Using National Public Health Accreditation to Explore Quality Improvement and Performance Management in Small Local Health Departments.

CONTEXT: This article focuses on 4 small local health departments (LHDs) that were in the process of seeking Public Health Accreditation Board (PHAB) reaccreditation or Pathways Recognition using PHAB Standards & Measures Version 2022. OBJECTIVE: The objective of this study was to explore the experiences of 4 small LHDs related to Quality Improvement (QI) and Performance Management (PM) in their pursuit of PHAB reaccreditation or Pathways Recognition. DESIGN: A team of researchers conducted 22 qualitative interviews with health department leaders and staff. Findings relative to QI/PM represent an embedded case study since they were part of a larger investigation. SETTING: The research team conducted interviews remotely with health departments located in the West and Midwest. PARTICIPANTS: Participants included adults at least 18 years old and employed in 1 of 4 health departments. MAIN OUTCOME MEASURES: Emergent themes from this qualitative investigation included using QI/PM tracking systems, building staff buy-in for QI/PM, integrating QI/PM into daily work, and advice for other health departments regarding QI/PM. RESULTS: Participants suggested that tracking systems helped them manage QI/PM processes. Staff buy-in for QI/PM was strengthened by building a sense of ownership of the process and connecting improvement processes to outcomes. Health departments integrated QI/PM into daily work by leadership modeling and communicating expectations. Advice for other health departments included finding a QI system that was easy to follow and recognizing the role of QI/PM in improving performance to better support the wellbeing of the community. CONCLUSIONS: QI/PM are important tools for health department effectiveness. Participants affirmed that the primary purposes of QI/PM are to enhance internal processes and improve community health outcomes. Study findings demonstrate how 4 small health departments integrated QI/PM into their public health practice.

Equipping the Public Health Workforce of the Future: Evaluation of an Evidence-Based Public Health Training Delivered Through Academic-Health Department Partnerships.

OBJECTIVE: Maintaining a skilled public health workforce is essential but challenging given high turnover and that few staff hold a public health degree. Situating workforce development within existing structures leverages the strengths of different organizations and can build relationships to address public health challenges and health equity. We implemented and evaluated an innovative, sustainable model to deliver an established evidence-based public health (EBPH) training collaboratively among Prevention Research Centers (PRC), local and state health departments, and Public Health Training Centers (PHTC). DESIGN: Quantitative data: quasi-experimental, 1-group pre-post. Qualitative data: cross-sectional. Data were collected between December 2021 and August 2022. SETTING: Four US sites, each a partnership between a PRC, local or state health department, and a PHTC. PARTICIPANTS: Governmental public health staff and representatives from other organizations that implement public health programs in practice settings. MAIN OUTCOME MEASURES: Course participants completed a pre- and postcourse survey self-rating 14 skills on a 5-point Likert scale. Differences were analyzed using mixed effects linear models. In-depth interviews (n = 15) were conducted with course faculty and partners to understand: (1) resources contributed, (2) barriers and facilitators, (3) benefits and challenges, and (4) resources needed to sustain this model. Interviews were transcribed verbatim, and a thematic analysis identified themes. RESULTS: Statistically significant increases in all skills were observed from pre- to postcourse (n = 241 at post, 90% response). The skills with the largest increases were understanding economic evaluation enough to inform decision-making (mean change = 1.22, standard error [SE] = 0.05) and developing an action plan (mean change = 1.07, SE = 0.07). Facilitators to delivering the course included having a shared goal of workforce development, existing course curricula, and dedicated funding for delivering the course. CONCLUSIONS: Collaborative delivery of the EBPH training can ameliorate the effects of high staff turnover, strengthen academic-practice relationships, and promote population-wide health and health equity.

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.

Understanding Misimplementation in U.S. State Health Departments: An Agent-Based Model.

INTRODUCTION: The research goal of this study is to explore why misimplementation occurs in public health agencies and how it can be reduced. Misimplementation is ending effective activities prematurely or continuing ineffective ones, which contributes to wasted resources and suboptimal health outcomes. METHODS: The study team created an agent-based model that represents how information flow, filtered through organizational structure, capacity, culture, and leadership priorities, shapes continuation decisions. This agent-based model used survey data and interviews with state health department personnel across the U.S. between 2014 and 2020; model design and analyses were conducted with substantial input from stakeholders between 2019 and 2021. The model was used experimentally to identify potential approaches for reducing misimplementation. RESULTS: Simulations showed that increasing either organizational evidence-based decision-making capacity or information sharing could reduce misimplementation. Shifting leadership priorities to emphasize effectiveness resulted in the largest reduction, whereas organizational restructuring did not reduce misimplementation. CONCLUSIONS: The model identifies for the first time a specific set of factors and dynamic pathways most likely driving misimplementation and suggests a number of actionable strategies for reducing it. Priorities for training the public health workforce include evidence-based decision making and effective communication. Organizations will also benefit from an intentional shift in leadership decision-making processes. On the basis of this initial, successful application of agent-based model to misimplementation, this work provides a framework for further analyses.

COVID-19 Vaccine Knowledge, Attitudes, and Practices in Alabama: The Case for Primary Health Care Providers.

OBJECTIVE: To examine knowledge, attitudes, and practices about COVID-19 in Alabama, with a primary focus on vaccination perception and utilization. DESIGN: We used a COVID-19 Knowledge, Attitudes, and Practices survey and recruited adult Alabama residents in April-May 2021. PARTICIPANTS: Initial surveys from 1324 Alabamian participants were considered for analysis; after careful review of incomplete responses, 953 were ultimately included for analysis. MAIN OUTCOME MEASURE: Vaccine behavior and hesitancy comprise a self-reported response contained in the survey instrument. Three primary vaccine groups were used to assess differences in demographic characteristics, health status, perception of susceptibility and severity of COVID-19, sources of information, and trust about COVID-19. RESULTS: Of the 953 survey participants included for analysis, 951 had self-identified vaccine status in which 153 (16.1%) reported to have received the vaccine at the time of the survey, 375 (39.4%) were very likely or somewhat likely to get an approved COVID-19 vaccine if it was offered, and 423 (44.5%) were somewhat unlikely or very unlikely to get an approved COVID-19 vaccine. Health care providers were the most trusted sources of information, regardless of vaccine status. For participants unlikely to receive a vaccine, social media and local news sources were consistently more trusted and utilized than those who were vaccinated or were likely to be. CONCLUSIONS: The perceptions among unvaccinated participants are actionable and provide teachable opportunities to decrease vaccine apprehension.

Exploring the Preliminary Steps of One County Health Department to Manage the COVID-19 Pandemic.

This case study describes how one county health department in Alabama used the best available evidence to address the needs of its citizens during the first 6 months of the COVID-19 pandemic. The authors explore issues of scope of authority by government officials, individual freedom versus population health, and challenges of health communication during a disease outbreak. Despite the availability of vaccines, boosters, and access to vaccines by children as young as 5 years, COVID-19 cases are on the rise across the United States more than 2 years after the official news broke out of Wuhan, China. Health officials have expressed concerns that backlash against governmental public health during the pandemic will limit public health authorities from responding to the traditional challenges that were present pre-COVID-19 and will remain in a post-COVID-19 world.

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.

Comparing the COVID-19 Responses in Cuba and the United States.

The purpose of this analytic essay is to contrast the COVID-19 responses in Cuba and the United States, and to understand the differences in outcomes between the 2 nations. With fundamental differences in health systems structure and organization, as well as in political philosophy and culture, it is not surprising that there are major differences in outcomes. The more coordinated, comprehensive response to COVID-19 in Cuba has resulted in significantly better outcomes compared with the United States. Through July 15, 2021, the US cumulative case rate is more than 4 times higher than Cuba's, while the death rate and excess death rate are both approximately 12 times higher in the United States. In addition to the large differences in cumulative case and death rates between United States and Cuba, the COVID-19 pandemic has unmasked serious underlying health inequities in the United States. The vaccine rollout presents its own set of challenges for both countries, and future studies can examine the comparative successes to identify effective strategies for distribution and administration. (Am J Public Health. 2021;111(12):2186-2193. https://doi.org/10.2105/AJPH.2021.306526).

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

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