Leveraging Social and Structural Determinants of Health at the Centers for Disease Control and Prevention: A Systems-Level Opportunity to Improve Public Health.

CONTEXT: Social and structural determinants of health (SDOH) have become part of the public health and health care landscape. The need to address SDOH is reinforced by morbidity and mortality trends, including a recent multiyear decrease in life expectancy and persistent health disparities. Leadership on SDOH-related efforts has come from public health, health care, private philanthropy, and nongovernmental entities. STRATEGY: The Centers for Disease Control and Prevention (CDC) has been addressing SDOH through both disease- or condition-specific programs and crosscutting offices. Guidance from public health partners in the field has led the CDC to consider more strategic approaches to incorporating SDOH into public health activities. IMPLEMENTATION: The CDC's crosscutting SDOH Workgroup responded to external recommendations to develop a specific vision and plan that aims to integrate SDOH into the agency's infrastructure. The group also sponsors CDC forums for sharing research and trainings on embedding SDOH in programs. The group created a Web site to centralize CDC SDOH research, data sources, practice tools, programs, and policies. PROGRESS: The CDC has shown strong leadership in prioritizing SDOH in recent years. Individual programs and crosscutting offices have developed various models aimed at ensuring that public health research and practice address SDOH. DISCUSSION: Building sustainable SDOH infrastructures in public health institutions that reach across multiple health topics and non-health organizations could increase chances of meeting public health morbidity and mortality reduction goals, including decreasing health disparities. Although public health priorities and socioeconomic trends will change over time, experience suggests that social and structural factors will continue to influence the public's health. The CDC and state, tribal, local, and territorial public health institutions have played important leadership roles in the system of community and service organizations that interface with communities they mutually serve to address SDOH. Continued capacity-building could help grow and sustain an SDOH infrastructure that advances this work.

The Critical Role of State Agencies in the Age of Evidence-Based Approaches: The Challenge of New Expectations.

Evidence-based approaches only benefit individuals when fully and effectively implemented. Since funding and monitoring alone will not ensure the full and effective implementation of effective strategies, state agencies have the opportunity to assess and modify current roles, functions, and policies to align with the requirements of evidence-based strategies. Based on a growing body of knowledge to guide effective implementation processes, state agencies, or designated partner organizations, can develop the capacity, mechanisms, and infrastructure to effectively implement evidence-based strategies. This article describes a framework that can guide this process. Informed by the literature and shaped by "real-world experience," the Active Implementation Frameworks provide a stage-matched approach to purposeful, active, and effective implementation.

When evidence is not enough: the challenge of implementing fall prevention strategies.

PROBLEM: As the evidence-based movement has advanced in public health, changes in public health practices have lagged far behind creating a science to service gap. For example, science has produced effective falls prevention interventions for older adults. It now is clearer WHAT needs to be done to reduce injury and death related to falls. However, issues have arisen regarding HOW to assure the full and effective uses of evidence-based programs in practice. SUMMARY: Lessons learned from the science and practice of implementation provide guidance for how to change practices by developing new competencies, how to change organizations to support evidence-based practices, and how to change public health systems to align system functions with desired practices. The combination of practice, organization, and system change likely will produce the public health benefits that are the promise of evidence-based falls prevention interventions. IMPACT ON PUBLIC HEALTH: For the past several decades, the emphasis has been solely on evidence-based interventions. Public health will benefit from giving equal emphasis to evidence-based implementation. IMPACT ON INDUSTRY: We now have over two decades of research on the effectiveness of fall prevention interventions. The quality of this research is judged by a number of credible international organizations, including the Cochrane Collaboration (http://www.cochrane.org/), the American and British Geriatrics Societies, and the Campbell Collaboration (http://www.campbellcollaboration.org/). These international bodies were formed to ponder and answer questions related to the quality and relevance of research. These developments are a good first step. However, while knowing WHAT to do (an evidence-based intervention) is critical, we also need to know HOW to effectively implement the evidence. Implementation, organization change, and system change methods produce the conditions that allow and support the full and effective use of evidence-based interventions. It is time to focus on utilization of implementation knowledge in public health. Without this focus the vast amount on new evidence being generated on the prevention of falls and related injuries among older adults will have little impact on their health and safety.

Women's reactions to HPV diagnosis: insights from in-depth interviews.

Research links certain types of the human papillomavirus (HPV) to subsequent development of cervical cancer. Women (n=52) recently diagnosed with HPV following an abnormal Pap smear participated in in-depth interviews to explore their knowledge of HPV, their emotional responses to diagnosis, and the extent of their disclosure of their HPV diagnosis to others. Women had many knowledge deficits about HPV. Emotions related primarily to stigma, fear, self-blame, powerlessness, and anger. Most women disclosed their disease to significant others, usually to a sexual partner. Women's lack of accurate knowledge may contribute to the array of emotions they experience. Whereas education about HPV may reduce the potency of these emotions, information alone may be inadequate for achieving optimal patient care. Health care providers can be important in treating the emotional elements associated with diagnosis as well as the condition itself.

The impact of endometrial ablation on hysterectomy rates in women with benign uterine conditions in the United States.

OBJECTIVE: To assess the impact of endometrial ablation on the utilization of hysterectomy in U.S. women with benign uterine conditions. METHODS: Data are from the State Inpatient and Ambulatory Surgery Databases of the Healthcare Cost and Utilization Project for six states, 1990-97. Women who underwent hysterectomy (ICD-9-CM codes 68.3, 68.4, 68.5, 68.51, 68.59, 68.9) and endometrial ablation (68.23, 69.29) and had benign uterine conditions (ICD-9-CM code 218.0 and CCS groupings 47, 171, 173, 175, 176, 215) were extracted. Comparative rates, length of stay, total charges, age, payer, hospital, and teaching status of the hospital are reported. RESULTS: The rates of hysterectomy decreased in three states: Colorado (37% decrease; 33 per 10,000 women in 1990 to 21 per 10,000 in 1997), Maryland (18% decrease; 17/10,000 in 1990 to 14/10,000 in 1997), and New Jersey (11% decrease; 9/10,000 to 8/10,000); were static in two states (Connecticut and New York) and increased in one state, Wisconsin (11% increase; 19/10,000 in 1994 to 21/10,000 in 1997). The rates for endometrial ablation increased in all states. The ratio of hysterectomy rates to endometrial ablation rates fell in each state across the 7 years. In two states (New York and New Jersey) the rate of endometrial ablation was equivalent to the rate of hysterectomies by 1997. The total combined rate for hysterectomy and endometrial ablation for women with benign uterine conditions for each state increased by more than 10%, with the exception of Maryland, which had an increase of only 5%, and Colorado, which had a decline of 23%. CONCLUSIONS: In the six states studied, the diffusion of endometrial ablation has had a varying impact on hysterectomy rates among women with benign uterine conditions. However, endometrial ablation is used as an additive medical technology rather than a substitute.