A process evaluation of the National Cancer Institute's Data-based Intervention Research program: a study of organizational capacity building

This paper reports on a qualitative process evaluation of the Data-based Intervention Research (DBIR) program, that was funded by the National Cancer Institute (NCI) and operated in 21 states and the District of Columbia. The goal of DBIR was to build a foundation within state health agencies to ensure the translation of cancer control science into practice. NCI's objective reflected the readiness of cancer control research for public health application, the paucity of cancer control activity within public health settings and the recognition that state health agencies could play a critical role in the effective transfer of research results into public health practice. The qualitative process evaluation reported in this paper is based on one case study of four DBIR programs. The present study indicates that the four state health agencies executed the DBIR program with fidelity. Also, the four states offered a balanced assessment of NCI's role in enabling the state agency operation of DBIR, providing numerous citations illustrating how NCI successfully facilitated organizational capacity as compared to fewer mentions of ways NCI was less than successful. Thus, in funding the DBIR model, NCI was successful in raising state health agency capacity to implement cancer prevention and control programming. Implications for capacity building in state health departments are discussed.     

Using data to plan public health programs: experience from state cancer prevention and control programs.

In 1989 the National Cancer Institute funded the second round of Data-Based Intervention Research (DBIR) cooperative agreements with state health agencies to implement a four-phase cancer prevention and control planning model that would establish ongoing cancer prevention and control programs. Activities included identifying and analyzing relevant data to develop a state cancer control plan. The authors reviewed the data analysis and planning activities of five DBIR projects to understand: how states use different types of available data to make public health planning decisions, in what ways available data were sufficient or insufficient for this planning, and perceived costs and benefits of a data-based planning approach. Many of the sources of and ways in which health statistics and behavioral data were used were consistent across states. Sources and use of data on the availability and utilization of health services and on cancer control policies were less consistent. Data were most useful in making decisions to address specific cancers, to target populations or regions, to identify general barriers, and to influence policy makers and the public. Data were less influential in identifying specific barriers within target populations and determining what proven intervention components should be implemented and how. The process of pulling this information together and involving working groups and coalitions was considered very beneficial in establishing the credibility of the state health agency in addressing the state''s cancer problem. This process relied on a national infrastructure that provided financial resources, sources of data, and research results.     

The National Breast and Cervical Cancer Early Detection Program: a comprehensive public health response to two major health issues for women.

The passage of the Breast and Cervical Cancer Mortality Prevention Act established a nationwide, comprehensive public health program to increase access to breast and cervical cancer screening services for women who are medically underserved. This act created the first opportunity for state health agencies to build a public health infrastructure for cancer control at the state and community levels. The Congress appropriated $30 million in fiscal year 1991 for the first year of this program. In the summer of 1991, the Centers for Disease Control and Prevention (CDC) used a competitive application process to fund the first eight states to establish early detection programs. Since then, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has become a nationwide program with a budget of $100 million. Thirty-five states and nine American Indian Tribes are supported to implement comprehensive screening programs. Fifteen states, three territories, and the District of Columbia receive planning and infrastructure grants as part of the Capacity Building Program. The NBCCEDP surveillance data through January 31, 1995 shows that 556,003 screening tests have been provided to women who are medically underserved. The success of NBCCEDP has contributed to the growing pressure on state health agencies to focus more attention and resources on chronic disease prevention and control.     

The best practices: use of the guidelines by ten state tobacco control programs

BACKGROUND: The Best Practices for Comprehensive Tobacco Control Programs by the Centers of Disease Control and Prevention was the first national resource to define the nine required components of a comprehensive state tobacco control program. This evaluation examined how states used the guidelines in their program planning, and identifies strengths and weaknesses of the guidelines. METHODS: During 2002-2003, data were collected and analyzed from ten state tobacco control programs on familiarity, funding, and use of the guidelines. Data were collected via written surveys and qualitative interviews with key tobacco control partners in the states. The typical number of participants interviewed was 17, representing an average of 15 agencies per state. RESULTS: Lead agencies and advisory agencies were the most familiar with the guidelines, while other state agencies were less aware of the guidelines. Participants' prioritization of the nine components was closely related to the lead agencies' estimated category expenditures. Three states modified the guidelines to develop more-tailored frameworks. Major strengths of the guidelines included providing a basic program framework and state-specific funding recommendations. The guidelines did not address implementation strategies or tobacco-related disparities, and had not been updated with current evidence-based research. CONCLUSIONS: The guidelines are important recommendations for state tobacco control programs. To continue to be useful to states, the guidelines need to be updated to address implementation and tobacco disparities, and include additional evidence-based examples. Active dissemination of updated guidelines needs to be increased beyond typical consumers to other tobacco control partners such as coalitions and other state agencies.     

Eat for health: a nutrition and cancer control supermarket intervention

The growing evidence linking dietary patterns to the incidence and prevention of chronic disease has prompted a number of prominent health and scientific agencies to publish dietary guidelines for the public. Some dietary guidelines address specific diseases, such as cancer or heart disease; others focus on overall health promotion. This situation has created a demand for nutrition education and information programs for the public. Increasingly, supermarkets are seen as potential sites for effective consumer education. Eat for Health is a joint research study by the National Cancer Institute (NCI) and Giant Food Inc., a regional supermarket chain in the Washington-Baltimore area. The study's goal was to test the feasibility of supermarkets as a site for consumer nutrition education. Eat for Health's educational focus was diet and cancer control issues in the context of dietary patterns that promote health. Particular attention was paid to reduction of fat intake and increases in consumption of dietary fiber from grains, vegetables, and fruits. Analysis of program results is currently underway; data should be available in early 1990.     

State administration and financing of family planning services

A 1971 survey by the Center for Family Planning Program Development consisted of a questionnaire mailed to health and welfare directors in 50 states and 5 federal jurisdictions concerning their family planning policies and administrative practices. 52 agencies responded; Guam, Mississippi, and Louisiana did not. The major funding for state health agencies was allocated by HEW and by maternal and child health (MCH) formula grants under Title 5 of the Social Security Act. 11 states made additional expenditures of $1.7 million for a variety of purposes. 21 states required local welfare departments to purchase services under the Medicaid program established by Title 19 of the Social Security Act. Administration was assigned to specific organizations within the state health agencies. 31 states reported a total of 128 full-time professional personnel, with 90 assigned at state headquarters level. In general, on a state-by-state basis, the full-time staff does not correspond to the size of the appropriations. Survey findings were useful measures of resource commitments to family planning services by state health and welfare agencies and provided data on future levels of resource requirements.     

Capacity of state health agencies to meet nutrition objectives in maternal and child health

Public health nutritionists in 54 official state health agencies were surveyed in 1987 to determine to what extent they were prepared to implement the Model State Nutrition Objectives developed by the Association of State and Territorial Public Health Nutrition Directors. Objectives related to services to the maternal and child health (MCH) population were the focus of one part of the survey. One half of all states have plans for nutrition services integrated into their state MCH plans. More than 75% of state agencies collect data on the nutritional status of pregnant and lactating women, infants, and preschool children. Fewer than half collect data on dietary intake patterns or nutrition knowledge. Thirty-one agencies reported a formal quality assurance program for one or more subsets of the MCH population. At least 75% of all states provide dietary intake recommendations, screening and assessment protocols, and policies concerning referrals to maternal and infant health programs. State health agencies are already involved in activities that will facilitate adoption of the model state nutrition objectives.     

Year 2000 health status indicators: a profile of California.

OBJECTIVES: To examine the health status of Californians using a set of 18 health status indicators (HSIs) corresponding to goals set forth in Healthy People 2000 and to develop a health status profile for use in research and surveillance, policy development program planning, and program evaluation. METHODS: Federal, state, and county data were used to evaluate California''s performance on 18 indicators of health status related to mortality, disease incidence, and health risks. RESULTS: By 1994, California had achieved Year 2000 objectives associated with seven HSIs and significant declines in mortality associated with two other HSIs. Nationally, California was ranked among the states with the lowest rates for infant mortality, lung cancer, female breast cancer, and syphilis but among states with the highest rates for homicide, AIDS, measles, tuberculosis, late prenatal care, childhood poverty, and poor air quality. CONCLUSIONS: California''s experience may provide a useful model for other state and local health agencies monitoring the health status of populations using HSIs associated with Year 2000 objectives.     

The National Cancer Institute's cancer information service: a new generation of service and research to the nation

The National Cancer Institute (NCI), the nation's leading agency for cancer information and research, mandated by the U.S. Congress to provide accurate, up-to-date information about cancer to all segments of the U.S. population, established the Cancer Information Service (CIS) on July 1, 1975. Using a two-pronged approach, the telephone information service and education programs for the public and health professionals, the CIS was designed to maximize its reach. In 1982, the CIS implemented three tools: the Call Record Form to record data about each call to the service, a national user survey, and a system of national test calls. These resulted in a rich data source and an infrastructure that allowed collaborative health communications research with the CIS to emerge later in the decade. As the CIS embarks on a new generation of service to the nation, it is now characterized by three vital components that advance the NCI's overall mission of cancer prevention and control: a Partnership Program, Multichannel Contact Centers, and a Health Communications Research Program.     

Asthma. The states' challenge.

At the national level, asthma is increasingly being recognized as an important public health problem. Because of the significant role of environmental exposure in asthma morbidity, public health agencies have a critical role to play in the surveillance and prevention of the disease. In April 1996, the Council of State and Territorial Epidemiologists, with assistance from the Centers for Disease Control and Prevention, surveyed state and territorial public health departments to determine the status of their asthma surveillance and intervention programs. Of the 51 health departments that responded, only eight reported that they had implemented an asthma control program within the previous 10 years. Reasons cited for not having programs included lack of funds, shortage of personnel, and asthma not being a priority. Most states were unable to assess the burden of asthma because they lack data or face barriers to using existing data. Removing barriers to the use of data is a first step toward defining the scope of the asthma problem.     

Structure and functions of state public health agencies in 2007

We sought to document the structure and functions of state public health agencies throughout the United States in 2007 and compare findings with those from a similar 2001 assessment. In 2007 a survey of the structure and functions of state public health agencies was sent to and completed by senior deputies in all 50 states and the District of Columbia (a 100% response rate). The results of the survey showed that all emerging practice areas in 2001 had expanded by 2007. Also, state health departments generally had greater levels of responsibility in 2007 than they did in 2001, emphasizing the need for continued support of governmental public health systems and research on the operations of those systems.     

State funding of comprehensive primary medical care service programs for medically underserved populations.

OBJECTIVES: This study examined the availability of state funding for comprehensive primary care programs and the need for primary care subsidies for medically underserved communities. METHODS: A brief questionnaire was used to ask health agencies in all 50 states whether their state funded a program that met our definition of comprehensive primary medical care practice programs. An in-depth written survey instrument was then administered to the states with programs. RESULTS: Almost half of all states provide some funds for the development and/or operation of comprehensive primary medical care practices. Expenditures in most states were found to be relatively modest in comparison with both federal funding and the total level of unmet need for primary care. States that subsidize primary care practices tend to follow the model established under the federal health centers program. CONCLUSIONS: The findings suggest the continued viability of the health center model of care, as well as the presence of some state support for such a program. However, in light of limited state resources for the development and operation of comprehensive practices, a continued and significant federal effort is imperative.     

Variability in mammography screening legislation across the states

Before passage of the Federal legislation, National Breast and Cervical Cancer Screening Act (NBCCSA) in 1991, over half the states (65%) had preexisting laws requiring health insurers, for example, Blue Cross/Blue Shield and HMOs, to provide services beyond the federal coverage for mammography screening and care following breast cancer. This study examined mammography screening legislation across the states. Data were derived from telephone interviews with six NBCCSA program directors or coordinators from July 1999 to October 1999. A review of existing documents from the Institute for Women's Policy Research, online data from the Centers for Disease Control and Prevention, and state laws provided by the Governmental Affairs Division of the American Cancer Society was undertaken. There was considerable variability in relation to factors potentially related to the extent of state laws. The states with the lowest age-adjusted breast cancer mortality rates among black women had the least comprehensive state legislation. Several states with the least percent of women above the federal poverty threshold also had the least comprehensive legislation. Some states had a wide gap between the provision of health insurance coverage and scope of legislation to ensure care following breast cancer. Some states were more aggressive in their efforts to ensure care following breast malignancy at diagnosis. Lessons could be learned by states that enacted the least comprehensive legislation. With the passage of the federal legislation nearly a decade ago, more women are receiving timely and available mammography screening, resulting in earlier diagnosis of breast cancer. Greater efforts must be undertaken by all states to provide the full array of breast cancer treatment for women in the millennium.     

School Health Practices for Children with Complex Medical Needs

Concern is growing about the adequacy and safety of health services provided for medically complex children in public schools. A national survey of state health and education agencies was conducted to learn if guidelines existed governing the practice of eight selected nursing procedures in schools. Thirteen states (26%) had no written guidelines, 13 states (26%) had guidelines only for medication administration, and only six states (12%) had guidelines for the eight selected nursing procedures.     

State Medicaid home health licensing and certification

This study collected and analyzed data on the number of licensed and certified home health care agencies and licensed home care/personal care agencies in the US. The study also examined the state laws and regulations pertaining to Medicaid home health agency requirements. There were 14,045 licensed home health agencies and 801 other licensed home care or personal care agencies in the US, but only 59 percent of these agencies were certified in 1998. The percent of certified agencies ranged from 22 percent in Maryland to 100 percent in ten states that only allowed certified agencies to provide home care. There was a wide range in the number of agencies in states with the average being 6.1 agencies per 100,000 population. The 41 states with state licensing of home health agencies had a wide range of policies but most were more lenient than the federal Medicare certification requirements.     

A Nationwide Survey of Financing Health-Related Services for Special Education Students

The Individuals with Disability Education Act (IDEA) requires state educational systems to provide school-based, health related services (RS). This survey determined the financing arrangements used by states for health-related services for school-aged children with disabilities. A survey was sent to directors of special education, Medicaid, and public health departments in each of the 50 states. Financial patterns for RS were sought at the state level for children ages 3-21 with disabilities for the 1993-1994 school year, the most recent year for which complete financial data were available. Univariate analyses probed the relationship between systems' variables and the extent of Medicaid usage by local education agencies. Respondents reported that schools tapped traditional health resources to supplement educational dollars in paying for related services in schools. Medicaid was by far the most common source with 29 states reporting established mechanisms for recouping Medicaid dollars and 10 states reporting phase-in activities. Seventeen states reported that departments of public health played some role in administration, training, and demonstrations, but only six states provided specific dollars for related services through the department. Use of private insurance was reported sporadically with only one state indicating a specific state-level program. Correlates of increased Medicaid usage were presence of interagency agreements (IAAs) (OR 11.1, p = 0.002), having specific personnel for school-based medical assistance (OR 17.7, p = 0.001), and utilizing school nursing services as a Medicaid optional service (OR 4.2, p = 0.048).     

State and Local Health Agency Engagement in HIE: A Cross-Sectional Survey

Objective

To characterize state and local health agency relationships with health information exchange organizations.

Introduction

There is growing interest in leveraging available health information exchange (HIE) infrastructures to improve public health surveillance (1). The Health Information Technology for Clinical and Economic Health Act and Meaningful Use criteria for electronic health record (EHR) systems are among the factors driving the development, adoption and use of HIEs. HIEs deliver or make accessible clinical and administrative data as patients are admitted, discharged, and transferred across hospitals, clinics, medical centers, counties, states and regions (2). While several HIE infrastructures exist (3), there is little evidence on the engagement in HIE initiatives by state and local health agencies.

Methods

An online survey of state and local health officials was conducted in six states where HIEs were known to be present. Half of the states were funded by the Centers for Disease Control and Prevention (CDC) to engage public health agencies in HIE activities; the other half received no such funding. A total of 143 officials were invited to participate; 73 (51%) responded. The survey asked respondents about their agencies awareness, engagement, and data exchange with HIEs. The survey further asked agencies about their perceptions of barriers and challenges to public health engagement with HIE organizations.

Results

Just 25% of agencies had a formal relationship, typically created through a memorandum of understanding or data usage agreement, with at least one nearby HIE. The majority (54%) of agencies either had no relationship (20%) or only an informal relationship (34%) with an HIE. The remaining agencies (18%) reported that no HIE existed in their jurisdiction. Agencies in states that had received CDC funding for HIE engagement were more likely (14 versus 2) to be formally partnered with an HIE.

Conclusions

Few public health agencies are formally engaged in HIE. Financial costs, human resources, and concerns regarding privacy/security were the top cited barriers to broader engagement in HIE. For public health to be an active participant in and reap the benefits of HIE, greater investment in state and local public health informatics capacity, including human resources, and education regarding HIE privacy and security practices are needed.     

Seeing the forest and the trees: using network analysis to develop an organizational blueprint of state tobacco control systems

In the United States, tobacco control activities are organized primarily in state tobacco control programs. These programs are comprised of public and private agencies working together to reduce tobacco use. The human, financial, and informational resources that go into state tobacco control programs are documented, and the outcomes of these programs have been studied in terms of health and health behavior. However, little is known about the organizational infrastructure that transforms the human, financial, and informational resources into positive health outcomes. This study examined the inter-organizational relationships among key partner agencies in eight state tobacco control programs. The state programs varied in terms of funding level, funding stability, and region of the country. Using a network analytic approach we asked an average of 14 agencies in each state program about their contacts and partnerships with the other key tobacco control agencies in their state program. Using network visualization and statistics we determined that the state networks shared some common features such as a highly central lead agency, but also had differences in network structure in terms of density and centralization. Using blockmodeling we found that, despite differences in state and program characteristics, there was a common organizational structure among the eight state programs. Understanding the inter-organizational relationships and the common organizational structures of state programs can aid researchers and practitioners in enhancing program capacity and in developing strategies for organizing effective public health systems.     

State Medicaid Home Health Licensing and Certification

ABSTRACT

This study collected and analyzed data on the number of licensed and certified home health care agencies and licensed home care/personal care agencies in the US. The study also examined the state laws and regulations pertaining to Medicaid home health agency requirements. There were 14,045 licensed home health agencies and 801 other licensed home care or personal care agencies in the US, but only 59 percent of these agencies were certified in 1998. The percent of certified agencies ranged from 22 percent in Maryland to 100 percent in ten states that only allowed certified agencies to provide home care. There was a wide range in the number of agencies in states with the average being 6.1 agencies per 100,000 population. The 41 states with state licensing of home health agencies had a wide range of policies but most were more lenient than the federal Medicare certification requirements.