored how structural empowerment and systems thinking enabled public health nutritionists to adapt to complex environments. Interviews with 14 dietitian-prepared nutritionists from state governmental public health agencies elucidated 3 key themes: leveraging relationships was essential to exercising structural empowerment and systems thinking; accessing resources and support were priorities in supporting public health nutrition initiatives; and addressing gaps in formal training, specific to systems thinking, enabled adaptability to work in public health settings. The findings highlight the need for broader examinations into strengthening access to organizational power structures; integrating systems thinking into public health operations; and sustaining professional development for the public health workforce, especially with limited resources. Enhancing access to organizational power structures and applying systems thinking can empower the public health workforce to better adapt to challenges by building relationships, accessing resources and support, and making informed decisions that positively impact population health.

Understanding critical factors associated with integration of community health workers into health and hospital systems.

Community health worker (CHW) models have been shown to improve health behaviors and health outcomes and reduce cost, particularly among low-income underserved populations. Consequently, health systems are increasingly employing CHWs to provide health services in clinical environments. A growing body of the literature suggests that effective integration of CHWs within the healthcare system is important to achieve the desired outcomes, but the question of how to achieve effective integration is less clear. This study seeks to explore the integration of CHWs within a large state university health system to identify factors critical to the effective integration of CHWs into the clinical care environment. We conducted a qualitative descriptive multiple embedded case study of the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within the UI Health System that currently employ CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. In total, six sub-units were enrolled, and 17 interviews were conducted with CHWs (n = 9), and administrators or healthcare providers (n = 8). Fourteen factors related to effective CHW integration were identified and organized in four categories: individual, team, organization, and community. Findings suggest that in addition to commonly recognized elements of effective CHW models including training, supervision, and the presence of a champion, programs must consider the organizational context in which the program is positioned as well as the ways in which both CHWs and the organization engage with communities served. This research can serve as a roadmap for health systems that seek to integrate CHWs within healthcare services and can be used to promote best practice in CHW integration.

Levers of Change: How to Help Build the Public Health Workforce of the Future.

CONTEXT: Public health leaders are working to rebuild the US public health workforce. Master of Public Health (MPH) programs have a stake in this, given their role in educating and training public health practitioners. Over the last 10 years, MPH programs have implemented changes to program structure, content, and approach, but workforce gaps persist. OBJECTIVE: This study sought to explore the factors that inform and influence MPH program design and changes they make in order to elucidate how MPH programs may be further engaged to help address current and future public health workforce needs. DESIGN: Sequential mixed-methods study. SETTING: US MPH programs accredited by the Council on Education for Public Health (CEPH), and applicants approved to seek accreditation. PARTICIPANTS: In total, 115 representatives representing at least 43% of the 215 accredited/applicant MPH programs in the United States. MAIN OUTCOME MEASURES: Factors that inform and influence programmatic and curricular changes within MPH programs. RESULTS: The shifts that MPH programs have made to program focus and the approaches used to support student competence development are influenced by individual, programmatic, institutional, and national factors, including faculty and staff background, access to resources, program team/faculty culture, access to resources, program placement, university priorities, and national policies. Most influential in catalyzing changes made by MPH programs between 2015 and 2020 were CEPH MPH accreditation standards, feedback from interested parties, learning best practices, university initiatives, and access to resources including funding and faculty. Identified factors served as facilitators and/or as barriers, depending on the context. CONCLUSIONS: There are multiple levers at different levels that may be utilized by national public health leaders, university administrators, and program constituents to effect change within MPH programs, helping them to be even better positioned to help address public health workforce needs of today and tomorrow.

Understanding the relationship between care team perceptions about CHWs and CHW integration within a US health system, a qualitative descriptive multiple embedded case study.

BACKGROUND: Community health workers (CHW) have grown in prominence within the healthcare sector, yet there is no clear consensus regarding a CHW's role, purpose, and value within health systems. This lack of consensus has the potential to affect how CHWs are perceived, utilized, and ultimately integrated within the healthcare sector. This research examines clinical care teams that currently employ CHWs to (1) understand how members of the care team perceive CHWs' purpose and value, and (2) consider how perceptions of CHWs are related to CHW integration within health care teams. METHODS: Researchers conducted a qualitative descriptive multiple embedded case study at the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within UI Health that are currently employing CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. RESULTS: In total, 6 sub-units were enrolled to participate, and 17 interviews were conducted with CHWs (n = 9), and administrators or health care providers (n = 8). Reported perceptions of CHWs were inconsistent across respondents. CHWs roles were not always understood, and the CHW's purpose and value was perceived differently by different members of the care team. Moreover, evaluation metrics did not always capture CHWs' value to the health care system. In some cases, care teams were more aligned around a shared understanding of the CHW's roles and purpose within the care team. When perceptions regarding CHWs were both positive and aligned, respondents reported higher levels of integration within the healthcare system. CONCLUSIONS: Alignment in a care team's perception of a CHW's role, purpose, and value within the health system could play an important role in the integration of CHWs within healthcare teams.

A New Baseline: Master of Public Health Education Shifting to Meet Public Health Needs.

CONTEXT: Schools and programs of public health have been preparing graduates to join the workforce for a century, but significant gaps in numbers and abilities exit. Many have called for a change to the status quo, to transform public health education to create a competent workforce able to address current and emergent needs. OBJECTIVE: This study explored if Master of Public Health (MPH) programs have shifted their program design, curriculum, and/or instructional methods (instructional design), and if so, how and why. DESIGN: A sequential mixed-methods study. SETTING: MPH programs accredited by the Council on Education for Public Health, and approved applicants. PARTICIPANTS: Some 43% of accredited MPH programs in the United States (n = 115) responded to the online survey (open November 21, 2019-December 20, 2019), providing a representative sample. Stratified purposeful sampling was used to select 8 MPH programs for follow-up semistructured interviews. Categorical and qualitative data were analyzed for trends, association, and themes. MAIN OUTCOME MEASURES: Degree of, types of, and reasons for shifts in MPH program instructional design considered and implemented. RESULTS: MPH programs in the United States have shifted their approaches and curriculum to meet identified and emergent workforce needs. In the last 5 years, 81% made changes to program design (focal competencies, admissions, graduation criteria), 88% to curriculum (added or removed courses, changed course content), and 65% to pedagogical methods (where and how learning is supported). CONCLUSIONS: Despite concerns about stagnation, MPH programs have shifted to competency-based education aligned with workforce needs, have adapted approaches to support diversity of future workers, and are focused on bolstering workforce readiness. These changes were made to enhance focus on knowledge acquisition, skills building, and professionalism, factors recognized as critical for success, and facilitate more engaged pedagogical strategies, working with communities for impact.

Results From a National Mixed-Methods Study Exploring Community Health Improvement Implementation: An Opportunity to Strengthen Public Health Systems Through Collective Action.

CONTEXT: There are multiple calls for public health agency role and workforce transformation to increase capacity to orchestrate cross-sectoral partnerships that set and implement strategies addressing the structural and social determinants of health. Mobilizing for Action through Planning and Partnerships (MAPP) may be one tool for collective action to improve population health and equity. However, little is known about the Action Cycle in MAPP and implementation of resulting community health improvement plans. OBJECTIVE: To explore the characteristics of MAPP users who completed the MAPP Action Cycle and factors that facilitated or inhibited implementation activities during this phase. METHODS: We used a sequential participatory mixed-methods design involving 2 phases of data collection. The first data collection phase included a Web-based survey using Qualtrics. The second data collection phase included qualitative key-informant interviews and focus groups. A national public health and health care advisory group informed the evaluation throughout the entire process to ground the process in practice and experience. RESULTS: This study showed that some MAPP participants do not conduct implementation activities as defined by the MAPP Action Cycle and of those who do, implementation activity varies by participant experiences conducting MAPP and accreditation status. The MAPP users who completed 3 or more rounds of MAPP were more likely to align and integrate MAPP within their agencies as well as organize a collaborative implementation process with partners. More resources and skills in planning that facilitate long-range partnerships were noted as key to implementation. CONCLUSIONS: Opportunity remains to improve implementation in MAPP. National leaders should explore and build capacity and infrastructure within public health agencies and with their partners to create a system of readiness and an infrastructure that support implementation over time.

Perceived Benefits of Collaboration Between Local Health Departments and Schools and Programs of Public Health: A Mixed-Methods Study.

OBJECTIVES: Collaboration between local health departments (LHDs) and schools and programs of public health (SPPH) may be a way to improve practice, education, and research. However, little is known about why LHDs and SPPH collaborate. This mixed-methods study addressed this issue by exploring what LHDs and SPPH perceive to be beneficial about their collaboration. METHODS: A mixed-methods study using quantitative and qualitative data was conducted. A survey of 2000 LHDs that completed the 2013 National Profile of LHDs measured how important and effective LHDs perceived 30 indicators of the 10 essential public health services to be for collaboration with SPPH. Focus groups were held with LHD officials and the faculty from SPPH to further explore their perceptions of the mutual benefits of their collaboration. RESULTS: This study showed that LHD officials and the faculty from SPPH valued their collaborative work because it can improve education and training, support public health accreditation, enhance LHD credibility, enhance LHD technological capabilities, and improve research and evidence-based practice. Benefits increased with an increase in the degree of collaboration. This also showed that LHD officials would like to collaborate more closely with SPPH. CONCLUSION: Collaboration between LHDs and SPPH is mutually beneficial, and close collaboration can help transform public health practice, education, and research. In light of this, more attention should be paid to developing goals and objectives for a collaborative agenda. Attention should be paid not only to the immediate needs of the organizations and individuals involved but also to their long-term goals and underlying desires. Funding opportunities to support the development of partnerships between LHDs and SPPH are needed to provide tangible tasks and opportunities for taking a more long-term and strategic view for collaborative relationships.

Master of Public Health Education in the United States Today: Building Leaders of the Future.

OBJECTIVES: For decades, there have been calls to action to change the status quo of public health education in the United States to respond to workforce needs and help reinforce capacity. During the last 10 years, schools and programs of public health have planned and implemented programmatic and curricular changes. This study explored the focus of master of public health (MPH) education in the United States today. METHODS: We used a 3-phase mixed-methods study to compile data to describe the current state and focus of MPH education in the United States via survey data collection (November-December 2019), semistructured interviews (January-February 2020), and document reviews. RESULTS: Survey responses represented at least 43% (93/215) of eligible MPH programs in the United States. Most respondents (86%, 99/115) reported that the primary focus of MPH education in the United States is to prepare graduates for public health practice and employment linked to public health, and 54% (59/109) reported that their MPH programs adopted this focus in the last 5 years. MPH programs invested in student learning, competence development, and supporting workforce readiness, including a focus on leadership abilities. Programs noted that they seek to develop strategic thinkers and engaged leaders with abilities to understand and address emergent public health needs. CONCLUSIONS: Public health education in the United States is in a period of change. MPH programs reported responding to workforce needs by closing gaps in workforce capacity and developing compassionate and professional leaders who can understand needs, collaborating with communities, and facilitating action that will ameliorate health disparities and promote social injustice by practicing public health in new ways.

Appreciative inquiry and the co-creation of an evaluation framework for Extension for Community Healthcare Outcomes (ECHO) implementation: a two-country experience.

Persistent gaps exist in healthcare workers' capacity to address HIV and tuberculosis in Asia and Africa due to constraints in resources and knowledge. Project ECHO (Extension for Community Healthcare Outcomes) leverages video-enabled technology to build workforce capacity and promote collaboration through mentorship and case-based learning. To understand current perceptions of ECHO participants and develop a comprehensive evaluation framework for ECHO implementation, we utilized modified appreciative inquiry guided focus group discussions (FGD) in India and Tanzania and called it SCORE (Strengths, Challenges, Opportunities, Results, and Evaluation). Content and thematic analysis of transcripts from FGDs and key-informant interviews triangulated perceptions of diverse stakeholders about ECHO implementation and identified key elements for development of the framework. The perceived strengths (S) were capacity building and establishing communities of practice. The perceived challenges (C) included securing resources, engaging leadership, and building systems for monitoring impact. Improved internet connectivity, addressing logistical challenges, encouraging session interactivity, and having strategic scale-up plans were perceived opportunities (O). Additionally, gathering measurable results (R) led to development of a comprehensive evaluation (E) framework. Contextualizing and facilitating SCORE with qualitative analysis of findings 6-12 months post-ECHO implementation may serve as a best practice to assess mid-course corrections to improve ECHO implementation quality.

Framing the Integration of Community Health Workers Into Health Care Systems Along Health Care and Community Spectrums.

Research calls for community health worker (CHW) integration within health systems, yet there is no agreement regarding what CHW integration is or guidance for how it can be achieved. This study examines factors associated with CHW integration in community and health care settings using a qualitative descriptive multiple-embedded case study of CHW teams at the University of Illinois at Chicago. Data were collected via semistructured interviews/document review and analyzed using thematic coding and quantitative content analysis. Factors associated with higher clinical integration included culture, communication, protocols, and training while higher community integration was associated with accessibility, relationships, and empathy.

A Protocol for a Comprehensive Monitoring and Evaluation Framework With a Compendium of Tools to Assess Quality of Project ECHO (Extension for Community Healthcare Outcomes) Implementation Using Mixed Methods, Developmental Evaluation Design.

Introduction: The United States Centers for Disease Control and Prevention (CDC), through U.S. President's Emergency Plan for AIDS Relief (PEPFAR), supports a third of all people receiving HIV care globally. CDC works with local partners to improve methods to find, treat, and prevent HIV and tuberculosis. However, a shortage of trained medical professionals has impeded efforts to control the HIV epidemic in Sub-Saharan Africa and Asia. The Project Extension for Community Healthcare Outcomes (ECHOTM) model expands capacity to manage complex diseases, share knowledge, disseminate best practices, and build communities of practice. This manuscript describes a practical protocol for an evaluation framework and toolkit to assess ECHO implementation. Methods and Analysis: This mixed methods, developmental evaluation design uses an appreciative inquiry approach, and includes a survey, focus group discussion, semi-structured key informant interviews, and readiness assessments. In addition, ECHO session content will be objectively reviewed for accuracy, content validity, delivery, appropriateness, and consistency with current guidelines. Finally, we offer a mechanism to triangulate data sources to assess acceptability and feasibility of the evaluation framework and compendium of monitoring and evaluation tools. Expected impact of the study on public health: This protocol offers a unique approach to engage diverse group of stakeholders using an appreciative inquiry process to co-create a comprehensive evaluation framework and a compendium of assessment tools. This evaluation framework utilizes mixed methods (quantitative and qualitative data collection tools), was pilot tested in Tanzania, and has the potential for contextualized use in other countries who plan to evaluate their Project ECHO implementation.