How Funding Policy Maintains Structural Inequity Within Indigenous Community-Based Organizations.

Despite efforts to increase investment in Indigenous health and well-being in the United States, disparities remain. The way in which health-promoting organizations are funded is one key mechanism driving the systemic, long-term health disparities experienced by Indigenous people in the US. Using Indigenous-led community-based organizations (ICBOs) that provide psychosocial care as a case study, we highlight multiple ways in which policies that regulate the external funding that ICBOs depend on must change to promote equity and allow the organizations to flourish and address unmet psychosocial needs for Indigenous community members. We use a system dynamics approach to discuss how "capability traps" arise from a misfit between external funding regulations and organizations' needs for sustainability and effective care provision. We provide suggestions for reforming funding policies that focus on improving ICBO sustainability.

Implementation strategies in the Exploration and Preparation phases of a colorectal cancer screening intervention in community health centers.

BACKGROUND: Adoption of colorectal cancer (CRC) screening has lagged in community health center (CHC) populations in the USA. To address this implementation gap, we developed a multilevel intervention to improve screening in CHCs in our region. We used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide this effort. Here, we describe the use of implementation strategies outlined in the Expert Recommendations for Implementing Change (ERIC) compilation in both the Exploration and Preparation phases of this project. During these two EPIS phases, we aimed to answer three primary questions: (1) What factors in the inner and outer contexts may support or hinder colorectal cancer screening in North Carolina CHCs?; (2) What evidence-based practices (EBPs) best fit the needs of North Carolina CHCs?; and (3) How can we best integrate the selected EBPs into North Carolina CHC systems? METHODS: During the Exploration phase, we conducted local needs assessments, built a coalition, and conducted local consensus discussions. In the Preparation phase, we formed workgroups corresponding to the intervention's core functional components. Workgroups used cyclical small tests of change and process mapping to identify implementation barriers and facilitators and to adapt intervention components to fit inner and outer contexts. RESULTS: Exploration activities yielded a coalition of stakeholders, including two rural CHCs, who identified barriers and facilitators and reached consensus on two EBPs: mailed FIT and navigation to colonoscopy. Stakeholders further agreed that the delivery of those two EBPs should be centralized to an outreach center. During Preparation, workgroups developed and refined protocols for the following centrally-delivered intervention components: a registry to identify and track eligible patients, a centralized system for mailing at-home stool tests, and a process to navigate patients to colonoscopy after an abnormal stool test. CONCLUSIONS: This description may be useful both to implementation scientists, who can draw lessons from applied implementation studies such as this to refine their implementation strategy typologies and frameworks, as well as to implementation practitioners seeking exemplars for operationalizing strategies in early phases of implementation in healthcare.

Implementation costs of sugary drink policies in the United States.

To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.

Effects of caregiver-child acculturation on child obesity among US Latino individuals.

OBJECTIVE: The goal of this study was to assess the association of Latino caregiver-child nativity status (US- and foreign-born) with child obesity using a nationally representative sample. METHODS: Using data from the National Health and Nutrition Examination Survey (NHANES 1999-2018), this study used generalized linear models to identify associations between caregiver-child nativity status (as a proxy for acculturation) and children's BMI. RESULTS: Compared with foreign-born caregiver-child dyads, US-born caregiver-child dyads had 2.35 times the risk of class 2 obesity (95% CI: 1.59-3.47) and 3.60 times the risk of class 3 obesity (95% CI: 1.86-6.96). Foreign-born caregiver and US-born child dyads had 2.01 times the risk of class 2 obesity (95% CI: 1.42-2.84) and 2.47 times the risk of class 3 obesity (95% CI: 1.38-4.44; p < 0.05 for class 2 and class 3). CONCLUSIONS: Compared with foreign-born Latino caregiver-child dyads, dyads with US-born caregivers and children and dyads with foreign-born caregivers and US-born children had significantly increased risk across the severe classes of obesity. Examining the influence and relationship of varying acculturation levels in an immigrant household will help guide more effective clinical and policy guidelines surrounding obesity and weight management in both pediatric and adult US Latino populations.

Evaluation of an Emergency Department Visit Data Mental Health Dashboard.

CONTEXT: Local health departments (LHDs) need timely county-level and subcounty-level data to monitor health-related trends, identify health disparities, and inform areas of highest need for interventions as part of their ongoing assessment responsibilities; yet, many health departments rely on secondary data that are not timely and cannot provide subcounty insights. OBJECTIVE: We developed and evaluated a mental health dashboard in Tableau for an LHD audience featuring statewide syndromic surveillance emergency department (ED) data in North Carolina from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). DESIGN: We developed a dashboard that provides counts, crude rates, and ED visit percentages at statewide and county levels, as well as breakdowns by zip code, sex, age group, race, ethnicity, and insurance coverage for 5 mental health conditions. We evaluated the dashboards through semistructured interviews and a Web-based survey that included the standardized usability questions from the System Usability Scale. PARTICIPANTS: Convenience sample of LHD public health epidemiologists, health educators, evaluators, and public health informaticians. RESULTS: Six semistructured interview participants successfully navigated the dashboard but identified usability issues when asked to compare county-level trends displayed in different outputs (eg, tables vs graphs). Thirty respondents answered all questions on the System Usability Scale for the dashboard, which received an above average score of 86. CONCLUSIONS: The dashboards scored well on the System Usability Scale, but more research is needed to identify best practices in disseminating multiyear syndromic surveillance ED visit data on mental health conditions to LHDs.

Translating knowledge into action for child obesity treatment in partnership with Parks and Recreation: study protocol for a hybrid type II trial.

BACKGROUND: Safe and effective treatment exists for childhood obesity, but treatment recommendations have largely not been translated into practice, particularly among racial and ethnic minorities and low-wealth populations. A key gap is meeting the recommended treatment of ≥26 h of lifestyle modification over 6-12 months. Fit Together is an effective treatment model that meets these recommendations by integrating healthcare and community resources. Pediatric providers screen children for obesity, deliver counseling, and treat co-morbidities, while Parks and Recreation partners provide recreation space for a community nutrition and physical activity program. METHODS: This study will use a hybrid type II implementation-effectiveness design to evaluate the effectiveness of an online implementation platform (the Playbook) for delivering Fit Together. Clinical and community partners in two North Carolina communities will implement Fit Together, using the Playbook, an implementation package designed to facilitate new partnerships, guide training activities, and provide curricular materials needed to implement Fit Together. An interrupted time series design anchored in the Process Redesign Framework will be used to evaluate implementation and effectiveness outcomes in intervention sites. Implementation measures include semi-structured interviews with partners, before and after the implementation of Fit Together, and quantitative measures assessing several constructs within the Process Redesign Framework. The participants will be children 6-11 years old with obesity and their families (n=400). Effectiveness outcomes include a change in child body mass index and physical activity from baseline to 6 and 12 months, as compared with children receiving usual care. Findings will be used to inform the design of a dissemination strategy guided by the PCORI Dissemination Framework. DISCUSSION: This project addresses the knowledge-to-action gap by developing evidence-based implementation tools that allow clinicians and communities to deliver effective pediatric obesity treatment recommendations. Future dissemination of these tools will allow more children who have obesity and their families to have access to effective, evidence-based care in diverse communities. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05455190 . Registered on 13 July 2022.

Comparative Evaluation of 2 Work Experience Approaches for Predominantly Black Youth in a Rural Community: Implications for Public Health Workforce Development.

CONTEXT: In order to create a more diverse workforce, there is a need to involve historically excluded youth in public health-related work. Youth involvement in asset-based work experience approaches is especially relevant for rural areas with workforce shortages. OBJECTIVE: To explore the public health workforce development implications of community-based career exploration and asset mapping work experience from the perspective of Black youth. DESIGN: We used qualitative in-depth interviews with youth, aged 14 to 22 years, who participated in a work experience program anchored in several rural counties in southeastern United States. A phenomenological lens was applied for qualitative analyses with iterative, team-based data coding. Participants were also surveyed pre- and postprogram to supplement findings. PROGRAM: A rural community-based organization's work experience program consisted of 2 tracks: (1) Youth Connect-a career exploration track that included work placement within community agencies; and (2) MAPSCorps-a track that employs youth to conduct asset mapping for their community. RESULTS: We interviewed 28 of 31 total participants in the 2 tracks. We uncovered 4 emergent profiles in how youth described shifts in their perceptions of community: (1) Skill Developers; (2) Community Questioners; (3) Community Observers; and (4) Community Enthusiasts. In comparing between tracks, youth who participated in work experience that involved asset mapping uniquely described increased observation and expanded view of community resources and had greater increases in research self-efficacy than youth who participated only in career exploration. CONCLUSION: Asset mapping work experience that is directly placed in rural communities can expose Black youth to and engage them in essential public health services (assessing and mobilizing community assets) that impact their community. This type of program, directly integrated into rural communities rather than placed near academic centers, could play a role in creating a more diverse public health workforce.

"If you're in a community together, then you're basically a family": Perceptions of community among a predominantly African-American/Black youth cohort in a semi-rural region in the Southeastern United States.

Geographic racism gives rise to health inequities that impact communities in detrimental ways. Southern ethnic minority groups, particularly African American/Black semi-rural communities, are subject to especially unjust outcomes in health, education, and wealth. Asset-based community development (ABCD) is a way of engaging with communities in participatory and positive ways that center community voices as expert. Youth can participate in ABCD, are sensitive to the ways in which their communities are structured, and have insights as to how to improve the places they live. We undertook a qualitative interview study which included a cognitive mapping exercise with 28 youth to understand how African American/Black youth who had participated in an ABCD-informed summer program conceptualized community and preferences about where they lived. Using a phenomenological approach to qualitative analysis, our study revealed that many youth defined community as a combination of people and place, enjoyed engaging with unique resources in their communities as well as seeking peace and quiet, experienced hardships as "something everybody knows" when observing constraints on their communities, and were committed to their communities and interested in seeing-and participating in-their flourishing. Our study provides a nuanced and contemporary understanding of the ways in which African American/Black semi-rural youth experience community which can contribute to cyclical asset-based development strategy aimed at empowering young people and improving health outcomes in resilient communities.

Simulation models of sugary drink policies: A scoping review.

INTRODUCTION: Simulation modeling methods are an increasingly common tool for projecting the potential health effects of policies to decrease sugar-sweetened beverage (SSB) intake. However, it remains unknown which SSB policies are understudied and how simulation modeling methods could be improved. To inform next steps, we conducted a scoping review to characterize the (1) policies considered and (2) major characteristics of SSB simulation models. METHODS: We systematically searched 7 electronic databases in 2020, updated in 2021. Two investigators independently screened articles to identify peer-reviewed research using simulation modeling to project the impact of SSB policies on health outcomes. One investigator extracted information about policies considered and key characteristics of models from the full text of included articles. Data were analyzed in 2021-22. RESULTS: Sixty-one articles were included. Of these, 50 simulated at least one tax policy, most often an ad valorem tax (e.g., 20% tax, n = 25) or volumetric tax (e.g., 1 cent-per-fluid-ounce tax, n = 23). Non-tax policies examined included bans on SSB purchases (n = 5), mandatory reformulation (n = 3), warning labels (n = 2), and portion size policies (n = 2). Policies were typically modeled in populations accounting for age and gender or sex attributes. Most studies focused on weight-related outcomes (n = 54), used cohort, lifetable, or microsimulation modeling methods (n = 34), conducted sensitivity or uncertainty analyses (n = 56), and included supplementary materials (n = 54). Few studies included stakeholders at any point in their process (n = 9) or provided replication code/data (n = 8). DISCUSSION: Most simulation modeling of SSB policies has focused on tax policies and has been limited in its exploration of heterogenous impacts across population groups. Future research would benefit from refined policy and implementation scenario specifications, thorough assessments of the equity impacts of policies using established methods, and standardized reporting to improve transparency and consistency.

Equitable Policies Need Equitable Practices: Alcohol- and Substance-Exposed Pregnancy as a Case Study.

There is clear need for more effective public health policies. Coupled with calls for more effective policies, increasing demand to address public health disparities experienced by systemically marginalized and historically oppressed groups emphasizes the long-standing need for policies that improve public health equity. Such need is highlighted when examining public health issues such as alcohol- and substance-exposed pregnancy (ASEP): Current policies are ineffective at reducing ASEP, and marginalized groups experience disproportionately lower benefits and higher negative consequences as a result of such policies. Powerful strategies to develop more effective policies that can account for the complexity of such issues, such as systems science methods (SSMs), are becoming popular. However, current best practices for such methods often do not emphasize the additional efforts that will be required to develop equitable, not just effective policies. Using ASEP as an example of a crucial complex issue requiring new policy, we suggest additional steps to include in SSM projects for developing more effective policies that will also help stakeholders determine high-equity policies to reduce health disparities. These steps include modeling structural differences experienced by marginalized groups via systemic racism and oppression, incorporating existing cultural and community sources of strength and resilience as key areas for policy development, and evaluating the sustainability of policies as a dimension of efficacy. We also discuss using community-based participatory approaches as a framework for all SSM processes to ensure that policy development itself is grounded in equitable shared decision-making for marginalized individuals.

Extending analytic methods for economic evaluation in implementation science.

BACKGROUND: Economic evaluations of the implementation of health-related evidence-based interventions (EBIs) are conducted infrequently and, when performed, often use a limited set of quantitative methods to estimate the cost and effectiveness of EBIs. These studies often underestimate the resources required to implement and sustain EBIs in diverse populations and settings, in part due to inadequate scoping of EBI boundaries and underutilization of methods designed to understand the local context. We call for increased use of diverse methods, especially the integration of quantitative and qualitative approaches, for conducting and better using economic evaluations and related insights across all phases of implementation. MAIN BODY: We describe methodological opportunities by implementation phase to develop more comprehensive and context-specific estimates of implementation costs and downstream impacts of EBI implementation, using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. We focus specifically on the implementation of complex interventions, which are often multi-level, resource-intensive, multicomponent, heterogeneous across sites and populations, involve many stakeholders and implementation agents, and change over time with respect to costs and outcomes. Using colorectal cancer (CRC) screening EBIs as examples, we outline several approaches to specifying the "boundaries" of EBI implementation and analyzing implementation costs by phase of implementation. We describe how systems mapping and stakeholder engagement methods can be used to clarify EBI implementation costs and guide data collection-particularly important when EBIs are complex. In addition, we discuss the use of simulation modeling with sensitivity/uncertainty analyses within implementation studies for projecting the health and economic impacts of investment in EBIs. Finally, we describe how these results, enhanced by careful data visualization, can inform selection, adoption, adaptation, and sustainment of EBIs. CONCLUSION: Health economists and implementation scientists alike should draw from a larger menu of methods for estimating the costs and outcomes associated with complex EBI implementation and employ these methods across the EPIS phases. Our prior experiences using qualitative and systems approaches in addition to traditional quantitative methods provided rich data for informing decision-making about the value of investing in CRC screening EBIs and long-term planning for these health programs. Future work should consider additional opportunities for mixed-method approaches to economic evaluations.

Opportunities to improve policy dissemination by tailoring communication materials to the research priorities of legislators.

BACKGROUND: Communicating research to policymakers is a complex and difficult process. Ensuring that communication materials have information or design aspects that appeal to groups of policymakers with different priorities could be a substantive improvement over current dissemination approaches. To facilitate a more nuanced design of policy communication materials and message framing, we identified and characterized groups of state legislators based on how they prioritize different characteristics of research. METHODS: We used deidentified data collected in 2012 on 862 state legislators belonging to the US liberal-moderate-conservative ideological spectrum and from all 50 US states. Legislators were grouped using latent class analysis based on how they prioritized 12 different characteristics of research (e.g., research is unbiased, presents data on cost-effectiveness, policy options are feasible). We fit initial models using 1-6 group solutions and chose the final model based on identification, information criteria, and substantive interpretation. RESULTS: Most legislators placed a high priority on research that was understandable (61%), unbiased (61%), available at the time that decisions are made (58%), and brief and concise (55%). The best model identified four groups of state legislators. Pragmatic consumers (36%) prioritized research that was brief and concise, provided cost-effectiveness analyses, and was understandably written. Uninterested skeptics (30%) generally did not place a high priority on any of the research characteristics. Conversely, one-quarter of legislators (25%) belonged to the Highly Informed Supporters group that placed a high priority on most characteristics of research. Finally, Constituent-Oriented Decision Makers (9%) prioritized research that was relevant to their constituents, delivered by someone they knew or trusted, available at the time decisions were made, and dealt with an issue that they felt was a priority for state legislative action. CONCLUSIONS: To maximize the impact of dissemination efforts, researchers should consider how to communicate with legislators who have distinct preferences, values, and priorities. The groups identified in this study could be used to develop communication materials that appeal to a wide range of legislators with distinct needs and preferences, potentially improving the uptake of research into the policymaking process. Future work should investigate how to engage skeptical legislators.

Health insurance coverage among American Indians and Alaska Natives in the context of the Affordable Care Act.

Objectives: American Indians and Alaska Natives (AI/AN) have a unique healthcare system uniquely interwoven with the Affordable Care Act (ACA). The aim of this study is to document changes in health insurance among AI/AN adults before and after implementation of the ACA.Design: We used data from the American Community Survey from 2008 to 2016 to examine trends in health insurance. We compared to Non-Hispanic Whites and stratified AI/AN adults with and without Indian Health Service (IHS) coverage. We used multivariate regression to evaluate the probability of health insurance post-ACA and included time period and subgroup interaction terms.Results: Public and private health insurance coverage increased post-ACA by 3.17 and 1.24 percentage points, respectively, but the percent uninsured remained high (37.7% of those with IHS coverage and 19.2% of those without). AI/AN in Medicaid Expansion states had a significantly greater percentage point (pp) increase in public insurance (6.31 pp, 95% CI 5.04-7.59) than AI/AN in non-expansion states (p < 0.001). There was a greater increase in private coverage among AI/AN without IHS compared to AI/AN with IHS coverage (p = 0.002).Conclusions: Despite improvements in healthcare insurance coverage for AI/AN, substantial disparities remain. The improvements appeared to be largely driven by Medicaid Expansion. Without specific considerations for AI/AN, future healthcare reforms could intensify health injustices and inequities they face.

The significant places of African American adults and their perceived influence on cardiovascular disease risk behaviors.

BACKGROUND: AA living in rural areas of the southeastern U.S. experience a disproportionate burden of cardiovascular disease (CVD) morbidity and mortality. Neighborhood environmental factors contribute to this disparity and may decrease the effectiveness of lifestyle interventions aimed at preventing CVD. Furthermore, the influence of neighborhood factors on AA CVD risk behaviors (i.e. physical activity) may be obscured by the use of researcher-defined neighborhoods and researcher-defined healthy and unhealthy places. The objective of this study was to elucidate the effects of neighborhood environments on AA CVD risk behaviors among AA adults who recently completed a lifestyle intervention. We specifically sought to identify AA adults' self-perceived places of significance and their perceptions of how these places impact CVD risk behaviors including diet, physical activity and smoking. METHODS: We conducted semi-structured interviews with AA adults (N = 26) living in two rural North Carolina counties (Edgecombe and Nash, North Carolina, USA). Participants were recruited from a community-based behavioral CVD risk reduction intervention. All had at least one risk factor for CVD. Participants identified significant places including where they spent the most time, meaningful places, and healthy and unhealthy places on local maps. Using these maps as a reference, participants described the impact of each location on their CVD risk behaviors. Data were transcribed verbatim and coded using NVivo 12. RESULTS: The average age of participants was 63 (SD = 10) and 92% were female. Places participants defined as meaningful and places where they spent the most time included churches and relatives' homes. Healthy places included gyms and parks. Unhealthy places included fast food restaurants and relatives' homes where unhealthy food was served. Place influenced CVD risk behaviors in multiple ways including through degree of perceived control over the environment, emotional attachment and loneliness, caretaking responsibilities, social pressures and social support. CONCLUSIONS: As we seek to improve cardiovascular interventions for rural AA in the American South, it will be important to further assess the effect of significant places beyond place of residence. Strategies which leverage or modify behavioral influences within person-defined significant places may improve the reach and effectiveness of behavioral lifestyle interventions.

Racial Residential Segregation and Race Differences in Ideal Cardiovascular Health among Young Men.

BACKGROUND: Race disparities in cardiovascular disease (CVD) related morbidity and mortality are evident among men. While previous studies show health in young adulthood and racial residential segregation (RRS) are important factors for CVD risk, these factors have not been widely studied in male populations. We sought to examine race differences in ideal cardiovascular health (CVH) among young men (ages 24-34) and whether RRS influenced this association. METHODS: We used cross-sectional data from young men who participated in Wave IV (2008) of the National Longitudinal Survey of Adolescent to Adult Health (N = 5080). The dichotomous outcome, achieving ideal CVH, was defined as having ≥4 of the American Heart Association's Life's Simple 7 targets. Race (Black/White) and RRS (proportion of White residents in census tract) were the independent variables. Descriptive and multivariate analyses were conducted. RESULTS: Young Black men had lower odds of achieving ideal CVH (OR = 0.67, 95% CI = 0.49, 0.92) than young White men. However, RRS did not have a significant effect on race differences in ideal CVH until the proportion of White residents was ≥55%. CONCLUSIONS: Among young Black and White men, RRS is an important factor to consider when seeking to understand CVH and reduce future cardiovascular risk.

Exploring Clusters of Risk and Association With Child Maltreatment in North Carolina Counties.

BACKGROUND: Decision makers face challenges in estimating local risk for child maltreatment and how best to prioritize which factors to intervene upon. METHODS: Using US Census and survey data for all US counties (N = 3141), we derived US county profiles characterized by the severity of child maltreatment risk factors observed at the county level, such as parental health, health care access, and economic distress. We estimated how five child maltreatment outcomes would vary across the profiles for North Carolina counties (n = 100): total maltreatment reports (including unsubstantiated and substantiated), substantiated neglect, substantiated abuse, whether services were received, and reported child's race/ethnicity. RESULTS: We derived three profiles of county-level child maltreatment risk: high, moderate, and low risk, denoting that predicted risk factors means within profiles were all high, moderate, or low levels compared to counties in other profiles. One risk factor did not follow this pattern: the drug overdose death rate. It was highest in the moderate-risk profile instead of the high-risk profile, as would have been consistent with other factor levels. Moderate-risk counties had the highest predicted rate of child maltreatment reports, with over 20 more reports per 10,000 residents compared to low-risk counties (95% CI, 1.38, 38.86). LIMITATIONS: We included only factors for which aggregate, county-level estimates were available, thus limiting inclusion of all relevant factors. CONCLUSIONS: Results suggest the need for increased family-based services and interventions that reduce risk factors such as economic distress and drug overdose deaths. We discuss the implications for tailoring county efforts to prevent child maltreatment.

Couple communication and contraception use in urban Senegal.

OBJECTIVES: Couple communication about family planning has been shown to increase uptake of contraception. However, couple communication is often measured based solely on one partner's report of communication. This research investigates the influence of couple-reported communication about family planning on current and future use of contraception using couple-level data. METHODS: We used baseline data from the Measurement, Learning, and Evaluation (MLE) project collected through household surveys in 2011 from a cross-sectional representative sample of women and men in urban Senegal to conduct secondary data analysis. We used multivariable logit models to estimate the average marginal effects of couple communication about family planning on current contraception use and future intention to use contraception. RESULTS: Couple communication about family planning reported by both partners was significantly associated with an increased likelihood of current use of contraception and with future intention to use contraception among non-contracepting couples. Couples where one partner reported discussing family planning had a 25% point greater likelihood of current contraception use than couples where neither partner reported discussing, while couples where both partners reported discussing family planning had a 56% point greater likelihood of current contraception use, representing more than twice the effect size. Among couples not using contraception, couples where one partner reported discussing family planning had a 15% point greater likelihood of future intention to use contraception than couples where neither partner reported discussing, while couples where both partners reported discussing family planning had a 38% point greater likelihood of future intention to use contraception. CONCLUSION: These findings underscore the importance of the inclusion of both partners in family planning programs to increase communication about contraception and highlight the need for future research using couple-level data, measures, and analysis.

Strengthening methods for tracking adaptations and modifications to implementation strategies.

BACKGROUND: Developing effective implementation strategies requires adequate tracking and reporting on their application. Guidelines exist for defining and reporting on implementation strategy characteristics, but not for describing how strategies are adapted and modified in practice. We built on existing implementation science methods to provide novel methods for tracking strategy modifications. METHODS: These methods were developed within a stepped-wedge trial of an implementation strategy package designed to help community clinics adopt social determinants of health-related activities: in brief, an 'Implementation Support Team' supports clinics through a multi-step process. These methods involve five components: 1) describe planned strategy; 2) track its use; 3) monitor barriers; 4) describe modifications; and 5) identify / describe new strategies. We used the Expert Recommendations for Implementing Change taxonomy to categorize strategies, Proctor et al.'s reporting framework to describe them, the Consolidated Framework for Implementation Research to code barriers / contextual factors necessitating modifications, and elements of the Framework for Reporting Adaptations and Modifications-Enhanced to describe strategy modifications. RESULTS: We present three examples of the use of these methods: 1) modifications made to a facilitation-focused strategy (clinics reported that certain meetings were too frequent, so their frequency was reduced in subsequent wedges); 2) a clinic-level strategy addition which involved connecting one study clinic seeking help with community health worker-related workflows to another that already had such a workflow in place; 3) a study-level strategy addition which involved providing assistance in overcoming previously encountered (rather than de novo) challenges. CONCLUSIONS: These methods for tracking modifications made to implementation strategies build on existing methods, frameworks, and guidelines; however, as none of these were a perfect fit, we made additions to several frameworks as indicated, and used certain frameworks' components selectively. While these methods are time-intensive, and more work is needed to streamline them, they are among the first such methods presented to implementation science. As such, they may be used in research on assessing effective strategy modifications and for replication and scale-up of effective strategies. We present these methods to guide others seeking to document implementation strategies and modifications to their studies. TRIAL REGISTRATION: clinicaltrials.gov ID: NCT03607617 (first posted 31/07/2018).

A Review of the Community Health Club Literature Describing Water, Sanitation, and Hygiene Outcomes.

The Community Health Club (CHC) model is a community-based health promotion program that utilizes water, sanitation, and hygiene (WASH) education as the first stage of a longitudinal development process. Although the CHC model has been implemented in fourteen countries over 20 years, this is the first review of the literature describing the model's outcomes and impact. We conducted a review of the literature that provided quantitative or qualitative evidence of CHC interventions focused on WASH in low- and middle-income countries. We identified 25 articles that met our inclusion criteria. We found six major outcomes: WASH behaviors and knowledge, social capital, collective action, health, and cost or cost-effectiveness. The most consistent evidence was associated with WASH behaviors and knowledge, with significant effects on defecation practices, hand washing behaviors, and WASH knowledge. We also found qualitative evidence of impact on social capital and collective action. CHCs catalyze favorable changes in WASH behaviors and knowledge, yielding outcomes commensurate with other WASH promotion strategies. This review provides insights into the model's theory of change, helping identify areas for further investigation. The CHC model's holistic focus and emphasis on individual and collective change offer promising potential to address multiple health and development determinants.

Depicting "the system": How structural racism and disenfranchisement in the United States can cause dynamics in community violence among males in urban black communities.

BACKGROUND: A complex system of factors interacting across time shapes community violence. It is not well understood how features of persons, institutions and communities interact as a "system" to produce escalating community violence. We aimed to integrate theoretical and experiential knowledge among young African-American urban males to develop a concept model of key causal structures driving dynamics of community violence escalation over time in a context of historical racism. METHODS: We analyzed three published sources (two documentary films and one ethnography) containing lived experience perspectives on community violence escalation among African American males in three U.S. cities experiencing civil unrest due to structural racism. Qualitative descriptive analysis identified features in three key thematic categories: racialized policies and practices, economic and social disenfranchisement, and intrapsychic factors. We used causal loop diagramming, a system dynamics method designed for depicting dynamic hypotheses about the system structure producing observed trends over time, to represent the dynamic relationships among identified individual and community variables. RESULTS: The concept model contained key feedback structures capable of generating exponential growth in violence - providing detailed dynamic hypotheses about how violence can beget more violence ("violence escalation") within a community. Referred to as reinforcing feedback loops, these dynamics involved development of kill-or-be-killed norms, civil unrest emerging from racially oppressive policies, internalizing the code of the streets to seek outward displays of power, and processes that get one "stuck" or not able to break out of the system of violence. CONCLUSIONS: Qualitative system dynamics methods offered an approach to uncover and hypothesize the complex, dynamic relationships between variables shaping violence escalation trends. The resulting causal loop diagram hypothesized dynamic mechanisms capable of creating and perpetuating racial disparities in community violence escalation, that can be tested in future research to inform action to break observed cycles of community violence.