Understanding Health Equity in Public Health Practice in the United States.

CONTEXT: Understanding the extent to which equity-focused work is occurring in public health departments (eg, in chronic disease programs) can identify areas of success and what is needed to move the needle on health equity. OBJECTIVE: The study objective was to characterize the patterns and correlates of equity-related practices in US state and territorial public health practice. DESIGN: The design was a multimethod (quantitative and qualitative), cross-sectional study. SETTING: The setting included US state and territorial public health departments. PARTICIPANTS: Chronic disease prevention practitioners (N = 600) completed self-report surveys in July 2022 through August 2022 (analyzed in September 2022 through December 2022). MAIN OUTCOME MEASURES: Health equity data were obtained across 4 domains: (1) staff skills, (2) work unit practices, (3) organizational priorities and values, and (4) partnerships and networks. RESULTS: There was a wide range in self-reported performance across the health equity variables. The highest values (those agreeing and strongly agreeing) were related to staff skills (eg, the ability to describe the causes of inequities [82%]). Low agreement was reported for multiple items, indicating the lack of systems for tracking progress on health equity (32%), the lack of hiring of staff members who represent disadvantaged communities (33%), and limited use of principles for community engagement (eg, sharing decision-making authority with partners [34%]). Qualitative data provided tangible examples showing how practitioners and their agencies are turning an array of health equity concepts into actions. CONCLUSIONS: There is urgency in addressing health equity and our data suggest considerable room for enhancing health equity practices in state and territorial public health. To support these activities, our findings provide some of the first information on areas of progress, gaps in practice, and where to target technical assistance, capacity building efforts, and accreditation planning.

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.

The Relationships Between State Health Department Practitioners' Perceptions of Organizational Supports and Evidence-Based Decision-Making Skills.

OBJECTIVES: Evidence-based decision making (EBDM) allows public health practitioners to implement effective programs and policies fitting the preferences of their communities. To engage in EBDM, practitioners must have skills themselves, their agencies must engage in administrative evidence-based practices (A-EBPs), and leaders must encourage the use of EBDM. We conducted this longitudinal study to quantify perceptions of individual EBDM skills and A-EBPs, as well as the longitudinal associations between the 2. METHODS: An online survey completed among US state health department practitioners in 2016 and 2018 assessed perceptions of respondents' skills in EBDM and A-EBPs. We used χ2 tests, t tests, and linear regressions to quantify changes over time, differences by demographic characteristics, and longitudinal associations between individual skills and A-EBPs among respondents who completed both surveys (N = 336). RESULTS: Means of most individual EBDM skills and A-EBPs did not change significantly from 2016 to 2018. We found significant positive associations between changes in A-EBPs and changes in EBDM skill gaps: for example, a 1-point increase in the relationships and partnerships score was associated with a narrowing of the EBDM skill gap (ß estimate = 0.38; 95% CI, 0.15-0.61). At both time points, perceived skills and A-EBPs related to financial practices were low. CONCLUSIONS: Findings from this study can guide the development and dissemination of initiatives designed to simultaneously improve individual and organizational capacity for EBDM in public health settings. Future studies should focus on types of strategies most effective to build capacity in particular types of agencies and practitioners, to ultimately improve public health practice.

Practitioner perspectives on building capacity for evidence-based public health in state health departments in the United States: a qualitative case study.

BACKGROUND: Public health agencies are responsible for implementing effective, evidence-based public health programs and policies to reduce the burden of chronic diseases. Evidence-based public health can be facilitated by modifiable administrative evidence-based practices (A-EBPs) (e.g., workforce development, organizational climate), yet little is known about how practitioners view A-EBPs. Thus, the purpose of this qualitative study was to understand state health department practitioners' perceptions about how A-EBPs are implemented and what facilitators and barriers exist to using A-EBPs. METHODS: Chronic disease prevention and health promotion program staff who were members of the National Association of Chronic Disease Directors were recruited to participate in telephone interviews using a snowball sampling technique. Interviews were transcribed verbatim, and transcripts were analyzed using a common codebook and the a priori method in NVivo. RESULTS: Twenty seven interviews were conducted with practitioners in four states (5-8 interviews per state). All practitioners felt that their work unit culture is positive and that leadership encouraged and expected staff to use evidence-based processes. Participants discussed the provision of trainings and technical assistance as key to workforce development and how leaders communicate their expectations. Access to evidence, partnerships, and funding restrictions were the most commonly discussed barriers to the use of A-EBPs and EBDM. CONCLUSIONS: Results of this study highlight practitioners' perspectives on promoting evidence-based public health in their departments. Findings can inform the development and refinement of resources to improve A-EBP use and organizational and leadership capacity of state health departments.

Adjusting the Equity Lens: Gaps in Addressing Health Equity in State Chronic Disease Prevention.

Purpose: Chronic diseases cause a significant proportion of mortality and morbidity in the United States, although risk factors and prevalence rates vary by population subgroups. State chronic disease prevention practitioners are positioned to address these issues, yet little is known about how health equity is being incorporated into their work. The purpose of this study was to explore perceptions of health equity in a sample of state chronic disease practitioners. Methods: Participants were selected in conjunction with a related evaluation of the National Association of Chronic Disease Directors (NACDD) capacity-building and evidence-based efforts. Four states were chosen for study based on variance in capacity. Directors in each of the states were interviewed and using snowball sampling, 8-12 practitioner interviews were conducted in each state, digitally audio recorded and transcribed. Using a comparative coding technique, themes and analyses were developed. Results: Comments from the practitioners fell into three main and inter-related categories. First, they discussed the varying degrees of integration of health equity in their work. The second theme was collaboration and the importance of working within and outside of departments, as well as with the community. The third theme related to measurement and the need for better data that can be used to garner support and measure impact. Conclusion: Chronic disease practitioners can play an important role in achieving health equity. Integrating this work more fully into chronic disease prevention and health promotion, developing strategic partnerships, tracking efforts, and measuring impact will improve practice and ultimately population health.

Health Departments With A Commitment To Health Equity: A More Skilled Workforce And Higher-Quality Collaborations.

Health equity is a public health priority, yet little is known about commitment to health equity in health departments, especially among practitioners whose work addresses chronic disease prevention. Their work places them at the forefront of battling the top contributors to disparities in morbidity and mortality. A random sample of 537 chronic disease practitioners working in state health departments was surveyed on health equity commitments, partnerships, and needed skills. A small percentage of respondents (2 percent) worked primarily on health equity, and a larger group (9 percent) included health equity as one of their multiple work areas. People who rated their work unit's commitment to health equity as high were more likely to engage with sectors outside of health and rate their leaders as high quality, and less likely to identify skills gaps in their work unit. Opportunities exist to more fully address health equity in state public health practice through organizational, institutional, and governmental policies, including those regarding resource allocation and staff training.

Administrative Evidence-based Practices in State Chronic Disease Practitioners.

INTRODUCTION: Research and lessons from community implementation have informed evidence-based practices that can improve the effectiveness of health initiatives. Administrative evidence-based practices (A-EBPs) facilitate the role of public health departments in implementing the most effective programs and policies. The purpose of this study is to describe A-EBPs in relation to characteristics of chronic disease practitioners in state health departments. METHODS: Randomly selected chronic disease practitioners who worked in state health departments were invited to complete an online survey in 2016. The survey included questions on five domains of A-EBPs: workforce development, leadership, culture and climate, relationships and partners, and financial practices. State-level variables that could potentially affect the use of A-EBPs were collected and used in a regression model. RESULTS: Analysis was conducted in 2016 on data from 571 respondents. Mean percentages of those who strongly agreed/agreed were lowest for financial practices (41.49%) and leadership (42.33%) with higher means for culture and climate (54.52%) and relationships and partners (58.71%). State poverty level was the only significant predictor of A-EBP scores after adjusting for other covariates in a regression model. CONCLUSIONS: These results show several areas of high agreement with A-EBP within the domains measured as well as opportunities for improvement. Highlighting the importance of A-EBPs to public health leadership level may enhance practice. There is also need for developing plans for an aging workforce and cultivating partnerships with health care and other sectors. Findings can be used to target training for enhancement of A-EBPs within state health departments.