Supporting Research and Evidence-Based Public Health Practice in State and Local Health Agencies

Abstract

Research is one of the 10 essential public health services and is a requirement for the advancement of public health practice. However, local and state public health agencies face many barriers to adopting evidence-based practices and engaging in the research needed to build on existing evidence. Barriers include limited time and funding, shortages of appropriately trained staff, and a lack of knowledge among practitioners about evidence-based public health (EBPH). Even for relatively well-equipped agencies, the nature of research presents challenges. For example, randomized control trials are frequently not feasible in the public health practice context, and less rigorous methods must be employed. Communities are an integral part of the public health practice environment, and their voice is an important consideration in the design and implementation of practice-based research. Community-based participatory research is one method that facilitates community engagement in research projects. This policy statement suggests several strategies to mitigate barriers to fully engaging in EBPH and practice-based research, including increasing partnerships between academia and public health practice entities, facilitating public health agencies’ access to evidence-based literature and resources, improving funding mechanisms to support research, and providing training opportunities to better equip the workforce with the skills needed to implement EBPH and engage in practice-based research. 

Relationship to Existing Policy Statements

This policy combines elements of APHA Policy Statements 6528 (Support of Research in Health Departments), 200412 (Support for Community Based Participatory Research in Public Health), and 6120 (Research in the Application of Behavioral Sciences) and replaces all three policies. 

Problem Statement

The 10 essential public health services were developed to describe public health activities that all communities should undertake and to serve as a framework for public health practice. Research, the 10th essential service, is located at the center of the essential services wheel to emphasize its relevance to the other nine services.[1] In addition to affording a basic foundation for public health functions, the 10 essential services provide structure for national voluntary public health accreditation. Domain 10 of the Public Health Accreditation Board’s Standards and Measures Version 1.5 “focuses on the role that health departments play in building and advancing the science of public health.”[2]

Evidence-based public health (EBPH) practice is modeled after the individual-focused, evidence-based medicine model, with the addition of variables to address contextual factors of the population or community.[3] EBPH is informed by research, and the quality of any given research project is often dependent on the model employed. Randomized control trials are considered the “gold standard,” but they are expensive, involve ethical issues when applied in public health settings, and sometimes have limited applicability outside the context of the study itself. Observational studies (e.g., cross-sectional, case-control, cohort, ecological) provide broader contextual variables that can make the findings more applicable but can also introduce confounding variables and lack random assignment of participants.[4] Epidemiological studies are useful in discovering relationships between variables but do not assess the effectiveness of interventions.[5] Qualitative studies (e.g., phenomenological or grounded theory) can provide depth of understanding and offer explanations, but they lack generalizability and are challenging to apply in other contexts.[6]

Research studies produce data that Brownson et al.[3] have categorized into three types. Type I data can elucidate causes, magnitude, severity, and preventability of disease. Type II data show the relative impact (evidence based, efficacious, promising, emerging) of specific interventions. Type III data provide the contextual conditions of interventions on the basis of factors such as the characteristics of the population targeted, interpersonal variables, organizational variables, social norms, and political and economic factors. The validity of published results is sometimes influenced (and sometimes undermined) by small sample sizes, bias, and small effect sizes.[7] 

Rychetnik et al. developed criteria useful in assessing evidence for public health interventions.[4] They noted that such interventions are complex, programmatic, and context dependent and suggested three questions to ask in evaluating research: (1) Is the research sufficient to support decision making? (2) What are the research outcomes? and (3) Is the research transferable to other contexts?[4] The capability of public health personnel to adequately answer these questions depends on their training, experience, and available time.

Although research is an essential function of public health, too many public health policy and program decisions are based on inadequate research and/or data.[8,9] Although research and practice in public health are sometimes described interchangeably,[8] the Centers for Disease Control and Prevention (CDC) distinguishes public health research and public health non-research. This distinction rests on the purpose as opposed to the topic or category of the activity. For example, the purpose of the national diabetes surveillance system is to describe the burden of diabetes and its complications at the national and state levels as a means of improving public health programs or services. In contrast, the purpose of the Lassa fever sentinel surveillance system was to generate baseline information and contribute to generalizable knowledge regarding this illness. No public health interventions were planned as part of the project, and study participants received no direct benefit. The national diabetes surveillance system is considered to be public health non-research, while the Lassa fever surveillance system is considered to be research.

Public health practice organizations have limited resources and practical means for generating research topics.[10,11] Research topics should be appropriately based on a public health agency’s mission or purpose. Examples include (1) burden of disease (determined through needs assessments), (2) the prevalence and incidence of morbidity and mortality, (3) known program or service failures, (4) topics that are emerging and exciting, and (5) impact on resources or stakeholder value (i.e., experts may be able to help prioritize needs).[8,10–13]

Although local health departments should help identify research topics,[14] these may also be driven by funder philosophies[13] or gaps discovered through literature reviews and/or community input.[8] State and local health departments receive most of their research and programmatic funding from federal and state agencies. However, funding from nongovernmental agencies, including hospital associations, voluntary health organizations, and health philanthropies, does raise ethical concerns about the influence of funder philosophies on selection of specific research topics and programs that could lead a health department to pursue a research agenda or undertake programs that do not reflect the community served or its health care needs.

Public health research should be duplicable, practical, and feasible[8,11,12] and should assess a program or policy’s health and economic impacts, potential risks from inaction, effects on inequities and vulnerable populations, and implications with respect to resolving public health dilemmas.[12] In addition, public health research should take into account a community’s diversity and its willingness to change or implement interventions.[8] Optimally, researchers and practitioners should collaborate to minimize the lag time between discovery of research findings and implementation of practice changes.[8,13]

The roles of public health agencies in research are to provide access to population health data sources, support data collection and reporting, and assist with evaluation and translation of research into sustained practice.[13,14] To effectively execute these functions, the public health workforce needs specialized knowledge related not only to prevention and public health practice but to relevant research findings published in the scientific literature.[15] If the workforce lacks this capacity, it can potentially be provided through outside support.[13] For instance, since all federally funded research requires review and approval by an institutional review board, state health department review boards can assist public health staff in designing assessments and evaluations that adhere to ethical principles for use of human participants by establishing protocols or policies regarding the collection and use of data from individuals and providing training opportunities in research ethics. 

Barriers to EBPH practice and research in public health agencies: In addition to being inequitably distributed, the current public health workforce is inadequately trained to meet the needs of the U.S. and global populations, which are facing several urgent priorities.[9,16,17] The workforce situation is further exacerbated by decreasing numbers and by limited racial/ethnic diversity. According to the 2013 National Association of City and County Health Officials (NACCHO) national profile, the local health department workforce decreased by about 12% from 2008 to 2013.[14] The U.S. public health workforce currently numbers about 500,000.[17] Public health agencies serving small populations have few staff and provide a limited array of services.

Studies of the qualifications of the public health workforce have shown that the majority do not have formal public health training (e.g., an MPH degree); only 17% of public health employees have a degree in public health.[15,18] One survey of the public health workforce across six states revealed that most positions requiring an MPH were at the state level or in larger district offices. The low public health pay scale does not incentivize formal public health training.[19] The public health workforce should be trained in social determinants of health and should raise awareness about how these determinants affect underserved populations.[20]

Appreciation for the role of research in improving public health varies among public health workers. Only 33% of respondents in one survey believed that more emphasis should be placed on public health systems and services research.[18] However, another study showed that more than half of local health departments surveyed had been involved in research activities within the preceding 2 years.[14] These activities included collecting, exchanging, and reporting data; applying research findings to agency practices; and developing and refining research plans or protocols.

Resource limitations add to the challenges faced by public health agencies in fulfilling their research role. Funding for many activities in local and state health agencies, including research, has been reduced in recent years.[21] Funding for this work, such as block grants, is highly dependent upon state and federal legislation, which can fluctuate according to congressional interests. Fellowships or internships can potentially increase research capacity while strengthening the relationship between academia and practice.[22] However, academic schools and programs and public health institutes are sometimes viewed by agencies as uninvolved in meeting the needs of public health practice (i.e., research-oriented training does not produce graduates adequately prepared to engage in such work).[19]

One impediment to the implementation of EBPH is practitioners’ lack of access to scientific information on public health risks and practices.[23–25] Public health is a very diverse field, which adds complexity to the process of finding information relevant to a particular topic.[24] Other information access barriers include (1) an inadequate understanding of what constitutes evidence-based information, (2) limited knowledge or skills regarding how to use electronic resources, (3) costs associated with accessing electronic resources, (4) limited time to engage in searches and process findings, and (5) limited ability to appropriately appraise the quality of research studies.[23–26] 

Several organizations have created databases to make current, relevant public health research available to public health practitioners. The Guide to Community Preventive Services, which can be accessed free online, provides systematic reviews to inform public health practice.[27] The guide needs to be emphasized as one of the best existing sources for EBPH interventions. Partners in Information Access for the Public Health Workforce, a collaboration of U.S. government agencies, public health organizations, and health sciences libraries, provides access to public health resources online.[28] Both of these resources are valuable contributions, but broader access to the latest information is still needed. Revere et al.[24] suggest that, to be optimally useful to public health practitioners, information should be easy to access and use, current, available for low or no cost, summarized, and focused on specific fields.

Promoting community involvement: Improvements in public health build on involvement and collaboration with community members.[29] Community-based participatory research (CBPR) is a well-established approach for engaging communities in research designed to improve health. CBPR is highly effective in connecting science to public health practice[30] and provides the context in which the external validity of research findings can be assessed. Effective engagement supports identification of research needs important to both communities and researchers.[31]

A robust body of literature outlines the various aspects of CBPR. Himmelman describes how community engagement varies from passive participation to equal partnership with researchers.[32] He identifies four levels on a continuum ranging from information sharing to community empowerment: networking (exchanging information for mutual benefit), coordinating (exchanging information for mutual benefit and altering activities), cooperating (exchanging information, altering activities, and sharing resources), and collaborating (exchanging information, altering activities, sharing resources, and exhibiting a willingness to enhance the capacity of another). These four levels provide a framework for assessing the depth of a community’s engagement in CBPR. Effective use of CBPR methods can foster long-term relationships between researchers and community members and assist in ensuring the sustainability of proven interventions.[33]

The National Institutes of Health (NIH) highlights five activities in which researchers can engage community members: (1) identifying research topics, (2) designing research protocols, (3) facilitating the participation of other community members in the study, (4) assessing results, and (5) assisting in the dissemination and implementation of findings.[29] In addition, Israel et al. describe eight principles inherent in a robust model of community-based research: (1) recognizing the community as an entity, (2) building on the strengths of the community, (3) facilitating collaborative partnerships, (4) integrating knowledge and action for mutual benefit, (5) promoting co-learning, (6) incorporating cyclical and iterative processes, (7) addressing health from positive and ecological perspectives, and (8) disseminating findings and knowledge gained.[31]

A primary benefit of CBPR beyond investigation of the health issue of interest is the opportunity to increase community capacity. Optimally, researchers should employ methods that encourage community empowerment rather than passive community participation. Doing so will strengthen communities’ ability to assess, analyze, and address their own concerns, reducing reliance on external expertise and resources. This recommendation is consistent with APHA’s emphasis on health equity.

Translating research findings into practice: One purpose of public health research is to discover and test innovations that can improve population health.[3,30] Equally important is dissemination of research findings, which should be an explicit expectation of researchers.[34] Dissemination of findings is a critical first step in moving discoveries into practice.

Dissemination practices and factors that influence successful dissemination of evidence-based practices have been widely studied.[35] Brownson et al. identified two important tenets: (1) dissemination is not automatic, and reliance on passive methods is likely to fail, and (2) dissemination is enhanced with involvement of stakeholders and use of methods that best fit the contexts of the audience.[36] In their survey, Tabak et al. found that while 36% of investigators assessed their dissemination efforts as excellent or good, almost as many (one third) identified their efforts as poor.[37] Factors influencing quality of dissemination included funding and differing priorities among key stakeholders such as policymakers, implementers, and researchers (e.g., promotion and tenure policies).

Practitioners face several challenges when implementing evidence-based public health programs or policies. The practice environment is often more complex than the controlled research environment. Also, individuals or organizations implementing a practice may not have been involved in the research validating the practice and may lack a full understanding. Finally, implementation processes can be influenced by multiple factors, including the characteristics of the individual adopter, the characteristics of the adopter’s organization, and the changes required to transition into the new practice.[38]

Wallerstein and Duran30 identified additional challenges to translation of research findings: (1) external validity (i.e., the ability to use findings from one context to another); (2) defining what evidence is, given differences between academic standards and community standards; (3) differences in language between academic and community partners, which can define their relationship; (4) the challenge of changing the relationship from investigator as authority and community as beneficiary to a true collaboration; (5) nonsustainability of relationships, often driven by external factors such as funding sources; and (6) lack of trust, a crucial element in developing partnerships focused on empowerment of the community. Additional complexity can occur from interactions among contexts, group dynamics, intervention/research, and the resulting outcomes.[30] 

Implementation of EBPH practices in communities is facilitated by researchers sharing findings with community partners. According to McDavitt et al., sharing findings builds trust between researchers and the community, supports the application of local contexts to research findings, promotes rapid adoption of evidence-based practices, and supports the development of interventions that reflect the culture of the community.[39]

A robust body of literature has described models for successfully conducting research in partnership with communities and for disseminating findings and translating them into practice. Employing such methods and models enhances the research process and increases the likelihood that findings that can improve effectiveness will be successfully integrated into practice.[40] 

Evidence-Based Strategies to Address the Problem

Public health/academic partnerships: Research conducted jointly by academic institutions and practice agencies has significant untapped potential to advance the public’s health. It helps health departments and their community partners determine the best mechanisms for solving public health problems and, in a constrained resource environment, discover which problems are most likely to be solvable. Research is an iterative process; as new solutions are discovered, studies can elucidate their effectiveness over older methods.

Differing cultures, processes, and incentives have made strong academic/practice partnerships challenging to achieve. In the late 1980s, the Institute of Medicine noted that public health practice and academic public health were generally isolated from one another.[41] More recently, a 2008 survey conducted by the National Association of County and City Health Officials determined that 88% of local health departments had some type of partnership with colleges or universities; 35% had formal written agreements.[42] Studies have shown that “academic health departments” (AHDs) help improve the competencies of both public health practitioners and students as they bridge the gap between research and practice and build on each other’s strengths.[42–44] In instances in which academic health departments have been established, memorandums of understanding (MOUs) have provided outlines of partnership expectations and responsibilities. One example is the AHD formed by the University of Tennessee’s Department of Public Health and the Knox County Health Department. Built on a strong, long-term working relationship, the agreed-upon MOU formalized their work together and led to the hiring of a coordinator funded equally by the two entities, to the establishment of a steering committee populated by equal numbers of university and health department personnel, and to the creation of a number of joint projects (e.g., public health grand rounds and joint research endeavors).[41] 

Effective AHDs require resources, including financial commitments for staff and projects and constant nurturing of relational aspects such as mutual trust and a commitment to each other’s needs.[41] Evidence has shown that such investments pay off by facilitating better student practice experiences, improving workforce development activities, and generating meaningful policies and joint research projects.[41,44] In addition, formal relationships between academia and public health have been shown to enhance data quality, to better reach underserved populations, and to fill knowledge gaps with scientific findings.[44]

While academic institutions frequently look to the NIH to fund their research efforts, the CDC has worked far more with state and local health departments to conduct research. The Prevention Research Centers network, established in 1981, is one mechanism created solely for conducting applied public health research. Academic health departments need to foster relationships with their CDC partners to capitalize on research opportunities that can help their communities.[45] More important, the federal government should continue to provide adequate funds for CDC and academic health department partnerships to improve community health.

Resources providing support for academic health departments include the Public Health Foundation, which hosts a free academic health department learning community for those who have already established or desire to establish an AHD. This learning community serves as a forum for participants to connect with and support each other as they move through the process of establishing and maintaining partnerships. The National Network of Public Health Institutes is also a resource for analysis and determination of best practices. These institutes, located in 31 states, are partnerships of government agencies, academia, and a variety of community-level organizations. They work to improve a state’s population health by fostering innovation, supporting nonpartisan health advocacy, promoting multisector information systems, and leveraging resources to facilitate health improvements.

Access to evidence-based literature: In 2010, the University of Massachusetts Medical School Library received funding from the National Network of Libraries of Medicine to launch a pilot program designed to improve information access for public health departments. The program, called the Public Health Information Access (PHIA) project, worked with six New England states and Colorado to provide desktop digital access to licensed e-resources for public health departments at special pricing. The program included customizable digital libraries for the pilot agencies, additional resources from hospital or academic libraries, and training on how to use the digital resources. A goal of the project was to determine whether this business model was sustainable and could be used to expand access nationwide.[26] 

An evaluation of the PHIA project focused on two categories: “usefulness and usage” and “dissemination challenges, strategies, and effectiveness.”[26] The results showed that the digital library was used  find evidence-based programs and contact information for those doing similar work, (3) discover cross-discipline evidence, and (4) locate articles related to Behavioral Risk Factor Surveillance System data, science and lab-related topics, and gray literature.[26] User feedback indicated that several positive outcomes resulted from the program. It helped restore access to the science base, helped workers to more effectively understand and critique evidence, made access more equitable for staff, assisted in workforce development, encouraged publication in refereed journals, shortened the time needed to acquire evidence-based resources, added credibility to practice work, and promoted evidence-based decision making and practices.[26] 

A primary barrier identified in the evaluation of the PHIA project was that agencies were short staffed and overworked, limiting the number of people who could attend training sessions and conduct searches. A culture change intervention was suggested to overcome this issue.[26] Another barrier was publisher licensing and pricing models. Many publishers had agreed to change their licensing and pricing models to accommodate the project, but several did not, which made it difficult to accurately estimate the cost of the PHIA model. To resolve this issue, it was suggested that the National Network of Libraries of Medicine facilitate access to these key resources through the network’s systems.[26]

Overall, the PHIA pilot program was found to successfully facilitate access to timely and useful information for health departments; however, the initial evaluation identified areas of need in order for the benefits of this model to be fully realized, including high-level buy in and commitment within public health departments and expansion of digital libraries to address identified gaps in information availability.[26] 

Community-based participatory research and public health research dissemination: To facilitate effective use of CBPR and translation of results into practice, several organizations provide useful guidance for communication, dissemination, and implementation of evidence-based strategies. These organizations include the Agency for Healthcare Research and Quality[46,47]; AcademyHealth[48]; the Community Engagement Program of the Clinical and Translational Science Institute at the University of California, San Francisco[35]; and the Office of Planning, Research and Evaluation of the U.S. Department of Health and Human Services.[49]

Opposing Arguments/Evidence

As discussed, state and local public health agencies are faced with challenges in terms of resources, time, staff skill levels, total number of staff, and funding. Lack of resources  is the primary argument against public health agency participation in research activities. According to some studies, public health agencies would be better served allocating scarce resources to problems for which there are known solutions. There is also concern that shifting resources to research could decrease resources for delivery of public health services, which may be legally mandated by state or local policymakers or expected by communities. Participation in research is key, however, to responding more effectively and efficiently to public health problems at all governmental levels.

Action Steps

1. Public health agencies should attempt to enter into MOUs or other formal relationships with academic partners to facilitate research.

• Journal access should be included in MOUs. 
• Training programs should be created or adopted to educate public health agency workers on available resources, access to and use of journal databases, and assessments of research/evidence quality.
• Strategies for professional development of public health workers and students should be formulated.
• Agencies should establish collaborative learning sessions for academic and professional staff.
• Academic health departments should work with communities to investigate opportunities for practice-based research.
• Joint positions should be created to serve as a bridge between health departments and academic institutions.
• Mentorship programs should be developed for public health practitioners and students.
• Advocacy opportunities should be explored.
• Teaching opportunities in academic settings should be provided for public health professionals.
• Data sharing programs should be generated or expanded.
• Voluntary public health accreditation requirements should be used to encourage training in research.

1. 2. Funding mechanisms and sources should increase the resources available for research without diminishing those allocated for public health services.

• • Organizations providing funds for public health activities (public and private) should compare research funding priorities with assessments of public health agency performance (e.g., certification reports, assessments of public health issues identified by states) and align funding for research with practice needs.
• • Advocates should urge Congress to invest in public health research at levels comparable to those of basic and clinical research (the Budget Reconciliation Act, approved in December 2015, included additional funding for NIH research).
• • Federal agencies funding public health research projects should require that peer-reviewed journal articles on these projects be submitted electronically to the National Library of Medicine's digital archive, PubMed Central, and made available within 12 months of publication. 
• • The resource libraries of the National Network of Libraries of Medicine should explore potential partnerships with and special pricing for public health agencies to facilitate access to evidence-based literature and journals.

1. 3. Public health training centers, schools and programs of public health, public health institutes, schools of nursing, and other health schools should develop models that reduce barriers and increase engagement with local and state health departments. Specifically, schools should:

• Actively recruit students to increase the quantity and diversity of the workforce.
• Revise curricula to ensure that students acquire knowledge, skills, and experience in community engagement methods.
• Regularly track the numbers and job preparation of the public health workforce in their catchment areas (e.g., through NACCHO or the Association of State and Territorial Health Officials). 
• Collaborate with agencies to offer training that facilitates local and state health department engagement in public health research.
• Provide models that demonstrate practice agency participation in public health research that aligns with the resources and capabilities of the agency.
• Collaborate to review current opportunities for community engagement in public health research at the local level, identify gaps, and develop courses to address gaps as a means of facilitating CBPR in public health research.
• Provide models for public health research that facilitates community empowerment as opposed to only community engagement.
• Develop models and strategies for facilitating dissemination, assessment, and adoption of evidence-based practices by local and state public health agencies.
• Gather evidence on the outcomes and accomplishments of public health academic/practice partnerships.

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