Peer Reviewed: The Role of State Health Departments in Supporting Community-based Obesity Prevention

Background

Recent national attention to obesity prevention has highlighted the importance of community-based initiatives. State health departments are in a unique position to offer resources and support for local obesity prevention efforts.

Community Context

In North Carolina, one-third of children are overweight or obese. North Carolina''s Division of Public Health supports community-based obesity prevention by awarding annual grants to local health departments, providing ongoing training and technical assistance, and engaging state-level partners and resources to support local efforts.

Methods

The North Carolina Division of Public Health administered grants to 5 counties to implement the Childhood Obesity Prevention Demonstration Project; counties simultaneously carried out interventions in the community, health care organizations, worksites, schools, child care centers, and faith communities.

Outcome

The North Carolina Division of Public Health worked with 5 local health departments to implement community-wide policy and environmental changes that support healthful eating and physical activity. The state health department supported this effort by working with state partners to provide technical assistance, additional funding, and evaluation.

Interpretation

State health departments are well positioned to coordinate technical assistance and leverage additional support to increase the strength of community-based obesity prevention efforts.     

A Framework for Mobilizing Communities to Advance Local Tobacco Control Policy: The Los Angeles County Experience

The Los Angeles County Tobacco Control and Prevention Program was significantly restructured in 2004 to improve capacity for local policy adoption. Restructuring included creating a fully staffed and trained policy unit; partnering with state-funded tobacco control organizations to provide high-quality, continuous technical assistance and training; implementing a highly structured policy adoption approach; expanding community capacity building; and establishing local coalitions to mobilize communities. Over the ensuing 6 years (2004–2010), 97 tobacco control policies were enacted in the county’s 88 cities and unincorporated area, including 79 that were attributable to the program. By comparison, only 15 policies were enacted from 1998 to 2003. Expanding policy adoption capacity through program restructuring may be achievable in other local jurisdictions.

KEY FINDINGS

• ▪From 2004 to 2010, 97 tobacco control policies were enacted in Los Angeles County’s 88 cities and unincorporated area, including 79 attributable to the program (only 15 policies were enacted from 1998 to 2003).
• ▪Increases in tobacco policy adoptions were attributed to the comprehensive restructuring efforts, including creating a Policy and Planning Unit, establishing key partnerships to provide technical assistance and training, extensive capacity building, use of policy organizing tools, and forming coalitions to mobilize communities.

Municipal-level tobacco control policies, such as indoor and outdoor smoking restrictions, play a vital role in local tobacco prevention and control efforts as well as in building grass roots support for state legislation.1 In 2004, the Los Angeles County Department of Public Health''s Tobacco Control and Prevention Program (TCPP) embarked on a comprehensive restructuring to focus its tobacco control efforts on local policy adoption in the county, a jurisdiction that has 88 cities and a large unincorporated area. We describe the elements of this transformation process and the lessons learned.     

Balancing Program and Research Integrity in Community Drug Abuse Prevention: Project STAR Approach

This paper focuses on the process of community-based drug prevention programming using an ongoing, multiple community project (Project STAR) as an illustration. Particular attention is paid to problems and strategies for balancing program and research integrity over the long-term. Specific strategies are discussed for obtaining and sustaining support for the program, quality control throughout program delivery, and accommodation of both research and program objectives.     

Building capacity for health promotion--a case study from China

During the period 1997-2000 a technical assistance project to build capacity for community-based health promotion was implemented in seven cities and one province in China. The technical assistance project formed part of a much larger World Bank supported program to improve disease prevention capabilities in China, commonly known as Health VII. The technical assistance project was funded by the Australian Agency for International Development. It was designed to develop capacity within the Ministry of Health (MOH) and the cities and province in the management of community-based health promotion projects, as well as supporting institutional development and public health policy reform. There are some relatively unique features of this technical assistance which helped shape its implementation and impact. It sought to provide the Chinese MOH and the cities and province with an introduction to comprehensive health promotion strategies, in contrast to the more limited information, education and communication strategies. The project was provided on a continuing basis over 3 years through a single institution, rather than as a series of ad hoc consultancies by individuals. Teaching and learning processes were developmental, leading progressively to a greater degree of local Chinese input and management to ensure sustainability and maintenance of technical support for the project. Based on this experience, this paper presents a model for capacity building projects of this type. It describes the education, training and planning activities that were the key inputs to the project, as well as the limited available evidence on the impact of the project. It describes how the project evolved over time to meet the changing needs of the participants, specifically how the content of the project shifted from a risk-factor orientation to a settings-based focus, and the delivery of the project moved from an expert-led approach to a more participatory, problem based learning approach. In terms of impact, marked differences before and after the implementation of the training activities were identified in key areas for reform, in addition to the self reported positive change in knowledge, and a high level of participant satisfaction. Key lessons are summarized. Technical assistance projects of this kind benefit from continuity and a high level of coordination, the provision of culturally and linguistically appropriate teaching, and a clear understanding of the need to match workforce development with organizational/institutional development.     

Critical factors in building local capacity to prevent and control injury: North Carolina's experience.

In fiscal years 1991-1992, a state injury control program awarded $258,000 to 33 local health departments for 50 community-based injury prevention projects. To determine whether this program helped build the capacity of local health departments to prevent injury, project reports were reviewed and project directors were surveyed. For four of six factors developed to assess capacity building, success was demonstrated for all local projects to some degree. However, continued support is necessary to assure that the local health departments can sustain this capacity and continue to develop proficiency in data monitoring and evaluation.     

Translating a Fall Prevention Intervention Into Practice: A Randomized Community Trial

Objectives. We examined whether community translation of an effective evidence-based fall prevention program via standard monetary support can produce a community-wide reduction in fall injuries in older adults and evaluated whether an enhanced version with added technical support and capacity building amplified the fall reduction effect.Methods. We completed a randomized controlled community trial among adults aged 65 and older in (1) 10 control communities receiving no special resources or guidance on fall prevention, (2) 5 standard support communities receiving modest funding to implement Stepping On, and (3) 5 enhanced support communities receiving funding and technical support. The primary outcome was hospital inpatient and emergency department discharges for falls, examined with Poisson regression.Results. Compared with control communities, standard and enhanced support communities showed significantly higher community-wide reductions (9% and 8%, respectively) in fall injuries from baseline (2007–2008) to follow-up (2010–2011). No significant difference was found between enhanced and standard support communities.Conclusions. Population-based fall prevention interventions can be effective when implemented in community settings. More research is needed to identify the barriers and facilitators that influence the successful adoption and implementation of fall prevention interventions into broad community practice.In 2010, injuries resulting from unintentional falls in adults aged 65 years and older accounted for 21 649 deaths nationally (54 per 100 000 population), which was the leading cause of fatal injury in that age group and the ninth overall cause of death.1 On the basis of 2011 emergency department data, the Centers for Disease Control and Prevention (CDC) estimated that more than 2.4 million unintentional fall injuries required treatment in emergency departments in adults aged 65 years and older, appreciably more than any other injury-related cause of emergency department visits.1 The CDC estimated that fatal and nonfatal unintentional falls in adults aged 65 years and older have lifetime costs greater than $18.6 billion (according to 2005 prices).2Wisconsin has a higher fall injury mortality rate than does the nation as a whole.3,4 In 2010, Wisconsinites aged 65 years and older had the second highest rate of unintentional fall injury fatality among all states for that age group, a rate of 111 per 100 000 population.1 Morbidity resulting from unintentional fall-related injuries in Wisconsin is also substantial. In 2010, the inpatient hospitalization rate due to falls was 2175 per 100 000 population aged 65 years and older,5 and the emergency department visit rate was 3892 per 100 000.6A challenge for the field of injury prevention and control is the translation of research findings into effective community-based prevention programs and practices.7 Systematic reviews report a steady increase in the number of effective interventions for the prevention of falls in older adults.8,9 Clinical practice guidelines and a compendium of community-based fall prevention programs have been published for prevention professionals.10,11 Despite the existence of evidence-based fall prevention interventions, there has been minimal widespread implementation by public health and aging agencies. Wandersman et al.12 identified the need for an effective way to bridge the gap between research and practice.To address the question of how best to translate evidence-based interventions into community practice and whether this translation can produce a community-wide reduction in hospitalizations and emergency department visits for fall injuries, we conducted a randomized community trial from May 2008 through January 31, 2012. The intervention provided enhanced technical and capacity-building support (enhanced support system) to facilitate implementation of the evidence-based fall prevention program, Stepping On. Stepping On, a multifaceted intervention developed by Clemson et al.,13 showed a 31% reduction in fall rate for program participants compared with nonparticipants.14 The enhanced support system provided technical assistance, capacity building, and support in community and infrastructure assessment; engagement of key agencies; and access to local data to build a broader strategy around fall prevention in the community. Here we describe the effect of the enhanced support system intervention on fall injury hospital and emergency department discharge occurrence in the enhanced support system communities compared with standard and control communities.     

Developing cancer control capacity in state and local public health agencies.

In 1986, the National Cancer Institute began a major grant program to enhance the technical capabilities of public health departments in cancer prevention and control. This effort, commonly referred to as "capacity building" for cancer control, provided funding to support eight State and one local health department. The program focused on developing the knowledge and skills of health department personnel to implement intervention programs in such areas as smoking cessation, diet modification, and breast and cervical cancer screening. The grants ranged from 2 to 5 years in length, with funding of $125,000 to $1.6 million per grant. The total for the program was $7.4 million. While the priorities set for these grants were nominally similar, their capacity building activities in cancer prevention and control evolved into unique interventions reflecting the individual needs and priorities of each State or locality. Their experiences illustrate that technical development for planning, implementing, and evaluating cancer prevention and control programs is a complex process that must occur at multiple levels, regardless of overall approach.(ABSTRACT TRUNCATED AT 250 WORDS)     

Peer Reviewed: Training and Technical Assistance to Enhance Capacity Building Between Prevention Research Centers and Their Partners

Introduction

The Centers for Disease Control and Prevention has administered the Prevention Research Centers Program since 1986. We quantified the number and reach of training programs across all centers, determined whether the centers'' outcomes varied by characteristics of the academic institution, and explored potential benefits of training and technical assistance for academic researchers and community partners. We characterized how these activities enhanced capacity building within Prevention Research Centers and the community.

Methods

The program office collected quantitative information on training across all 33 centers via its Internet-based system from April through December 2007. Qualitative data were collected from April through May 2007. We selected 9 centers each for 2 separate, semistructured, telephone interviews, 1 on training and 1 on technical assistance.

Results

Across 24 centers, 4,777 people were trained in 99 training programs in fiscal year 2007 (October 1, 2006-September 30, 2007). Nearly 30% of people trained were community members or agency representatives. Training and technical assistance activities provided opportunities to enhance community partners'' capacity in areas such as conducting needs assessments and writing grants and to improve the centers'' capacity for cultural competency.

Conclusion

Both qualitative and quantitative data demonstrated that training and technical assistance activities can foster capacity building and provide a reciprocal venue to support researchers'' and the community''s research interests. Future evaluation could assess community and public health partners'' perception of centers'' training programs and technical assistance.     

Using a participatory approach to provide assistance to community-based organizations: the Seattle Partners Community Research Center.

Community-based organizations (CBOs), including grassroots, voluntary organizations, are an important part of any strategy for addressing social determinants of health. Because of the challenges faced by CBOs, "enabling systems" may be neededto help them survive and fulfill theirmissions, andresearchers have a variety of skills that allow them to play a role in such systems. The potential for researchers to play a role in supporting CBOs led the Seattle Urban Research Center (known as Seattle Partners) to establish a community research center (CRC) as one of its core projects. This article describes the operation of the Seattle Partners CRC and gives examples of how it has worked collaboratively with CBOs in providing technical assistance. The Discussion section draws from the CRC experience to examine the benefits and challenges of collaboration and the trade-off between capacity building and providing direct technical assistance in promoting long-term CBO viability.     

The SISTA pilot project: understanding the training and technical assistance needs of community-based organizations implementing HIV prevention interventions for African American women--implications for a capacity building strategy

The disproportionate rates of HIV/AIDS among African American women in the U.S. signify the ongoing need for targeted HIV prevention interventions. Additionally, building the capacity of service providers to sustain prevention efforts is a major concern. The Centers for Disease Control and Prevention (CDC) conducted a pilot project to disseminate the Sisters Informing Sisters about Topics on AIDS (SISTA), an HIV prevention intervention designed for African American women. The project was to inform the diffusion process and examine the training and technical assistance needs of participating community-based organizations. Results demonstrated a need for extensive pre-planning and skills-building prior to implementation.     

Perceptions of evidence-based programs among community-based organizations tackling health disparities: a qualitative study

Dissemination of prevention-focused evidence-based programs (EBPs) from research to community settings may improve population health and reduce health disparities, but such flow has been limited. Academic-community partnerships using community-based participatory research (CBPR) principles may support increased dissemination of EBPs to community-based organizations (CBOs). This qualitative study examined the EBP-related perceptions and needs of CBOs targeting underserved populations. As part of PLANET MassCONECT, a CBPR study, we conducted six key informant interviews with community leaders and four focus groups with CBO staff members in Boston, Worcester and Lawrence, Massachusetts, in 2008. Working definitions of EBPs among CBO staff members varied greatly from typical definitions used by researchers or funders. Key barriers to using EBPs included: resource constraints, program adaptation challenges and conflicts with organizational culture. Important facilitators of EBP usage included: program supports for implementation and adaptation, collaborative technical assistance and perceived benefits of using established programs. This exploratory study highlights differences among key stakeholders regarding the role of evidence in program planning and delivery. An updated perspective should better incorporate CBO perspectives on evidence and place greater, and much needed, emphasis on the impact of context for EBP dissemination in community settings.     

The SISTA Pilot Project: Understanding the Training and Technical Assistance Needs of Community-Based Organizations Implementing HIV Prevention Interventions for African American Women-Implications for a Capacity Building Strategy

ABSTRACT

The disproportionate rates of HIV/AIDS among African American women in the U.S. signify the ongoing need for targeted HIV prevention interventions. Additionally, building the capacity of service providers to sustain prevention efforts is a major concern. The Centers for Disease Control and Prevention (CDC) conducted a pilot project to disseminate the Sisters Informing Sisters about Topics on AIDS (SISTA), an HIV prevention intervention designed for African American women. The project was to inform the diffusion process and examine the training and technical assistance needs of participating community-based organizations. Results demonstrated a need for extensive pre-planning and skills-building prior to implementation.     

Cross-cultural considerations in the conduct of community-based participatory research

This article explores cross-cultural challenges that arise when university and community members collaborate in community-based participatory research. As part of a project for primary prevention of human immunodeficiency virus (HIV) infection, researchers trained community leaders to jointly develop a research question and conduct a pilot qualitative study in a Puerto Rican community in Massachusetts. Different priorities of the community and university members about HIV as a research topic underscored the need to continuously reflect on developing a research question in community-based participatory research. Recognizing the cultural assumptions of both university and community members is an important component of capacity building among collaborative research teams.     

Injury prevention capacity building in New York State: federal support played a significant role.

Federal funds contributed substantively to an expanded infrastructure for injury prevention (IP) in New York State at all levels. Indicators of capacity building included increased recognition of injury as a priority public health (PH) issue, enhanced interagency collaboration around IP, stimulation of planning around preventive strategies, training of more PH practitioners in IP, improved use of injury surveillance data, increased local IP projects, development of a PH approach to violence prevention, and broadened statutory authority for IP. Practical "lessons learned" offer generalizable insights. Specific funding strategies to support IP infrastructure and to link research with application can maximize the effectiveness of future injury capacity building efforts.     

The President's Emergency Plan for AIDS Relief: from successes of the emergency response to challenges of sustainable action

The President's Emergency Plan for AIDS Relief (PEPFAR) has made a major contribution to the reduction of the global HIV/AIDS burden. The program initially focused on rapidly scaling up treatment and prevention services in fifteen low-income countries, then transitioned to an approach that emphasizes sustainability, defined as the capacity to maintain program services after financial, managerial, and technical assistance from the United States and other external donors essentially ceases. Today, PEPFAR continues to expand its HIV prevention, treatment, and care activities while also supporting capacity-building initiatives, coordination efforts, and implementation science. The latter is research focused on improving service delivery, maximizing cost-effectiveness, and achieving public health impact. Recent advances in both scientific knowledge and the provision of prevention, treatment, and care services have bred cautious optimism about greatly reducing the spread of HIV. However, success will require a substantial increase in resources, strengthened health systems, renewed commitment to HIV prevention, and well-financed efforts to develop an effective HIV vaccine.     

Community-based prevention marketing: organizing a community for health behavior intervention

This article describes the application and refinement of community-based prevention marketing (CBPM), an example of community-based participatory research that blends social marketing theories and techniques and community organization principles to guide voluntary health behavior change. The Florida Prevention Research Center has worked with a community coalition in Sarasota County, Florida to define locally important health problems and issues and to develop responsive health-promotion interventions. The CBPM framework has evolved as academic and community-based researchers have gained experience applying it. Community boards can use marketing principles to design evidence-based strategies for addressing local public health concerns. Based on 6 years of experience with the "Believe in All Your Possibilities" program, lessons learned that have led to revision and improvement of the CBPM framework are described.     

The role of research in a technical assistance agency: the case of the 'German Agency for Technical Co-operation'

Technical assistance agencies have a sustainable impact on the health systems of the countries they are operating in. As well as policy-makers at the national level, technical assistance agencies see themselves confronted that their interventions should be based on evidence, usually meaning the results of research. This study has the aim to analyse role of research in the implementation of technical assistance. We sent a questionnaire to all health project managers of the 'German Agency for Technical Co-operation' and performed a qualitative case study in one of the health projects. Forty-seven of 80 (58.8%) of the questionnaires were completed and sent back. The managers considered publications of International Organisations (IOs), scientific articles and local research as most important for their work. The case study showed application problems in the daily work. Research use not only depends on the relevance of the data but also on analytical skills, linguistic barriers and technical access to research by the potential users. The role of knowledge and information management has to be clearly defined in an organisation of technical assistance. The specific needs at the different levels have to be analysed so that skills and resources can be allocated adequately.     

“It takes more than a fellowship program”: reflections on capacity strengthening for health systems research in sub-Saharan Africa

Sub-Saharan Africa (SSA) experiences an acute dearth of well-trained and skilled researchers. This dearth constrains the region’s capacity to identify and address the root causes of its poor social, health, development, and other outcomes. Building sustainable research capacity in SSA requires, among other things, locally led and run initiatives that draw on existing regional capacities as well as mutually beneficial global collaborations. This paper describes a regional research capacity strengthening initiative—the African Doctoral Dissertation Research Fellowship (ADDRF) program. This Africa-based and African-led initiative has emerged as a practical and tested platform for producing and nurturing research leaders, strengthening university-wide systems for quality research training and productivity, and building a critical mass of highly-trained African scholars and researchers. The program deploys different interventions to ensure the success of fellows. These interventions include research methods and scientific writing workshops, research and reentry support grants, post-doctoral research support and placements, as well as grants for networking and scholarly conferences attendance. Across the region, ADDRF graduates are emerging as research leaders, showing signs of becoming the next generation of world-class researchers, and supporting the transformations of their home-institutions. While the contributions of the ADDRF program to research capacity strengthening in the region are significant, the sustainability of the initiative and other research and training fellowship programs on the continent requires significant investments from local sources and, especially, governments and the private sector in Africa. The ADDRF experience demonstrates that research capacity building in Africa is possible through innovative, multifaceted interventions that support graduate students to develop different critical capacities and transferable skills and build, expand, and maintain networks that can sustain them as scholars and researchers.     

Participatory research strategies in nuclear risk management for native communities

The Nuclear Risk Management for Native Communities (NRMNC) project is a collaborative academic, community-based, tribal project, which conducts the three essential elements of participatory research: research, education, and community action, named here as "community-based hazards management." This article describes the goals and outcomes of this effort in assisting Native American communities in Nevada, Utah, and Southern California affected by nuclear fallout from U.S. weapons testing in the 1950s and 1960s. The NRMNC project sought to create new models for dealing with health research and risk communication needs in an environmental justice setting. The following results of this four-year project are discussed: (1) building a community-based environmental health infrastructure, (2) building community capacities through workshops and educational materials, (3) conducting both technical and community research, and (4) facilitating community-based hazards management planning. We describe such positive outcomes as the improvements in the scientific database through participatory research activities, the development of equitable relationships between scientists and community members, and the creation of a sustaining program intervention for long-term community needs. The project's outcomes are presented as an expansion to limited scientific risk management outcomes in the environmental health field that often are solely quantitative and lack relevance to community concerns about environmental health impacts from contamination.