Peer Reviewed: Public Health Surveillance for Mental Health

Public health systems have relied on public health surveillance to plan health programs, and extensive surveillance systems exist for health behaviors and chronic disease. Mental health has used a separate data collection system that emphasizes measurement of disease prevalence and health care use. In recent years, efforts to integrate these systems have included adding chronic disease measures to the Collaborative Psychiatric Epidemiology Surveys and depression measures to the Behavioral Risk Factor Surveillance System; other data collection systems have been similarly enhanced. Ongoing challenges to integration include variations in interview protocols, use of different measures of behavior and disease, different interval reference periods, inclusion of substance abuse disorders, dichotomous vs continuous variables, and approaches to data collection. Future directions can address linking surveillance efforts more closely to the needs of state programs, increasing child health measurements in surveys, and improving knowledge dissemination from survey analyses.     

Peer Reviewed: Measuring the Impact of Public Health Policys

Effective health policies and allocation of public health resources can substantially improve public health. An objective of public health practitioners and researchers is to identify key metrics that would help improve effective policies and terminate poor ones. We review articles published in 2008 surrounding measurement issues for public health policy and present a set of recommendations for future emphasis. We found that a set of consensus metrics for population health performance should be developed. However, considerable work is needed to develop appropriate metrics covering policy approaches that can affect large populations, intervention approaches within organizations, and individual-level behavioral approaches for prevention or disease management.     

Peer Reviewed: Publishing on Policy: Trends in Public Health

Our goal was to explore the number and topics of policy articles published in general public health journals. We conducted an audit of articles in 16 public health journals from 1998 through 2008. Results showed no trends for the decade studied; only 3.7% of all articles published in these journals were policy-related, and the topics most represented were smoking/tobacco, health care, and school policy. As policy research on public health issues continues to develop, researchers have an opportunity to increase dissemination through publication in general public health journals.     

Peer Reviewed: Use of Peer Groupings to Assess County Public Health Status

Introduction

The Community Health Status Indicators Project was undertaken to produce county-specific reports assessing the status of community health for local jurisdictions throughout the United States. To accomplish this assessment, the Community Health Status Indicators Project team selected peer groupings of counties to monitor and analyze the health of local communities relative to peer communities.

Methods

To identify peer counties, the project team used 5 categorical county demographic variables, a specified order for applying criteria, and a predetermined target for peer grouping size to subdivide counties into homogeneous subgroups called peer groupings.

Results

Eighty-eight peer groupings were developed with 14–58 counties in each. The average size of each peer grouping was 35 counties. All peer groupings included counties representing at least 6 states.

Discussion

Peer groupings are very useful for community health assessment. They convey the range of health status indicator values for similar counties, serve as a basis for expected numbers of reportable diseases, and provide a method for comparing communities with peer and U.S. medians. To maintain their usefulness, peer groupings must be updated periodically.     

Peer Reviewed: Designing Competencies for Chronic Disease Practice

Introduction

Competencies are the cornerstone of effective public health practice, and practice specialties require competencies specific to their work. Although more than 30 specialty competency sets have been developed, a particular need remained to define competencies required of professionals who practice chronic disease prevention and control. To that end, the National Association of Chronic Disease Directors (NACDD) engaged a group of stakeholders in developing competencies for chronic disease practice.

Methods

Concept mapping was blended with document analysis of existing competencies in public health to develop a unique framework. Public health experts reviewed the results, providing extensive and richer understanding of the issues.

Results

The final product presents an integrated picture that highlights interrelationships among the specific skills and knowledge required for leading and managing state chronic disease programs. Those competencies fall into 7 clusters: 1) lead strategically, 2) manage people, 3) manage programs and resources, 4) design and evaluate programs, 5) use public health science, 6) influence policies and systems change, and 7) build support.

Conclusion

The project yielded a framework with a categorization scheme and language that reflects how chronic disease practitioners view their work, including integrating communications and cultural competency skills into relevant job functions. Influencing policies and systems change has distinct relevance to chronic disease practice. We suggest uses of the competencies in the field.     

Peer Reviewed: Reframing School Dropout as a Public Health Issue

Good education predicts good health, and disparities in health and in educational achievement are closely linked. Despite these connections, public health professionals rarely make reducing the number of students who drop out of school a priority, although nearly one-third of all students in the United States and half of black, Latino, and American Indian students do not graduate from high school on time. In this article, we summarize knowledge on the health benefits of high school graduation and discuss the pathways by which graduating from high school contributes to good health. We examine strategies for reducing school dropout rates with a focus on interventions that improve school completion rates by improving students' health. Finally, we recommend actions health professionals can take to reframe the school dropout rate as a public health issue and to improve school completion rates in the United States.     

Competencies of Florida School Health Educators

This study examined and compared the importance of specific competencies for bachelor's level and master's level school health educators in Florida. A survey instrument utilizing a five-point scale was administered to 69 respondents to ascertain the importance of 135 competencies in the areas of administration, evaluation, general health knowledge, and communication. Results of the analysis of data indicate that bachelor's level health educators require competencies necessary for the direct delivery of health instruction, while master's level health educators need to possess specific competencies in administration and evaluation.     

Assessing Competencies of the Public Health Workforce in a Frontier State

The purpose of this study was to determine the level of perceived proficiency of a public health workforce based on the Public Health Practice Core Competencies. The Public Health Profile and Training Needs Assessment questionnaire was mailed out to public health employees representing mostly public health nursing, environmental health, mental health, and public health management/administration (n = 696). Nearly three-quarters (74%) of participants were female and 96% reported being white. Eighty one percent of participants were currently employed full-time. The majority of participants were trained at the bachelors level (54%). The response rate was 63.9%. Findings from this study show that all disciplines reported higher perceived proficiency in the Communication skills domain compared to the other seven skills domains. Perceived low skills domains included financial planning and management skills and policy development/program planning skills among public health nurses, mental health professionals, and environmental health specialists. Management/administration level staff reported their lowest perceived proficiency in Basic Public Health Science skills. Each group had different strengths and weaknesses and the necessary level of skill needed differs among discipline groups, thus future trainings on the Public Health Core Competencies should be discipline specific.     

Peer Reviewed: Assessing Calcium Intake in Postmenopausal Women

Introduction

Because foods fortified with calcium are increasingly available, the calcium content of calcium-fortified foods may not be adequately captured in traditional assessments of dietary intake, such as dietary records analyzed with commercially available software. The primary objective of our study was to design and test a calcium-focused food frequency questionnaire (CFFFQ) including foods naturally rich in calcium and calcium-fortified foods. Secondary objectives were to review calcium sources and adequacy of intake in black and in white postmenopausal women.

Methods

We studied a convenience sample of 46 black and 139 white postmenopausal women (mean [SD] age 69.4 [5.8] years). Subjects completed a multiple-pass interview for 24-hour recall of foods eaten and the 46-item CFFFQ.

Results

The correlation between measures for total daily calcium intake was moderately strong (r = 0.53, P < .001). The CFFFQ estimated greater total daily calcium intake than did the 24-hour recall (mean [SD], 1,021 [624] mg/d vs 800 [433] mg/d, P < .001). As daily calcium intake increased, the 24-hour recall increasingly underreported calcium (r = 0.41, P < .001) compared with the CFFFQ. Cross-tabulation and Χ² analyses found that the CFFFQ had greater specificity for lower calcium intakes. For calcium classified by food groups, there was moderate correlation for dairy (r = 0.56, P < .001) and fruits (r = 0.43, P < .001). The CFFFQ overestimated mean total calcium compared with the 24-hour recall by 221 mg/d (P < .001), including within racial groups (195 mg/d for black women, P = .04, and 229 mg/d for white women, P < .001). Dairy was the primary calcium source for both groups (55% of intake for black women and 57% of intake for white women).

Conclusion

The CFFFQ can be used to identify postmenopausal women with inadequate calcium intakes (<800 mg/d) and to identify key sources of dietary calcium. Older black women consume less daily calcium than do older white women.     

Peer Reviewed: Principles to Guide the Development of Population Health Incentives

Improving population health is not simple. Many instruments are available for changing behavior and consequent outcomes. However, the following basic principles should guide development of any incentive arrangement: 1) identify the desired outcome, 2) identify the behavior change that will lead to this outcome, 3) determine the potential effectiveness of the incentive in achieving the behavior change, 4) link a financial incentive directly to this outcome or behavior, 5) identify the possible adverse effects of the incentive, and 6) evaluate and report changes in the behavior or outcome in response to the incentive.A wide range of financial and nonfinancial incentives is available to encourage efficient behaviors and discourage costly and unproductive ones. Evidence for the beneficial effects of incentive programs has been slow to emerge, partly because such evidence must show how behaviors have changed because of the incentive. Nevertheless, the potential for incentive programs in health care seems large, and research should support their design and assess their effect.     

Professional Competencies and Training Needs of Professional Social Workers in Integrated Behavioral Health in Primary Care

The Affordable Care Act has led to a widespread movement to integrate behavioral health services into primary care settings. Integrated behavioral health (IBH) holds promise for treating mild to moderate psychiatric disorders in a manner that more fully addresses the biopsychosocial spectrum of needs of individuals and families in primary care, and for reducing disparities in accessing behavioral health care. For behavioral health practitioners, IBH requires a shift to a brief, outcome-driven, and team-based model of care. Despite the fact that social workers comprise the majority of behavioral health providers in IBH settings, little research has been done to assess the extent to which social workers are prepared for effective practice in fast-paced primary care. We conducted a survey of social workers (N = 84) in IBH settings to assess the following: (1) Key competency areas for social work practice in IBH settings and (2) Self-rated preparedness for effective practice in IBH settings. Online snowball sampling methods were used over a period of 1 month. Results indicate that social workers feel prepared for general practice in IBH settings, but would benefit from additional training in IBH-specific competency areas identified in the survey. Findings can help guide social work training to improve workforce preparedness for practice in IBH settings in the wake of health care reform.     

Peer Reviewed: Measuring Population Health Outcomes

An ideal population health outcome metric should reflect a population''s dynamic state of physical, mental, and social well-being. Positive health outcomes include being alive; functioning well mentally, physically, and socially; and having a sense of well-being. Negative outcomes include death, loss of function, and lack of well-being. In contrast to these health outcomes, diseases and injuries are intermediate factors that influence the likelihood of achieving a state of health. On the basis of a review of outcomes metrics currently in use and the availability of data for at least some US counties, I recommend the following metrics for population health outcomes: 1) life expectancy from birth, or age-adjusted mortality rate; 2) condition-specific changes in life expectancy, or condition-specific or age-specific mortality rates; and 3) self-reported level of health, functional status, and experiential status. When reported, outcome metrics should present both the overall level of health of a population and the distribution of health among different geographic, economic, and demographic groups in the population.

By far, the most fundamental use of summary measures of population health is to shift the centre of gravity of health policy discourse away from the inputs . . . and throughputs . . . of the health system towards health outcomes for the population. This is not to imply that the resources used and activities undertaken by national or regional health systems are unimportant; quite the contrary. But our understanding of their roles and importance is more appropriate if guided by the real "bottom line," namely their influence on population health. Michael C. Wolfson (1)

     

Peer Reviewed: Assessing Perceptions of and Responses to Multiple Health Risks Among the Southern Poor

Introduction

We explored perceptions of and responses to multiple health risks among people living in poverty in the southern United States.

Methods

We conducted 12 focus groups and interviewed 66 focus group participants in 3 southern US cities (Birmingham, Alabama; Jackson, Mississippi; and Columbia, South Carolina). Thematic analysis was used to identify major themes.

Results

Study participants worried most about chronic health conditions and the costs to treat those conditions. Feelings of threat were influenced by family health history and race. Barriers to health-protective behaviors included time, work, family, apathy, and low response efficacy. Physical activity and checking blood pressure were the health-protective behaviors in which participants most often engaged.

Conclusion

Our results will be useful for the development of interventions that target the southern poor. Intervention messages should address the barriers that poor people face when attempting to engage in health-protective behaviors and should help strengthen people''s confidence in their ability to change their behaviors.     

Peer Reviewed: Depression as a Major Component of Public Health for Older Adults

Although public health is often conceptualized only as the prevention of physical illness, recent data suggest that mental illnesses are increasingly relevant to the mission of disease prevention and health promotion. Projections are that by 2020, depression will be second only to heart disease in its contribution to the global burden of disease as measured by disability-adjusted life years. Also, as the population ages, successive cohorts of older adults will account for increasingly larger segments of the U.S. population. We present the diagnostic criteria for, prevalence of, and risk factors for depressive disorders among older adults; the challenges of recognizing and treating depression in this population; the cost-effectiveness of relevant public health interventions; and the public health implications of these disorders.     

Peer Reviewed: Workplace Health Promotion in Washington State

The workplace is a powerful setting to reach large numbers of at-risk adults with effective chronic disease prevention programs. Missed preventive care is a particular problem for workers with low income and no health insurance. The costs of chronic diseases among workers — including health care costs, productivity losses, and employee turnover — have prompted employers to seek health promotion interventions that are both effective and cost-effective. The workplace offers 4 avenues for delivering preventive interventions: health insurance, workplace policies, health promotion programs, and communications. For each of the avenues, the evidence base describes a number of preventive interventions that are applicable to the workplace. On the basis of the evidence and of our work in Washington State, we present a public health approach to preventing chronic diseases via the workplace. In addition to relying on the evidence, this approach makes a compelling business case for preventive interventions to employers.     

Peer Reviewed: Multisector Partnerships in Population Health Improvement

Many new initiatives for population health improvement feature partnerships of leaders and organizations across multiple sectors of society. The purpose of this article is to review 1) the rationale for such partnerships as an important, if not essential, tool for population health improvement; 2) key organizational and contextual factors that appear to be associated with effective multisector partnerships; and 3) the limited evidence regarding the effect of such partnerships on population health outcomes. We conclude that systems thinking — accounting for the collective effect of many actors and actions — is essential to organizing and sustaining efforts to improve population health, and to evaluating them. More research is needed to understand how and why multisector partnerships are formed and sustained and the conditions under which multisector partnerships are necessary or more effective than other strategies for population health improvement. Research on and evaluation of multisector partnerships also need to incorporate more standard measures of partnership contexts, characteristics, and strategies and adopt longitudinal and prospective designs to accelerate social learning in this area. Finally, studies of multisector partnerships must be alert to the value of such initiatives to individuals and communities apart from any direct and measurable impact on population health.     

Peer Reviewed: Grading and Reporting Health and Health Disparities

Report cards are widely used in health for drawing attention to performance indicators. We developed a state health report card with separate grades for health and health disparities to generate interest in and awareness of differences in health across different population subgroups and to identify opportunities to improve health. We established grading curves from data for all 50 states for 2 outcomes (mortality and unhealthy days) and 4 life stages (infants, children and young adults, working-age adults, and older adults). We assigned grades for health within each life stage by sex, race/ethnicity, socioeconomics, and geography. We also assigned a health disparity grade to each life stage. Report cards can simplify complex information for lay audiences and garner media and policy maker attention. However, their development requires methodologic and value choices that may limit their interpretation.     

Peer Reviewed: Children With Special Health Care Needs: Acknowledging the Dilemma of Difference in Policy Responses to Obesity

Children with special health care needs (SHCN) account for part of the increasing prevalence of childhood obesity in the general population and can face an elevated risk for obesity. The federal government, in partnership with states, has assumed the role of steward for this vulnerable population and supports a network of services designed to promote their health through increased access to quality health services. Addressing obesity-related health risks among children with SHCN requires policies that support family- and community-based initiatives in addition to health services. We discuss the ethics of child obesity policy from the perspective of children with SHCN and their families, and identify salient issues to optimize benefits for children and families. We refer to the dilemma of difference to identify policy concerns that are specific to children with SHCN and ethically may require different approaches. Determining the appropriate mix of inclusive and special obesity prevention initiatives for children with SHCN and identifying approaches to ensure their full participation in community-based obesity prevention activities present challenges. Children with SHCN from low-income and minority communities are particularly vulnerable and warrant special attention.     

Peer Reviewed: The Ethical Basis for Promoting Nutritional Health in Public Schools in the United States

Schools may have an ethical obligation to act in response to the precipitous increase in the incidence of obesity among children. Using a bioethics framework, we present a rationale for school programs to improve the nutritional quality of students'' diets. Because children are required to spend half their waking hours in school and because they consume a substantial portion of their daily food there, school is a logical focus for efforts to encourage healthy dietary behaviors to prevent obesity and its consequent individual and collective costs. We suggest that beyond strategic considerations, the concept of the common good justifies actions that may appear to conflict with freedom of choice of children, parents, and school staff, or with the interests of food and beverage companies.     

Peer Reviewed: Investment in Safe Routes to School Projects: Public Health Benefits for the Larger Community

Introduction

The Safe Routes to School (SRTS) program is designed to encourage active and safe transportation for children to school. This report examines the potential broader impact of these programs on communities within 0.5 mile (0.8 km) of schools.

Methods

We used a geographic information system to generate estimates of the land area within 0.5 mile of public schools in 4 U.S. Census-defined categories: 37 large urban areas, 428 small urban areas, 1088 metropolitan counties (counties in metropolitan statistical areas excluding the urban areas), and 2048 nonmetropolitan counties. We estimated population at the county level or at the U.S. Census-defined urban-area level using data from the 2000 U.S. Census.

Results

In large urban areas, 39.0% of the land area was within 0.5 mile of a public school, and in small urban areas, 26.5% of the land area was within 0.5 mile of a public school. An estimated 65.5 million people in urban areas could benefit from SRTS projects. In nonurban areas, 1% or less of land is within 0.5 mile of a public school.

Conclusion

Results suggest that SRTS projects in urban areas can improve the walking and bicycling environment for adults as well as for children, the target users. Investment in SRTS can contribute to increased physical activity among children and adults.