Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) in Appalachia: protocol for a group randomized, delayed intervention trial.

Appalachian regions of Kentucky and Ohio are hotspots for colorectal cancer (CRC) mortality in the USA. Screening reduces CRC incidence and mortality; however, screening uptake is needed, especially in these underserved geographic areas. Implementation science offers strategies to address this challenge. The aim of the current study was to conduct multi-site, transdisciplinary research to evaluate and improve CRC screening processes using implementation science strategies. The study consists of two phases (Planning and Implementation). In the Planning Phase, a multilevel assessment of 12 health centers (HC) (one HC from each of the 12 Appalachian counties) was conducted by interviewing key informants, creating community profiles, identifying HC and community champions, and performing HC data inventories. Two designated pilot HCs chose CRC evidence-based interventions to adapt and implement at each level (i.e., patient, provider, HC, and community) with evaluation relative to two matched control HCs. During the Implementation Phase, study staff will repeat the rollout process in HC and community settings in a randomized, staggered fashion in the remaining eight counties/HCs. Evaluation will include analyses of electronic health record data and provider and county surveys. Rural HCs have been reluctant to participate in research because of concerns about capacity; however, this project should demonstrate that research does not need to be burdensome and can adapt to local needs and HC abilities. If effective, this approach could be disseminated to HC and community partners throughout Appalachia to encourage the uptake of effective interventions to reduce the burden of CRC.

We conducted a multi-site study to evaluate and improve CRC screening processes using implementation science strategies at multiple levels including the patient, provider, health center, and community. Our goals were to increase rates of guideline-recommended CRC screening, follow-up, and referral-to-care in an Appalachian, medically underserved population.

Assessment of Kentucky's Local Health Department Cross-Jurisdictional Sharing: Strategy for Maximizing Efficiency.

OBJECTIVE: The purpose of this study was to examine patterns of cross-jurisdictional sharing across the 61 local public health jurisdictions (LHJs) in Kentucky. The opportunities to reduce the cost-of-service delivery for Kentucky's LHJs via cross-jurisdictional sharing present a mechanism to address financial instability across the state by achieving economies of scale, especially among smaller jurisdictions. DESIGN: A cross-sectional study design was used to examine patterns of cross-jurisdictional sharing across the 61 LHJs in Kentucky. The survey tool utilized was designed by the Center for Sharing Public Health Services, an initiative managed by the Kansas Health Institute with support from the Robert Wood Johnson Foundation. RESULTS: Seventy-two percent of the 61 LHJs in Kentucky responded to the survey. The majority of responding jurisdictions sharing services were rural, single-county jurisdictions, utilizing service-related informal sharing arrangements. The majority of health departments, when asked to identify which programmatic areas shared service arrangements were focused in, listed those services requiring intensive staff training such as Health Access Nurturing Development Services (HANDS) and epidemiology. Of particular interest were the services most infrequently shared such as communicable disease screening and treatment. CONCLUSIONS: This study suggests that, pre-COVID-19, a core group of primarily rural, single-county Kentucky local health departments has experience with cross-jurisdictional sharing. Among this group, engagement in informal arrangements was the form of cross-jurisdictional sharing predominantly used, with few jurisdictions reporting shared functions with joint oversight. When considering the potential benefits and efficiencies that cross-jurisdictional sharing can provide to public health departments and their communities, for some, COVID-19 may have been a catalyst to engage in sharing across health department jurisdictional lines.

Developing a Public Health Improvement Consortium in Appalachian Kentucky: Harnessing the Power of the Local Collective.

Many Appalachian counties in Kentucky are known for poor health and limited resources, however, by harnessing the power of relationships in the eight counties of the Kentucky River Area Development District, a team developed a public health improvement consortium to maximize power of the local collective.

Resources Used by Federally Qualified Health Center Leadership to Learn About Preventive Care Interventions.

Federally qualified health centers (FQHCs) serve patient populations that commonly have low preventive care utilization rates. Implementation of preventive care interventions (PCIs) may help decrease these care deficiencies. A survey of Kentucky FQHC leaders was conducted in 2019 to determine resources used to learn about PCIs and how leaders decide to implement them. Nineteen of Kentucky's 24 FQHCs completed the survey for a participation rate of 79%. Among participating FQHC leadership, the 3 resources that were very or somewhat likely to be used to learn about PCIs were advice or consultation from peers (100%), professional associations (95%), and nonacademic conferences/meetings (90%). The state primary care association and statewide community health center network were listed as the most helpful resources. These results highlight the types of resources used by FQHC leadership to learn about PCIs. Understanding preferred learning methods can help researchers improve outreach to FQHCs and facilitate dissemination of PCIs.

Building Cancer Prevention and Control Research Capacity in Rural Appalachian Kentucky Primary Care Clinics During COVID-19: Development and Adaptation of a Multilevel Colorectal Cancer Screening Project.

This study describes the development of a colorectal cancer (CRC) screening multilevel intervention with four primary care clinics in rural Appalachian Kentucky. We also discuss barriers experienced by the clinics during COVID-19 and how clinic limitations and needs informed project modifications. Four primary care clinics were recruited, key informant interviews with clinic providers were conducted, electronic health record (EHR) capacity to collect data related to CRC screening and follow-up was assessed, and a series of meetings were held with clinic champions to discuss implementation of strategies to impact clinic CRC screening rates. Analysis of interviews revealed multilevel barriers to CRC screening. Patient-level barriers included fatalism, competing priorities, and financial and literacy concerns. The main provider- and clinic-level barriers were provider preference for colonoscopy over stool-based testing and EHR tracking concerns. Clinics selected strategies to address barriers, but the onset of COVID-19 necessitated modifications to these strategies. Due to COVID-19, changes in clinic staffing and workflow occurred, including provider furloughs, a state-mandated pause in elective procedures, and an increase in telehealth. Clinics adapted screening strategies to match changing needs, including shifting from paper to digital educational tools and using telehealth to increase annual wellness visits for screening promotion. While significant delays persist for scheduling colonoscopies, clinics were encouraged to promote stool-based tests as a primary screening modality for average-risk patients.

Geographic Variation in the Structure of Kentucky's Population Health Systems: An Urban, Rural, and Appalachian Comparison.

Introduction: Research examining geographic variation in the structure of population health systems is continuing to emerge, and most of the evidence that currently exists divides systems by urban and rural designation. Very little is understood about how being rural and Appalachian impacts population health system structure and strength. Purpose: This study examines geographic differences in key characteristics of population health systems in urban, rural non-Appalachian, and rural Appalachian regions of Kentucky. Methods: Data from a 2018 statewide survey of community networks was used to examine population health system characteristics. Descriptive statistics were generated to examine variation across geographic regions in the availability of 20 population health activities, the range of organizations that contribute to those activities, and system strength. Data were collected in 2018 and analyzed in 2020. Results: Variation in the provision of population health protections and the structure of public health systems across KY exists. Urban communities are more likely than rural to have a comprehensive set of population health protections delivered in collaboration with a diverse set of multisector partners. Rural Appalachian communities face additional limited capacity in the delivery of population health activities, compared to other rural communities in the state. Implications: Understanding the delivery of population health provides further insight into additional system-level factors that may drive persistent health inequities in rural and Appalachian communities. The capacity to improve health happens beyond the clinic, and the strengthening of population health systems will be a critical step in efforts to improve population health.

Extension as a Backbone Support Organization for Physical Activity Promotion: A Collective Impact Case Study From Rural Kentucky.

BACKGROUND: Rural counties in the United States face daunting structural issues that reduce their populations' physical activity levels, including geographic isolation as well as deficits in infrastructure, public transportation, health care providers, and funding. METHODS: Funding from the Centers for Disease Control and Prevention provided an opportunity to assess how Extension enhanced the collective impact of systems-level physical activity promotion programming through a multisectoral coalition in Clinton County, Kentucky. RESULTS: The Extension-led coalition accomplished the 6 essential functions of a backbone support organization by identifying obesity as a critical local issue (function 1: providing overall strategic direction), developing a multisectoral coalition (function 2: facilitating dialog between partners), compiling data on the county's physical activity infrastructure (function 3: managing data collection and analysis), creating communication channels (function 4: handling communication), organizing community awareness events (function 5: coordinating community outreach), and securing additional grants (function 6: mobilizing funding). The average rating of Extension's leadership across multiple dimensions by 3 coalition members in a postproject survey was "excellent" on a 5-point Likert scale. CONCLUSIONS: Extension is well positioned through their mission, broad community engagement, data collection, needs assessment, community and academic relationships, and embeddedness in local communities to serve as the backbone support organizations for rural physical activity promotion coalitions.

Standardizing a federally qualified health center's preventive care processes: Use of failure modes and effects analysis.

: A multisite federally qualified health center used a Failure Modes and Effects Analysis to identify and correct potential challenges to the implementation of the proactive office encounter model. This model is designed to proactively identify and close preventive care gaps through electronic medical record use, new workflows, and staff training.

A Change-Management Approach to Closing Care Gaps in a Federally Qualified Health Center: A Rural Kentucky Case Study.

Effective organizational change requires intentional planning. We applied Kotter's 8-Step Process for Leading Change model in understanding and evaluating how a federally qualified health center in rural Kentucky implemented a significant organizational change - a proactive office encounter (POE) model - to improve preventive care service delivery, close care gaps, and reduce health disparities among its patients. We completed qualitative interviews with 21 clinic personnel (eg, administrators, physicians, support staff, care coordinators) who were directly involved with POE implementation. We found evidence of steps 1 through 7 of Kotter's 8 steps of change in the POE implementation process. Step 8, anchoring new approaches in the organizational culture, was an area for improvement. Change-management models, such as Kotter's 8-Step Process for Leading Change, provide a systematic guide for health clinics to implement sustainable organizational change aimed at improving patient health outcomes.

Pursuing Public Health Accreditation: A Focus on HOW.

INTRODUCTION: Balancing competing imperatives of conserving scarce resources while improving organizational performance and community health, many local health departments (LHDs) have decided to pursue national, voluntary public health accreditation as a guide to improvement, but how to do so in the most efficient way possible remains a question for many. METHODS: This study employed a participatory action research approach in which LHD directors and accreditation coordinators from 7 accredited and 3 late-stage accreditation ready Kentucky LHD jurisdictions participated. Participants organized a set of accreditation deliverables into a chronological sequencing of each site's accreditation readiness process, which was then coded by researchers to identify similarities and differences. RESULTS: All participating jurisdictions had all-hazards emergency operations plans and public health emergency operations plans while none had workforce development plans, quality improvement plans, or performance management plans before launching accreditation readiness activities. Also identified were the number of accreditation deliverables attempted, simultaneously, by each site and the importance of specific deliverables having a singular focus. Sequences of work on specific deliverables by the majority of participants included completing work on the quality improvement plan immediately, followed by the performance management plan, the Community Health Assessment before the Community Health Improvement Plan, and a strategic plan, followed by a workforce development plan. Factors influencing accreditation readiness processes, elements for sustaining processes, and lessons learned throughout the pursuit of accreditation were also provided by participants. CONCLUSIONS: Recognizing the impact of staff availability, staff skill sets, training, and available financial resources on the pursuit of accreditation, participants determined that aggregating lessons learned into a flowchart highlighting the interconnectedness of accreditation deliverables could produce a road map for LHDs. Accreditation deliverables could be attempted in a logical, efficient order particularly valuable to small LHDs with limited resources and yet adaptable for those jurisdictions able to devote more resources to the process.

Cross Jurisdictional Boundaries to Build a Health Coalition: A Kentucky Case Study.

Cross-jurisdictional sharing is accomplished through collaboration across jurisdictional boundaries to deliver essential public health services and solve problems that cannot be easily addressed by single organizations or jurisdictions. Partners across 10 counties and three public health jurisdictions of the Barren River Area Development District (BRADD) convened as Barren River Initiative to Get Healthy Together (BRIGHT), a community health improvement coalition. Focus groups and interviews with BRIGHT members indicate that the use of effective strategies to focus collaborative health improvement efforts fosters a cohesive coalition even when the group is populated by individuals from across public health jurisdictional boundaries. Focusing strategies identified included: the importance of organizing workgroups so members can draw upon expertise, adoption of a community engagement model for health assessment and improvement; and use of a facilitator, who offers guidance and administrative support to groups and focuses members on accomplishing goals.

Facilitating Community Health Improvement Capacity Through Nongovernmental Public Health Partners.

The purpose of this study was to evaluate the effectiveness of the Facilitating the Community Health Improvement Process training in increasing the capacity of nongovernmental public health partners to serve as facilitators and supporters of community health improvement coalitions. Ten members of WellCare Advocacy and Community-Based Program teams (CommUnity Advocates) serving communities across the country were identified to participate in the pilot training group. They completed pre- and posttraining surveys to evaluate knowledge of community health improvement process models and facilitation techniques, as well as qualitative interviews to assess use of training material 6 months after the training. Results of the project revealed successful use of content from the training, which enhanced the impact of nongovernmental public health partners as facilitators of community health improvement planning and implementation.

Adaptation of an Evidence-Based Intervention to Improve Preventive Care Practices in a Federally Qualified Health Center in Appalachian Kentucky.

University collaboration with a federally qualified health center resulted in adaptation and implementation of an evidenced-based intervention promoting preventive care, including cancer screening. Here, we focus on strategic planning, formative research, staff commitment, patient perceptions, data refinements, and organizational investments; successes, lessons learned, and challenges are also discussed.

Organizational Variation in Implementation of an Evidence-Based Human Papillomavirus Intervention.

INTRODUCTION: "1-2-3 Pap" is a video-based intervention designed to improve human papillomavirus (HPV) vaccine adherence rates among young women in rural Eastern Kentucky. The efficacy trial for the original intervention linked video exposure with increased likelihood of vaccine series completion among the target audience. Given their historic focus on prevention, local health departments were selected as pilot sites to study implementation of 1-2-3 Pap in a public health setting and identify site-specific variations in its implementation. METHODS: A mixed-method, pre- and post-comparison pilot study conducted between October 2013 and April 2014 addressed three primary research questions: (1) how specific implementation planning activities using existing organizational resources and processes affect the selection and optimization of dissemination channels for evidence-based public health interventions; (2) what organizational resources, processes, or other attributes facilitate or impede implementation of evidence-based public health interventions; and (3) how variation in dissemination channels corresponds with intervention outcomes. RESULTS: Although analysis conducted in October 2014 found that the pilot study did not generate significant changes in HPV vaccine rates, data yielded from the Organizational Readiness to Change Assessment survey instrument and process evaluation interviews revealed variation in pre-study planning and in the use and coordination of staff, the adaptation of materials provided for implementation, and sites' ability to access HPV vaccine rate data throughout the study. CONCLUSIONS: The mixed-method pilot study advances dissemination and implementation science through identification of variation in planning activities and use of organizational resources and processes for implementation of prevention interventions in public health settings.

Collective Impact through Public Health and Academic Partnerships: A Kentucky Public Health Accreditation Readiness Example.

In the ever-changing, resource-limited public health environment, the use of partners found in the faculty and students of Colleges of Public Health can provide training, consultation, and technical assistance needed to increase local health department (LHD) workforce capacity to meet new public health demands including national public heath accreditation. This manuscript describes the provision of the backbone support activities of facilitation, data management, and project management by University of Kentucky's College of Public Health to Kentucky's LHDs seeking national public health accreditation.

The Journey toward Voluntary Public Health Accreditation Readiness in Local Health Departments: Leadership and Followership Theories in Action.

Local health department directors' intent on getting their organizations ready for accreditation must embrace the blurring of leader/follower lines and create an accreditation readiness team fueled not by traditional leader or follower roles but by teamship.

Public health accreditation: rubber stamp or roadmap for improvement.

OBJECTIVES: We identified the characteristics of local health departments (LHDs) that intended to seek accreditation, and also examined the association between that intent and a complete community health assessment (CHA), community health improvement plan, agency strategic plan, or other specific accreditation requirements. METHODS: We analyzed data from the 2010 profile survey of LHDs conducted by the National Association of County and City Health Officials (n = 267). RESULTS: Those LHDs that conducted a CHA (adjusted odds ratio [AOR] = 0.62; 95% confidence interval [CI] = 0.38, 1.00; P = .05) and developed a strategic plan (AOR = 0.30; 95% CI = 0.12, 0.74; P = .01) were less likely to have an intent to pursue accreditation in the first 2 years of the program. By contrast, those LHDs that were engaged in quality improvement (QI) activities were approximately 2.6 times more likely to pursue accreditation compared with those LHDs that did not have any QI activities (P < .001). CONCLUSIONS: Based on our findings, national public health accreditation might be the vehicle LHDs could use to improve their operating environments, better manage their resources, and reap the rewards associated with meeting national industry standards.

Designing for dissemination: lessons in message design from "1-2-3 pap".

Despite a large number of evidence-based health communication interventions tested in private, public, and community health settings, there is a dearth of research on successful secondary dissemination of these interventions to other audiences. This article presents the case study of "1-2-3 Pap," a health communication intervention to improve human papillomavirus (HPV) vaccination uptake and Pap testing outcomes in Eastern Kentucky, and explores strategies used to disseminate this intervention to other populations in Kentucky, North Carolina, and West Virginia. Through this dissemination project, we identified several health communication intervention design considerations that facilitated our successful dissemination to these other audiences; these intervention design considerations include (a) developing strategies for reaching other potential audiences, (b) identifying intervention message adaptations that might be needed, and (c) determining the most appropriate means or channels by which to reach these potential future audiences. Using "1-2-3 Pap" as an illustrative case study, we describe how careful planning and partnership development early in the intervention development process can improve the potential success of enhancing the reach and effectiveness of an intervention to other audiences beyond the audience for whom the intervention messages were originally designed.

Quality improvement activities of local health departments during the 2008-2010 economic recession.

BACKGROUND: A review of the work of researchers in the field of quality reveals a connection between the use of quality improvement (QI) concepts and improved financial performance. The disconnect between the expanding role of public health and the levels of per capita spending to support this role suggests that local health departments with a change in funding might benefit by employing QI to increase service delivery efficiency. PURPOSE: To examine the relationship between changes in local health department (LHD) total revenue during the 2008-2010 economic recession and changes in LHD quality improvement activities during the same period. METHODS: A matched-pairs study assessed change in revenue and associated change in QI activities at two points of time, 2008 and 2010. The study was completed in 2013. A proportional odds regression model estimated the adjusted ORs, measuring the association between change in QI activities and total revenue change, controlling for demographics, leadership QI training, and accreditation intention. RESULTS: Neither changes in revenue nor changes in expenses predicted change in QI activities in LHDs. Enhanced QI activities were found in LHDs led by a director with a master's degree, led by directors trained in QI, or those serving medium-sized (50,000-499,000) jurisdictions. CONCLUSIONS: This study revealed that neither changes in revenue nor changes in LHD expenses predict enhanced QI activities. Rather, improvements appear to be more related to characteristics of local health department leaders, which suggests areas to focus on for future efforts in public health services improvement.

Partners for public health.

Hospitals and public health departments share the same goals.