The Hows of Resident-Driven Community Empowerment toward Health Equity.

BACKGROUND: This article details community engagement, design, and implementation strategies for the Raices-Xidid-Roots (RXR) Academy. RXR provided a linguistically accessible and culturally relevant curriculum to residents of Spanish and Somali-speaking immigrant, asylee, and refugee backgrounds. OBJECTIVES: This study examined the implementation of the RXR program, including participation and adjustments needed to foster participant engagement and active voice, and explored participant actions to address self-identified aspirations as part of participation. RXR's goal was to empower Morgan County, Colorado, Spanish- and Somalispeaking cohorts of residents from immigrant, asylee, and refugee backgrounds such that they could autonomously plan, create, and sustain programs and organizations to meet their community needs. METHODS: The observational study design included process and implementation evaluative approaches, including interview, project team meeting debriefings, and course organizer reflections, to identify and address implementation challenges, learn how the program met participants' needs, and understand keys to maintaining participant engagement. RESULTS: Cultural adaptation of the content was key to maintaining consistent participant engagement, including delivering programming in participant preferred languages and tailoring curriculum to participant cultural practices. Participants indicated that language barriers had previously prevented them from accessing the content provided by the program's curriculum. Adaptations included adjusting meeting logistics, participant compensation, and unit timing. The Two RXR Academy cohorts developed initiatives that addressed community-identified needs. LESSONS LEARNED: Three RXR design elements supported participant engagement and development of community power: 1) language access beyond the language justice model by providing programming in the participants' preferred language, 2) cultural adaptation of programming, and 3) community ownership and active voiceConclusions: The RXR program provided opportunities for skill development among Morgan County's non-native English-speaking residents and led to the design and implementation of resident-driven projects.

Making Vaccines Equitably Available to All Persons in Pima County, Arizona, 2020-2021.

We review the Pima County (Arizona) Health Department's efforts to achieve equitable COVID-19 vaccine distribution in a county with a social vulnerability index of 0.88. We expedited vaccine distribution, focusing on equitable distribution, implementing a multi-point of dispensing approach, and using a periurban and rural strategy. Pima County has one of the highest vaccine distribution percentages among the highest social vulnerability index quartiles and is more than 10 percentage points ahead of other large counties in Arizona in vaccine uptake. (Am J Public Health. 2022;112(11):1560-1563. https://doi.org/10.2105/AJPH.2022.307040).

Striking a Balance between Program-Specific and Portfolio-Level Evaluation: Lessons Learned from a Multi-Site Evaluation on the Texas-Mexico Border.

Funders are increasingly making strategic investments across multiple grantees, aiming for their portfolio to improve targeted outcomes in a specific issue area. To this end, funders might use multi-site evaluation (MSE) approaches to examine the impact of their collective investments. However, it is important to recognize that each program-and its own program evaluation-must be tailored to its setting, population, and local context to best meet the needs of its target population. Therefore, multi-site evaluations need to account for this complexity. This paper describes the Sí Texas project, a large initiative of eight grantees implementing different integrated behavioral health models to improve physical and mental health outcomes along the Texas-Mexico border. With over 4,200 MSE study participants, the evaluation for Sí Texas used a partnership-centered approach to both enhance the evidence base and build local organizational capacity. This paper describes this approach, the process of tailoring evaluation practices to the grantees' context, and the challenge of balancing consistency at the grantee-level for the portfolio multi-site evaluation. Successes, challenges, and lessons learned related to study design, data collection, grantee partnership, and capacity building are discussed.

Beyond CHNAS: Performance Measurement for Community Health Improvement.

RESEARCH OBJECTIVE: Non-profit hospitals are required to work with community organizations to prepare Community Health Needs Assessment (CHNA) and implementation strategy (IS). In concert with the health care delivery system's transformation from volume to value and efforts to enhance multi-sector collaboration, such community health improvement (CHI) processes have the potential to bridge efforts of the health care delivery sector, public health agencies, and community organizations to improve population health. Having a shared measurement system is critical to achieving collective impact, yet despite the availability of community-level data from a variety of sources, many CHI processes lack clear, measurable objectives and evaluation plans. Through an in-depth analysis of ten exemplary CHI processes, we sought to identify best practices for population health measurement with a focus on monitoring collaborative implementation strategies. STUDY DESIGN: Based on a review of the scientific literature, professional publications and presentations, and nominations from a national advisory panel, we identified 10 exemplary CHI processes. Criteria of choice were whether (1) the CHIs articulate a clear definition of intended outcomes; (2) clear, focused, measurable objectives and expected outcomes, including health equity; (3) expected outcomes are realistic and addressed with specific action plans; and (4) whether the plans and their associated performance measures become fully integrated into agencies and become a way of being for the agencies. We then conducted an in-depth analysis of CHNA, IS, and related documents created by health departments and leading hospitals in each process. POPULATION STUDIED: U.S. hospitals. PRINCIPAL FINDINGS: Community health improvement processes benefit from a shared measurement system that indicate accountability for specific activities. Despite the importance of measurement and evaluation, existing community health improvement efforts often fall short in these areas. There is more variability in format and content of ISs than CHNAs; the most developed models include population-level goals/objectives and strategies with clear accountability and metrics. Other hospital IS's are less developed.Although all U.S. hospitals are familiar with performance measurement in their management, this familiarity does not seem to carry over to Community Benefit and CHNA efforts. Indeed, 5 of the 10 CHI processes we examined have some Accountable Care Organization (ACO) involvement, where population-health performance measures are commonplace. Yet this involvement is not mentioned in the CHNAs and ISs, nor are ACO data cited. CONCLUSIONS: Strengthening the CHNA regulations to require that hospitals report the evaluation measures they intend to monitor based on an established community health improvement model could help communities demonstrate impact. As in other areas of health care, performance measures should be tailored to implementation strategy, with clear indication of accountability, and move from outputs to process and outcome measures with established validity and reliability. IMPLICATIONS FOR POLICY OR PRACTICE: Although performance measurement is now commonplace throughout the health care system, the individuals who manage CHI processes may not be that familiar with this approach. This suggests that it is important to develop practitioners' knowledge and skills needed to use it population health data effectively.

Making Better Use of Population Health Data for Community Health Needs Assessments.

RESEARCH OBJECTIVE: Non-profit hospitals are required to work with community organizations to prepare a Community Health Needs Assessment (CHNA) and implementation strategy (IS). In concert with the health care delivery system's transformation from volume to value and efforts to enhance multi-sector collaboration, such community health improvement (CHI) processes have the potential to bridge efforts of the health care delivery sector, public health agencies, and community organizations to improve population health. Having a shared measurement system is critical to achieving collective impact, yet despite the availability of community-level data from a variety of sources, many CHI processes lack clear, measurable objectives and evaluation plans. Through an in-depth analysis of ten exemplary CHI processes, we sought to identify best practices for population health measurement with a focus on measures for needs assessments and priority setting. STUDY DESIGN: Based on a review of the scientific literature, professional publications and presentations, and nominations from a national advisory panel, we identified 10 exemplary CHI processes. Criteria of choice were whether (1) the CHIs articulate a clear definition of intended outcomes; (2) clear, focused, measurable objectives and expected outcomes, including health equity; (3) expected outcomes are realistic and addressed with specific action plans; and (4) whether the plans and their associated performance measures become fully integrated into agencies and become a way of being for the agencies. We then conducted an in-depth analysis of CHNA, IS, and related documents created by health departments and leading hospitals in each process. POPULATION STUDIED: U.S. hospitals. PRINCIPAL FINDINGS: Census, American Community Survey, and similar data are available for smaller areas are used to describe the populations covered, and, to a lesser extent, to identify health issues where there are disparities and inequities.Common data sources for population health profiles, including risk factors and population health outcomes, are vital statistics, survey data including BRFSS, infectious disease surveillance data, hospital & ED data, and registries. These data are typically available only at the county level, and only occasionally are broken down by race, ethnicity, age, poverty.There is more variability in format and content of ISs than CHNAs; the most developed models include population-level goals/objectives and strategies with clear accountability and metrics. Other hospital IS's are less developed. CONCLUSIONS: The county is the unit of choice because most population health profile data are not available for sub-county areas, but when a hospital serves a population more broadly or narrowly defined, appropriate data are not available to set priorities or monitor progress.Measure definitions are taken from the original data sources, so comparisons across measures is difficult. Thus, although CHNAs cover many of the same topics, the measures used vary markedly. Using the same community health profile, e.g. County Health Rankings, would simplify benchmarking and trend analysis.Implications for Policy or Practice: It is important to develop population health data that can be disaggregated to the appropriate geographical level and to groups defined by race and ethnicity, socioeconomic status, and other factors associated with health outcomes.

Advancing Quality Improvement in Public Health Departments Through a Statewide Training Program.

OBJECTIVES: To examine the effectiveness of an ongoing statewide public health quality improvement training program (PH QI 101) among 4 cohorts of training participants. DESIGN: We conducted a mixed-method evaluation of the PH QI 101 training program that included measures of participants' satisfaction, learning, behavior change, and participants' translation and spread to their organizations what was learned. Data analysis included descriptive quantitative statistics and qualitative reviews. The Mann-Whitney U test was used to examine changes in participants' confidence to conduct a QI project from pre- to posttraining and 6 months posttraining. PARTICIPANTS: Two hundred two staff members from 37 North Carolina local health departments. INTERVENTION: An 8-month experiential learning process in which participants learn to use QI methods by applying them to a specific project. RESULTS: More than 90% of participants reported satisfaction with the program. Median scores on perceived self-confidence to conduct a QI project significantly increased for all training waves. At least 85% of participants reported spreading QI tools to coworkers posttraining. Two-thirds of participants in 3 waves reported that the QI project conducted during the training was at the sustaining results stage. Most participants in 3 of the training waves reported initiating new QI projects at their health department following training. Facilitators to implementation included interest and support from managers and leaders. Lack of interest and competing priorities among other staff were key barriers to implementation. CONCLUSIONS: This program successfully trained 4 waves of public health professionals in QI tools and methods. Leader training and involvement was a key addition to the adapted model. This statewide approach may serve as a model to other states as they seek to achieve national accreditation standards.

Effects of performance improvement programs on preparedness capacities.

OBJECTIVE: In response to public health systems and services research priorities, we examined the extent to which participation in accreditation and performance improvement programs can be expected to enhance preparedness capacities. METHODS: Using data collected by the Local Health Department Preparedness Capacities Assessment Survey, we applied a series of weighted least-squares models to examine the effect of program participation on each of the eight preparedness domain scores. Participation was differentiated across four groups: North Carolina (NC) accredited local health departments (LHDs), NC non-accredited LHDs, national comparison LHDs that participated in performance or preparedness programs, and national comparison LHDs that did not participate in any program. RESULTS: Domain scores varied among the four groups. Statistically significant positive participation effects were observed on six of eight preparedness domains for NC accreditation programs, on seven domains for national comparison group LHDs that participated in performance programs, and on four domains for NC non-accredited LHDs. CONCLUSIONS: Overall, accreditation and other performance improvement programs have a significant and positive effect on preparedness capacities. While we found no differences among accredited and non-accredited NC LHDs, this lack of significant difference in preparedness scores among NC LHDs is attributed to NC's robust statewide preparedness program, as well as a likely exposure effect among non-accredited NC LHDs to the accreditation program.

Declining trends in local health department preparedness capacities.

OBJECTIVES: We examined local health department (LHD) preparedness capacities in the context of participation in accreditation and other performance improvement efforts. MetHODS: We analyzed preparedness in 8 domains among LHDs responding to a preparedness capacity instrument from 2010 through 2012. Study groups included LHDs that (1) were exposed to a North Carolina state-based accreditation program, (2) participated in 1 or more performance improvement programs, and (3) had not participated in any performance improvement programs. We analyzed mean domain preparedness scores and applied a series of nonparametric Mann-Whitney Wilcoxon tests to determine whether preparedness domain scores differed significantly between study groups from 2010 to 2012. RESULTS: Preparedness capacity scores fluctuated and decreased significantly for all study groups for 2 domains: surveillance and investigation and legal preparedness. Significant decreases also occurred among participants for plans and protocols, communication, and incident command. Declines in capacity scores were not as great and less likely to be significant among North Carolina LHDs. CONCLUSIONS: Decreases in preparedness capacities over the 3 survey years may reflect multiple years of funding cuts and job losses, specifically for preparedness. An accreditation program may have a protective effect against such contextual factors.

Accreditation and emergency preparedness: linkages and opportunities for leveraging the connections.

BACKGROUND: Public health officials must frequently demonstrate the quality and value of public health services, especially during challenging fiscal climates. One of the ways that public health quality and accountability have been demonstrated is through the use of accreditation and standard setting initiatives. OBJECTIVE: The objective of this analysis was to identify existing alignment opportunities between standards established by the Public Health Accreditation Board (PHAB) and the Centers for Disease Control and Prevention's (CDC's) public health preparedness (PHP) capabilities in order to optimize and leverage the connections for state and local public health professionals. DESIGN: During March-May 2012, a PHAB/PHP crosswalk was developed by a research team from the CDC's Office for State, Tribal, Local and Territorial Support and Office of Public Health Preparedness and Response's Division of State and Local Readiness to examine the intersection of the PHP capabilities and the PHAB standards. The PHAB/PHP crosswalk used the CDC Public Health Preparedness Capabilities: National Standards for State and Local Planning (PHP Capabilities) and the PHAB Standards and Measures, Version 1.0 (PHAB Standards) as its source documents. To help illustrate the results of the crosswalk, alignment was also depicted through a network graph to transform the results into a visual depiction of the linkages between PHP capabilities and PHAB standards. RESULTS: The most direct links to emergency preparedness were found in PHAB Domains 2 and 5. Opportunities for improved alignment were found throughout the standard documents, particularly in PHAB Domains 3, 8, and 11. The most direct links to accreditation were found in PHP capabilities 1, 2, 3, and 4. CONCLUSIONS: The results highlight the synergy between the infrastructure and foundational elements represented by accreditation and targeted programmatic activities supported by preparedness funding.

Creating quality improvement culture in public health agencies.

OBJECTIVES: We conducted case studies of 10 agencies that participated in early quality improvement efforts. METHODS: The agencies participated in a project conducted by the National Association of County and City Health Officials (2007-2008). Case study participants included health directors and quality improvement team leaders and members. We implemented multiple qualitative analysis processes, including cross-case analysis and logic modeling. We categorized agencies according to the extent to which they had developed a quality improvement culture. RESULTS: Agencies were conducting informal quality improvement projects (n = 4), conducting formal quality improvement projects (n = 3), or creating a quality improvement culture (n = 4). Agencies conducting formal quality improvement and creating a quality improvement culture had leadership support for quality improvement, participated in national quality improvement initiatives, had a greater number of staff trained in quality improvement and quality improvement teams that met regularly with decision-making authority. Agencies conducting informal quality improvement were likely to report that accreditation is the major driver for quality improvement work. Agencies creating a quality improvement culture were more likely to have a history of evidence-based decision-making and use quality improvement to address emerging issues. CONCLUSIONS: Our findings support previous research and add the roles of national public health accreditation and emerging issues as factors in agencies' ability to create and sustain a quality improvement culture.

Improving public health preparedness capacity measurement: development of the local health department preparedness capacities assessment survey.

OBJECTIVE: To address limitations in measuring the preparedness capacities of health departments, we developed and tested the Local Health Department Preparedness Capacities Assessment Survey (PCAS). METHODS: Preexisting instruments and a modified 4-cycle Delphi panel process were used to select instrument items. Pilot test data were analyzed using exploratory factor analysis. Kappa statistics were calculated to examine rater agreement within items. The final instrument was fielded with 85 North Carolina health departments and a national matched comparison group of 248 health departments. RESULTS: Factor analysis identified 8 initial domains: communications, surveillance and investigation, plans and protocols, workforce and volunteers, legal infrastructure, incident command, exercises and events, and corrective action. Kappa statistics and z scores indicated substantial to moderate agreement among respondents in 7 domains. Cronbach α coefficients ranged from 0.605 for legal infrastructure to 0.929 for corrective action. Mean scores and standard deviations were also calculated for each domain and ranged from 0.41 to 0.72, indicating sufficient variation in the sample to detect changes over time. CONCLUSION: The PCAS is a useful tool to determine how well health departments are performing on preparedness measures and identify opportunities for future preparedness improvements. Future survey implementation will incorporate recent Centers for Disease Control and Prevention's Public Health Preparedness Capabilities: National Standards for State and Local Planning.

Early evaluation results from a statewide quality improvement training program for local public health departments in North Carolina.

CONTEXT: Many state and local public health agencies have developed accreditation systems and are utilizing quality improvement (QI) methods and tools to improve the public health infrastructure. Development of strategies to support and build the capacity of the public health workforce to apply QI can help advance these efforts. OBJECTIVE: This article describes the adaptation and creation of a standardized QI training program for local health departments (LHDs), explores the effectiveness of the program in increasing the confidence of the LHD staff to apply QI methods and tools, and discusses lessons learned from the first cohort of the program. METHODS: An existing program designed for health care professionals was pilot tested, adapted, and used in 8 LHDs. A formative evaluation of the new public health QI training program was conducted through a hybrid internal and external evaluation model. Pre/postsurveys were used to measure participant satisfaction and the capacity of LHD staff to conduct QI. RESULTS: Staff from 8 LHDs successfully completed the program and 94% of participants reported that they were satisfied with the overall training program. Seventy percent of participants reported a higher perceived confidence in conducting a QI project, and all participants reported sharing QI tools and methods with their coworkers. CONCLUSION: These findings suggest that QI training programs using methods and tools previously applied in health care and other industries can be successfully adapted to public health. Although additional studies are needed to validate the results, this training model can be used to inform future work in developing a standardized QI training program in public health.

Effectiveness of public health quality improvement training approaches: application, application, application.

CONTEXT: Quality improvement (QI) has been identified as a key strategy to improve the performance of state and local public health agencies. Quality improvement training effectiveness has received little attention in the literature. OBJECTIVES: To evaluate the effectiveness of 3 QI training types: webinars, workshops, and demonstration site activities on improving participant knowledge, skill, and ability to conduct QI through a questionnaire conducted after training participation. DESIGN: We used a natural experimental design hypothesizing that demonstration site participants would have the greatest gains on outcomes of interest compared with webinar and workshop participants. Bivariate and multivariate models were used to examine outcome differences between questionnaire respondents who participated in various training types. PARTICIPANTS: Local health department employees who participated in the 3 training strategies. MAIN OUTCOME MEASURES: Measures included knowledge and skill gain, skill application, QI receptivity, and ability to successfully participate in a QI project. RESULTS: Two hundred eighty-four unique individuals who work in 143 health departments completed the questionnaire for a 59% response rate. The majority of these health departments serve midsize populations. Demonstration site respondents had significantly greater gains in knowledge and skills, skill application, and ability to successfully participate in a QI project. Webcast training participants had significantly higher QI receptivity in adjusted models. Respondents who participated in both webcast and demonstration site trainings had higher mean scores on all outcomes when compared with demonstration site single training participants, these differences were significant in unadjusted models. CONCLUSION: Our findings suggest that QI training for public health agency employees should include both didactic training on QI content and opportunities for QI application. Future research should examine if this approach can effectively increase successful participation in QI projects for staff in LHDs of all sizes.

Informing the national public health accreditation movement: lessons from North Carolina's accredited local health departments.

To advance understanding of public health accreditation, we analyzed data on the North Carolina Local Health Department Accreditation program. We surveyed accredited health departments on barriers to and supports of accreditation preparation, performance on accreditation standards, and benefits and improvements after accreditation. All 48 accredited agencies responded to the survey. All agencies improved policies to prepare for accreditation and met most accreditation standards. Forty-six percent received local funds for accreditation preparation. The most common barrier to accreditation preparation was time and schedule limitations (79%). Fifty percent of agencies acted on suggestions for improvement, and 67% conducted quality improvement activities. Benefits of accreditation included improvements in local partnerships. Agencies of all sizes conducted accreditation activities, were successfully accredited, and experienced benefits resulting from accreditation.

Public health case studies in diabetes prevention and control: innovation, partnerships, and funding.

BACKGROUND: In 2006, we conducted case studies of 4 North Carolina local health departments (LHDs) that scored highly on an index of diabetes prevention and control performance, to explore characteristics that may serve as barriers or facilitators of diabetes prevention and control services. METHODS: Case studies involving in-depth interviews were conducted at 4 LHDs. Sites were selected on the basis of 2 variables, known external funding for diabetes services and population size, that were associated with performance in diabetes prevention and control in a 2005 survey of all North Carolina LHDs. Fourteen interviews (individual and group) were conducted among 17 participants from the 4 LHDs. The main outcome measures were LHD characteristics that facilitate or hinder the performance of diabetes programs and services. RESULTS: Interviews revealed that all 4 high-performing LHDs had received some sort of funding from a source external to the LHD. Case study participants indicated that barriers to additional service delivery included low socioeconomic status of the population and lack of financial resources. Having a diabetes self-management education program that was recognized by the American Diabetes Association appeared to be a facilitator of diabetes services provision. Other facilitators were leadership and staff commitment, which appeared to facilitate the leveraging of partnerships and funding opportunities, leading to enhanced service delivery. LIMITATIONS: The small number of LHDs participating in the study and the cross-sectional study design were limitations. CONCLUSION: Leadership, staff commitment, partnership leveraging, and funding appear to be associated with LHD performance in diabetes prevention and control services. These factors should be further studied in future public health systems and services research.

The association of changes in local health department resources with changes in state-level health outcomes.

We explored the association between changes in local health department (LHD) resource levels with changes in health outcomes via a retrospective cohort study. We measured changes in expenditures and staffing reported by LHDs on the 1997 and 2005 National Association of County and City Health Officials surveys and assessed changes in state-level health outcomes with the America's Health Rankings reports for those years. We used pairwise correlation and multivariate regression to analyze the association of changes in LHD resources with changes in health outcomes. Increases in LHD expenditures were significantly associated with decreases in infectious disease morbidity at the state level (P = .037), and increases in staffing were significantly associated with decreases in cardiovascular disease mortality (P = .014), controlling for other factors.