RESEARCH AND PRACTICE
Overcoming Inertia: Increasing Public Health Departments’ Access to Evidence-Based Information and Promoting Usage to Inform Practice Nancy R. LaPelle, PhD, Karen Dahlen, MLS, Barbara A. Gabella, MSPH, Ashley L. Juhl, MSPH, and Elaine Martin, DA
In 2010, the New England Region–National Network of Libraries of Medicine at University of Massachusetts Medical School received funding to improve information access for public health departments in 6 New England states and Colorado. Public health departments were provided with desktop digital access to licensed e-resources available through special pricing. In January through mid-April 2012, we evaluated the effectiveness of providing access to and training for using e-resources to public health department staff to motivate usage in practice. We found that additional strategies are needed to accomplish this. (Am J Public Health. 2014;104:77–80. doi:10.2105/AJPH. 2013.301404)
Access to scientific evidence is vital to evidence-based public health and evidence-based decision-making, yet access is underutilized, limited, or both.1,2 Many public health departments (PHDs) have no access to evidence-based resources beyond those provided by the National Library of Medicine or its funding.3,4 Factors influencing evidence-based practice include information access, training, skills, leadership vision, and organizational change.5--9 By 2009, tools giving access to evidence-based information to policymakers existed but all were underutilized, as was training or technical assistance to enhance
uptake.2 By 2012 many PHDs experienced massive reductions in staff or resources resulting in variable awareness of the value of using evidence to inform decision-making.8 Barriers to information access include competing responsibilities, lack of full-text access, credibility of information retrieved, and infrequent training on information searching.1 Better methods of indexing, searching, and filtering information through single portal access, archiving information, and early notification of relevant information can improve access and movement toward evidence-based practice.10 Beginning in 2010, University of Massachusetts Medical School Library received National Network of Libraries of Medicine funding for its Public Health Information Access (PHIA) project, which provides (1) direct electronic access to full-text scientific literature to a convenience sample of state PHDs in 6 New England states and Colorado, (2) training, and (3) a pilot for a sustainable business model to expand access nationwide. Resources selected (see the box on the next page) for a digital library were based on national initiatives,11,12 suggestions from PHD grant partners, and metrics on resource use from publishers. The PHIA project adds journals as it identifies articles frequently requested through subsidized delivery service (Loansome Doc; National Library of Medicine, Bethesda, MD). The 7 PHDs customized the digital library template on their intranet or used shared file capability with links to e-resources. Hospital and academic medical libraries in each state provide resources not available through the digital library.
METHODS The PHIA project evaluation aimed to (1) assess usefulness and usage of resources provided and (2) identify effective dissemination strategies PHDs used to motivate utilization and compare them with factors identified in the literature. From January through mid-April 2012, the evaluator collected qualitative data regarding digital library usage in the 7 states. Evaluation interview questions addressed digital library use and usefulness, impact on practice, and effectiveness of training on using digital library resources. The evaluator interviewed lead contacts at 7 PHDs and their library partners and collected information from digital library users in PHDs
January 2014, Vol 104, No. 1 | American Journal of Public Health
via focus groups, interviews, and surveys. In all, we collected data from 50 participants across the 7 PHDs. The evaluator transcribed and subjected to a thematic analysis13---15 all data from focus groups, surveys, and telephone interviews.
RESULTS Evaluation findings related to the 2 broad categories of (1) usefulness and usage and (2) dissemination challenges, strategies, and effectiveness.
Usefulness and Usage Interviewees noted using digital library resources to d
d
d
d
Search for a. Peer-reviewed articles to inform program planning or grant-writing, b. Evidence-based programs or contact information for other states doing similar work, c. Cross-discipline evidence, d. Articles related to Behavioral Risk Factor Surveillance System and other health survey data, e. Science and lab-related topics, and f. Gray literature; Stay current on latest research and epidemiology methods; Review e-books and guidelines for care and treatment; and Subscribe to e-alerts from STAT!Ref (Teton Data Systems, Jackson, WY) or PHIA-funded journals.
The PHIA project tracked PHIA-funded directaccess journal usage electronically (Table 1). Lead contacts at PHDs said PHIA “restores access to our science base,” allows full understanding or critique of evidence, makes access equitable to all staff (beyond those with academic affiliations), fosters workforce development, and encourages publishing in refereed journals. The PHD workforce users said it shortens time to acquire evidence-based resources (making travel to medical libraries or identification of staff with academic affiliations unnecessary), adds credibility to their work and promotes evidence-based practice. All PHDs gave positive feedback on article delivery. Users said full-text articles, PubMed, and article delivery service were the most useful digital library components.
LaPelle et al. | Peer Reviewed | Research and Practice | 77
RESEARCH AND PRACTICE
Example of Resources Provided to Public Health Departments by the Public Health Information Access Project Single-title e-journals available through the digital library page included d
American Journal of Tropical Medicine and Hygiene Health Affairs
d
Journal of Agricultural Health and Safety
d
Journal of Food Protection
d
Journal of Medical Entomology
d
Journal of Public Health Policy
d
Journal of Studies on Alcohol and Drugs
d
Journal of Wildlife Research
d d
New England Journal of Medicine Pediatrics
d
Public Health Reports
d
Annual Reviews (n = 8)
d
American Society for Microbiology (n = 12)
d
Centers for Disease Control and Prevention (n = 3)
d
Mary Ann Liebert (n = 11)
d d
Oxford University Press (n = 25) Sage (n = 8)
d
Springer (n = 24)
d
University of Chicago Press (n = 6)
DISCUSSION The PHIA program addressed many barriers1,8 by providing onsite training; time-saving, full-text access to credible resources; early notification of relevant information through PubMed myNCBI; quick turnaround on article delivery service via library partners; and affordable EndNote licenses (Thomson Reuters, New York, NY) to archive and reuse information. Some states provided additional training. In some PHDs, staff acknowledged being so unaccustomed to having these resources that a culture change intervention, beyond training and access, was needed to overcome inertia and promote usage of digital library resources to inform evidence-based practice. Literature5---7,9,10 and Colorado’s experience suggest that this intervention should include strong leadership promoting evidence-based practice, collaboration, and organizational change. Of the 7 PHDs, Colorado came closest to addressing all factors promoting use of evidence-based resources:
Publisher packages included access to an additional 97 e-journals: d
library] really made our commitment to [evidence-based public health] possible.
A limited number of copies of EndNote, subsidized by Thomson Reuters, were distributed to public health departments to encourage saving information for use and reuse.
d
Seven hours of hands-on training included practice locating, appraising, and saving information with their own digital library pages. About 18 public health professionals per site attended. Note. Resources included specialized databases (notably PubMed), other licensed databases, e-books, journals, and notable reports provided through Internet Protocol address authentication and enterprise licensing for all public health departments. Databases included an e-book collection through STAT!Ref, CABI’s Global Health, and The Cochrane Library. Resources are reviewed and updated depending on usage and cost of use.
The PHIA training covered all resources accessible via the digital library page and their application to practice and trained about 18 trainees per PHD. After training, most felt comfortable with PubMed searches and Loansome Doc requests. Connecticut proactively offered 1.5-hour demonstrations of resources to 80 additional people. Colorado offered Prevention Services Division (PSD) staff additional training on searching and rating evidence and integrating it into evidence-based strategic planning.16---19
restoring a culture of evidence-based practice, by identifying appropriate, committed PHD staff with the authority to champion evidence-based practice and usage of digital library resources. Most PHDs relied on staff trained by PHIA to disseminate knowledge about the digital library throughout their organization. However, some described this strategy as ineffective. Colorado applied Brownson’s approach to evidence-based public health practice,16,17 training about 60 PSD staff to conduct literature reviews by using the digital library to inform future strategy.18,19 A PSD informant observed:
Dissemination Challenges, Strategies, and Effectiveness Every PHD mentioned being short-staffed and overworked, limiting the number attending trainings and doing searches. Most advocated
78 | Research and Practice | Peer Reviewed | LaPelle et al.
We in PSD would never have attempted the large obesity prevention literature review in 2.5 months without the ease of access to full text articles and systematic reviews and without the timely document delivery. Having the [digital
d
d
They engaged PSD staff in using the digital library to conduct a large literature review collaboratively across areas of expertise. They used the review to inform collaborative strategic planning with external partners. Their division directors consistently supported the use of scientific literature, regardless of its convenience.
The PHIA project began as a small demonstration pilot to provide limited resources licensed for access to only potential users or about 10% to 15% of the PHD staff. Publishers included in the digital library agreed to change their licensing and pricing model to accommodate PHIA. Publishers of a few key public health journals have not yet agreed to such changes, so access to these is through the subsidized article delivery service. Therefore, essential to the success of estimating costs of this model is the National Network of Libraries of Medicine network of resource libraries and their literature collections that make the delivery service and access to these key public health journals possible. According to our evaluation findings, giving access to evidence-based resources and
American Journal of Public Health | January 2014, Vol 104, No. 1
25 717
374 30
2519 2340
24 28
1993 1695
32 23
547 149 557 219 579 220
providing training were useful and necessary first steps. Yet more could be done. Strong leadership and collaboration to promote literature review help reinforce a culture of evidence-based practice. The PHIA project is adding digital library access to 4 more states, and adding digital library resources on the basis of gaps identified by this evaluation and surveys done in each state. Evaluation is needed in added states to explore findings further. The University of Massachusetts Library and the National Library of Medicine are seeking additional national funding sources to extend this effort nationwide. j
1935
7582 1774 656 179 716 165
15 381 1585 1384 1218 846 1031
515
91 37
32 22
29 2
49 41
0 14
68
Mar 2012
18 45
2162
19 26
1690
60
1144
57 3
1420
9
1707
0
879
0
877
University of Chicago Press (5)
Monthly totals
492 159 499 27 86 0 Oxford University Press (15) Springer (21)
224 0
470 84
863 1172 655 791 Medicine (1)
New England Journal of
1405
2033
1918
497 128 571 145 547 63 413 160
728 76
1120 1354 1002 421
762
1177
5 4
43
0 0
52
0 0 0 0
0
0
0
Annual Reviews (10)
0
0
0
15
10
33
150
About the Authors
Public Health Reports (1)
Nov 2011 Oct 2011 Sep 2011 Aug 2011 Jul 2011 Jun 2011 May 2011 Apr 2011 Mar 2011 Feb 2011 Jan 2011 Publisher (No. Titles)
TABLE 1—Sample Digital Library Usage Statistics From January 2011 Through March 2012 Across 7 Public Health Departments
Dec 2011
Jan 2012
Feb 2012
Total
RESEARCH AND PRACTICE
Nancy R. LaPelle is with the Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester. Karen Dahlen is an independent consultant based in Fort Collins, CO. Barbara A. Gabella and Ashley L. Juhl are with the Prevention Services Division of the Colorado Department of Public Health and Environment, Denver. Elaine Martin is with the Lamar Soutter Library at the University of Massachusetts Medical School. Correspondence should be sent to Nancy R. LaPelle, 43 Whispering Brook Rd, Marlborough, MA 01752 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted April 16, 2013.
Contributors The Public Health Information Access project was originated by E. Martin. The evaluation study was conceptualized by N. R. LaPelle who also led the writing of the article. K. Dahlen assisted with the identification of evaluation participants, interview script development, and collection of usage statistics. B. A. Gabella and A. L. Juhl originally were among evaluation informants from the Colorado public health department. All authors contributed to critical revisions of the article in providing feedback on initial drafts and subsequent revisions. All authors contributed substantially to the development of the article.
Acknowledgments This project and evaluation research were funded under contract HHS-N-276-2011-00010-C with the University of Massachusetts Medical School and awarded by the Department of Health and Human Services, National Institutes of Health, National Library of Medicine. The authors would like to acknowledge Lisa Miller, MD, MSPH, director of the Disease Control and Environmental Epidemiology Division at the Colorado Department of Public Health and Environment, for her persistent support and previous efforts to get scientific literature at the fingertips of public health practitioners. In addition, we would like to express appreciation to Judy Nordberg for her assistance in preparation of the article.
January 2014, Vol 104, No. 1 | American Journal of Public Health
Human Participant Protection No protocol approval was necessary for this study because no human participants were involved.
References 1. Revere D, Turner AM, Madhavan A, et al. Understanding the information needs of public health practitioners: a literature review to inform design of an interactive digital knowledge management system. J Biomed Inform. 2007;40(4):410---421. 2. Brownson RC, Chriqui JF, Stamatakis KA. Understanding evidence-based public health policy. Am J Public Health. 2009;99(9):1576---1583. 3. O’Neall MA, Brownson RC. Teaching evidencebased public health to public health practitioners. Ann Epidemiol. 2005;15(7):540---544. 4. Whitener BL, Van Horne VV, Gauthier AK. Health services research tools for public health professionals. Am J Public Health. 2005;95(2):204---207. 5. Wandersman A, Duffy J, Flaspohler P, et al. Bridging the gap between prevention research and practice: the interactive systems framework for dissemination and implementation. Am J Community Psychol. 2008;41(3-4): 171---181. 6. Dodson EA, Baker EA, Brownson RC. Use of evidence-based interventions in state health departments: a qualitative assessment of barriers and solutions. J Public Health Manag Pract. 2010;16(6):E9---E15. 7. Jacobs JA, Clayton PF, Dove C, et al. A survey tool for measuring evidence-based decision making capacity in public health agencies. BMC Health Serv Res. 2012;12:57. 8. Noonan RK, Wilson KM, Mercer SL. Navigating the road ahead: public health challenges and the interactive systems framework for dissemination and implementation. Am J Community Psychol. 2012;50(3-4): 572---580. 9. Glasgow RE, Vinson C, Chambers D, et al. National Institutes of Health approaches to dissemination and implementation science: current and future directions. Am J Public Health. 2012;102(7):1274---1281. 10. LaPelle NR, Luckmann R, Simpson EH, Martin ER. Identifying strategies to improve access to credible and relevant information for public health professionals: a qualitative study. BMC Public Health. 2006;6:89---102. 11. American Public Health Association, Council on Linkages Between Academia and Public Health Practice. Core competencies for public health professionals. 2009. Available at: http://www.phf.org/programs/council/ Pages/default.aspx/competenciesinformation.htm. Accessed September 2, 2012. 12. Centers for Disease Control and Prevention, University of Washington’s Center for Public Health Informatics. Competencies for public health informaticians. 2009. Available at: http://www.cdc.gov/InformaticsCompetencies. Accessed September 2, 2012. 13. LaPelle N. Simplifying qualitative data analysis using general purpose software tools. Field Methods. 2004;16 (1):85---108. 14. Crabtree BF, Miller WL. Doing Qualitative Research in Primary Care: Multiple Strategies. 2nd ed. Newbury Park, CA: Sage Publications; 1999. 15. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. Thousand Oaks, CA: Sage Publications; 1994.
LaPelle et al. | Peer Reviewed | Research and Practice | 79
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16. Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-Based Public Health. London, UK: Oxford University Press; 2003. 17. Brownson RC, Fielding JE, Maylahn CM. Evidencebased public health: a fundamental concept for public health practice. Annu Rev Public Health. 2009;30:175---201. 18. Jacobs JA, Jones E, Gabella BA, Spring B, Brownson RC. Tools for implementing an evidence-based approach in public health practice. Prev Chronic Dis. 2012;9:E116. 19. Colorado Department of Public Health and Environment, Prevention Services Division. Colorado Obesity Integration Project. 2012. Available at: http://www.coprevent. org/search/label/OIP. Accessed September 2, 2012.
The Impact of Childhood Mobility on Exposure to Neighborhood Socioeconomic Context Over Time Elisabeth Dowling Root, PhD, and Jamie L. Humphrey, MPH
We used the 1998–1999 Early Childhood Longitudinal Study— Kindergarten Cohort, with data collected in kindergarten, first, third, fifth, and eighth grades, in a descriptive analysis of associations between early childhood residential mobility frequency and neighborhood context changes. We found that children who move frequently appear initially to move into higher-socioeconomic-status neighborhoods but eventually move back to lower-socioeconomicstatus neighborhoods, exposing frequent movers to diverse neighborhood contexts. These findings have implications for policy and research that seeks to link neighborhood context to health. (Am J Public Health. 2014;104:80–82. doi:10.2105/ AJPH.2013.301467)
In 2011 approximately 12% of US children aged 5 to 17 years changed residences.1 Previous research has associated frequent
residential mobility with numerous adverse and long-term educational, behavioral, emotional, and mental health issues; physical health outcomes; and inconsistent or lacking preventive health services.2,3 As children move, they are also exposed to new neighborhood environments.4 Although the literature on neighborhood context and health suggests that residential socioeconomic status (SES) has an impact on a wide range of health outcomes,4---12 most studies that examine these dynamics are conducted with cross-sectional study designs because longitudinal data are largely unavailable. In fact, very little literature even examines how children’s neighborhood contexts change over time. This knowledge gap compromises our ability to study and understand the impacts of neighborhood on children’s health over time because we do not know (1) whether children move to neighborhoods with similar or different socioeconomic characteristics and (2) whether children who move frequently maintain consistently upward or downward trajectories in neighborhood SES with each subsequent move. Using a nationally representative longitudinal data set, we examined how often children moved during early childhood and the socioeconomic contexts of neighborhoods children move to and from over time. The findings from this study have implications for future research examining the impact of neighborhood environments on health.
METHODS We drew data from the Early Childhood Longitudinal Study—Kindergarten Cohort (ECLS-K), maintained by the National Center for Educational Statistics.13 The ECLS-K is a nationally representative longitudinal study of 21 410 children in the United States who began kindergarten during the 1998---1999 school year. Five waves of data were collected, in kindergarten, first, third, fifth, and eighth grades. The National Center for Educational Statistics established a complex process for following children who changed schools so researchers could study the effects of mobility on child well-being. Details of the survey methods, including attrition and sample limitations, are described in materials available as a supplement to the online version of this article at http://www.ajph.org and elsewhere.14
80 | Research and Practice | Peer Reviewed | Root and Humphrey
Residential mobility was assessed at each wave of the study by the parent interview question, “Why did you move?” Families were categorized as “stayers” if they did not indicate a change in residence at any point during the study period, “movers” if they changed residences 1 time, and “frequent movers” if they changed residences 2 or more times. The ECLS-K provided census tract of residence for each wave except fifth grade, which we linked to measures of neighborhood SES derived from the 2000 US Census and the 2005--2009 American Community Survey. We developed 3 indices of neighborhood SES—the Townsend and Carstairs Indices and the Centers for Disease Control and Prevention’s Index of Local Economic Resources—and 3 single variable measures—percentage below the federal poverty line, percentage with a college education, and median household income.12,15---17 We compared the mean values of neighborhood SES indicators for stayers, movers, and frequent movers by using analysis of variance tests in SAS version 9.3 (SAS Institute, Cary, NC). We applied survey weights to all estimates using the jackknife method.
RESULTS After we applied sample weights, 18 950 children were included in the analyses. Between kindergarten and eighth grade, 22.9% of families moved once and 6.3% moved 2 or more times. At baseline, movers and frequent movers lived in lower SES neighborhoods compared with stayers for all SES measures (Table 1). Over time, both movers and frequent movers in the ECLS-K sample moved to higher SES neighborhoods, although frequent movers appear to move back to lower SES neighborhoods during their final move (Figure 1 and materials available as a supplement to the online version of this article at http://www.ajph.org). Additional results can be found in the online supplemental material.
DISCUSSION This study provides evidence of significant movement and change in neighborhood context over time among children in the ECLS-K. Perhaps the most novel finding relates to the diversity of experiences among frequent movers who appear initially to move into higher SES
American Journal of Public Health | January 2014, Vol 104, No. 1
Overcoming Inertia: Increasing Public Health Departments’ Access to Evidence-Based Information and Promoting Usage to Inform Practice Nancy R. LaPelle, PhD, Karen Dahlen, MLS, Barbara A. Gabella, MSPH, Ashley L. Juhl, MSPH, and Elaine Martin, DA
In 2010, the New England Region–National Network of Libraries of Medicine at University of Massachusetts Medical School received funding to improve information access for public health departments in 6 New England states and Colorado. Public health departments were provided with desktop digital access to licensed e-resources available through special pricing. In January through mid-April 2012, we evaluated the effectiveness of providing access to and training for using e-resources to public health department staff to motivate usage in practice. We found that additional strategies are needed to accomplish this. (Am J Public Health. 2014;104:77–80. doi:10.2105/AJPH. 2013.301404)
Access to scientific evidence is vital to evidence-based public health and evidence-based decision-making, yet access is underutilized, limited, or both.1,2 Many public health departments (PHDs) have no access to evidence-based resources beyond those provided by the National Library of Medicine or its funding.3,4 Factors influencing evidence-based practice include information access, training, skills, leadership vision, and organizational change.5--9 By 2009, tools giving access to evidence-based information to policymakers existed but all were underutilized, as was training or technical assistance to enhance
uptake.2 By 2012 many PHDs experienced massive reductions in staff or resources resulting in variable awareness of the value of using evidence to inform decision-making.8 Barriers to information access include competing responsibilities, lack of full-text access, credibility of information retrieved, and infrequent training on information searching.1 Better methods of indexing, searching, and filtering information through single portal access, archiving information, and early notification of relevant information can improve access and movement toward evidence-based practice.10 Beginning in 2010, University of Massachusetts Medical School Library received National Network of Libraries of Medicine funding for its Public Health Information Access (PHIA) project, which provides (1) direct electronic access to full-text scientific literature to a convenience sample of state PHDs in 6 New England states and Colorado, (2) training, and (3) a pilot for a sustainable business model to expand access nationwide. Resources selected (see the box on the next page) for a digital library were based on national initiatives,11,12 suggestions from PHD grant partners, and metrics on resource use from publishers. The PHIA project adds journals as it identifies articles frequently requested through subsidized delivery service (Loansome Doc; National Library of Medicine, Bethesda, MD). The 7 PHDs customized the digital library template on their intranet or used shared file capability with links to e-resources. Hospital and academic medical libraries in each state provide resources not available through the digital library.
METHODS The PHIA project evaluation aimed to (1) assess usefulness and usage of resources provided and (2) identify effective dissemination strategies PHDs used to motivate utilization and compare them with factors identified in the literature. From January through mid-April 2012, the evaluator collected qualitative data regarding digital library usage in the 7 states. Evaluation interview questions addressed digital library use and usefulness, impact on practice, and effectiveness of training on using digital library resources. The evaluator interviewed lead contacts at 7 PHDs and their library partners and collected information from digital library users in PHDs
January 2014, Vol 104, No. 1 | American Journal of Public Health
via focus groups, interviews, and surveys. In all, we collected data from 50 participants across the 7 PHDs. The evaluator transcribed and subjected to a thematic analysis13---15 all data from focus groups, surveys, and telephone interviews.
RESULTS Evaluation findings related to the 2 broad categories of (1) usefulness and usage and (2) dissemination challenges, strategies, and effectiveness.
Usefulness and Usage Interviewees noted using digital library resources to d
d
d
d
Search for a. Peer-reviewed articles to inform program planning or grant-writing, b. Evidence-based programs or contact information for other states doing similar work, c. Cross-discipline evidence, d. Articles related to Behavioral Risk Factor Surveillance System and other health survey data, e. Science and lab-related topics, and f. Gray literature; Stay current on latest research and epidemiology methods; Review e-books and guidelines for care and treatment; and Subscribe to e-alerts from STAT!Ref (Teton Data Systems, Jackson, WY) or PHIA-funded journals.
The PHIA project tracked PHIA-funded directaccess journal usage electronically (Table 1). Lead contacts at PHDs said PHIA “restores access to our science base,” allows full understanding or critique of evidence, makes access equitable to all staff (beyond those with academic affiliations), fosters workforce development, and encourages publishing in refereed journals. The PHD workforce users said it shortens time to acquire evidence-based resources (making travel to medical libraries or identification of staff with academic affiliations unnecessary), adds credibility to their work and promotes evidence-based practice. All PHDs gave positive feedback on article delivery. Users said full-text articles, PubMed, and article delivery service were the most useful digital library components.
LaPelle et al. | Peer Reviewed | Research and Practice | 77
RESEARCH AND PRACTICE
Example of Resources Provided to Public Health Departments by the Public Health Information Access Project Single-title e-journals available through the digital library page included d
American Journal of Tropical Medicine and Hygiene Health Affairs
d
Journal of Agricultural Health and Safety
d
Journal of Food Protection
d
Journal of Medical Entomology
d
Journal of Public Health Policy
d
Journal of Studies on Alcohol and Drugs
d
Journal of Wildlife Research
d d
New England Journal of Medicine Pediatrics
d
Public Health Reports
d
Annual Reviews (n = 8)
d
American Society for Microbiology (n = 12)
d
Centers for Disease Control and Prevention (n = 3)
d
Mary Ann Liebert (n = 11)
d d
Oxford University Press (n = 25) Sage (n = 8)
d
Springer (n = 24)
d
University of Chicago Press (n = 6)
DISCUSSION The PHIA program addressed many barriers1,8 by providing onsite training; time-saving, full-text access to credible resources; early notification of relevant information through PubMed myNCBI; quick turnaround on article delivery service via library partners; and affordable EndNote licenses (Thomson Reuters, New York, NY) to archive and reuse information. Some states provided additional training. In some PHDs, staff acknowledged being so unaccustomed to having these resources that a culture change intervention, beyond training and access, was needed to overcome inertia and promote usage of digital library resources to inform evidence-based practice. Literature5---7,9,10 and Colorado’s experience suggest that this intervention should include strong leadership promoting evidence-based practice, collaboration, and organizational change. Of the 7 PHDs, Colorado came closest to addressing all factors promoting use of evidence-based resources:
Publisher packages included access to an additional 97 e-journals: d
library] really made our commitment to [evidence-based public health] possible.
A limited number of copies of EndNote, subsidized by Thomson Reuters, were distributed to public health departments to encourage saving information for use and reuse.
d
Seven hours of hands-on training included practice locating, appraising, and saving information with their own digital library pages. About 18 public health professionals per site attended. Note. Resources included specialized databases (notably PubMed), other licensed databases, e-books, journals, and notable reports provided through Internet Protocol address authentication and enterprise licensing for all public health departments. Databases included an e-book collection through STAT!Ref, CABI’s Global Health, and The Cochrane Library. Resources are reviewed and updated depending on usage and cost of use.
The PHIA training covered all resources accessible via the digital library page and their application to practice and trained about 18 trainees per PHD. After training, most felt comfortable with PubMed searches and Loansome Doc requests. Connecticut proactively offered 1.5-hour demonstrations of resources to 80 additional people. Colorado offered Prevention Services Division (PSD) staff additional training on searching and rating evidence and integrating it into evidence-based strategic planning.16---19
restoring a culture of evidence-based practice, by identifying appropriate, committed PHD staff with the authority to champion evidence-based practice and usage of digital library resources. Most PHDs relied on staff trained by PHIA to disseminate knowledge about the digital library throughout their organization. However, some described this strategy as ineffective. Colorado applied Brownson’s approach to evidence-based public health practice,16,17 training about 60 PSD staff to conduct literature reviews by using the digital library to inform future strategy.18,19 A PSD informant observed:
Dissemination Challenges, Strategies, and Effectiveness Every PHD mentioned being short-staffed and overworked, limiting the number attending trainings and doing searches. Most advocated
78 | Research and Practice | Peer Reviewed | LaPelle et al.
We in PSD would never have attempted the large obesity prevention literature review in 2.5 months without the ease of access to full text articles and systematic reviews and without the timely document delivery. Having the [digital
d
d
They engaged PSD staff in using the digital library to conduct a large literature review collaboratively across areas of expertise. They used the review to inform collaborative strategic planning with external partners. Their division directors consistently supported the use of scientific literature, regardless of its convenience.
The PHIA project began as a small demonstration pilot to provide limited resources licensed for access to only potential users or about 10% to 15% of the PHD staff. Publishers included in the digital library agreed to change their licensing and pricing model to accommodate PHIA. Publishers of a few key public health journals have not yet agreed to such changes, so access to these is through the subsidized article delivery service. Therefore, essential to the success of estimating costs of this model is the National Network of Libraries of Medicine network of resource libraries and their literature collections that make the delivery service and access to these key public health journals possible. According to our evaluation findings, giving access to evidence-based resources and
American Journal of Public Health | January 2014, Vol 104, No. 1
25 717
374 30
2519 2340
24 28
1993 1695
32 23
547 149 557 219 579 220
providing training were useful and necessary first steps. Yet more could be done. Strong leadership and collaboration to promote literature review help reinforce a culture of evidence-based practice. The PHIA project is adding digital library access to 4 more states, and adding digital library resources on the basis of gaps identified by this evaluation and surveys done in each state. Evaluation is needed in added states to explore findings further. The University of Massachusetts Library and the National Library of Medicine are seeking additional national funding sources to extend this effort nationwide. j
1935
7582 1774 656 179 716 165
15 381 1585 1384 1218 846 1031
515
91 37
32 22
29 2
49 41
0 14
68
Mar 2012
18 45
2162
19 26
1690
60
1144
57 3
1420
9
1707
0
879
0
877
University of Chicago Press (5)
Monthly totals
492 159 499 27 86 0 Oxford University Press (15) Springer (21)
224 0
470 84
863 1172 655 791 Medicine (1)
New England Journal of
1405
2033
1918
497 128 571 145 547 63 413 160
728 76
1120 1354 1002 421
762
1177
5 4
43
0 0
52
0 0 0 0
0
0
0
Annual Reviews (10)
0
0
0
15
10
33
150
About the Authors
Public Health Reports (1)
Nov 2011 Oct 2011 Sep 2011 Aug 2011 Jul 2011 Jun 2011 May 2011 Apr 2011 Mar 2011 Feb 2011 Jan 2011 Publisher (No. Titles)
TABLE 1—Sample Digital Library Usage Statistics From January 2011 Through March 2012 Across 7 Public Health Departments
Dec 2011
Jan 2012
Feb 2012
Total
RESEARCH AND PRACTICE
Nancy R. LaPelle is with the Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester. Karen Dahlen is an independent consultant based in Fort Collins, CO. Barbara A. Gabella and Ashley L. Juhl are with the Prevention Services Division of the Colorado Department of Public Health and Environment, Denver. Elaine Martin is with the Lamar Soutter Library at the University of Massachusetts Medical School. Correspondence should be sent to Nancy R. LaPelle, 43 Whispering Brook Rd, Marlborough, MA 01752 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted April 16, 2013.
Contributors The Public Health Information Access project was originated by E. Martin. The evaluation study was conceptualized by N. R. LaPelle who also led the writing of the article. K. Dahlen assisted with the identification of evaluation participants, interview script development, and collection of usage statistics. B. A. Gabella and A. L. Juhl originally were among evaluation informants from the Colorado public health department. All authors contributed to critical revisions of the article in providing feedback on initial drafts and subsequent revisions. All authors contributed substantially to the development of the article.
Acknowledgments This project and evaluation research were funded under contract HHS-N-276-2011-00010-C with the University of Massachusetts Medical School and awarded by the Department of Health and Human Services, National Institutes of Health, National Library of Medicine. The authors would like to acknowledge Lisa Miller, MD, MSPH, director of the Disease Control and Environmental Epidemiology Division at the Colorado Department of Public Health and Environment, for her persistent support and previous efforts to get scientific literature at the fingertips of public health practitioners. In addition, we would like to express appreciation to Judy Nordberg for her assistance in preparation of the article.
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Human Participant Protection No protocol approval was necessary for this study because no human participants were involved.
References 1. Revere D, Turner AM, Madhavan A, et al. Understanding the information needs of public health practitioners: a literature review to inform design of an interactive digital knowledge management system. J Biomed Inform. 2007;40(4):410---421. 2. Brownson RC, Chriqui JF, Stamatakis KA. Understanding evidence-based public health policy. Am J Public Health. 2009;99(9):1576---1583. 3. O’Neall MA, Brownson RC. Teaching evidencebased public health to public health practitioners. Ann Epidemiol. 2005;15(7):540---544. 4. Whitener BL, Van Horne VV, Gauthier AK. Health services research tools for public health professionals. Am J Public Health. 2005;95(2):204---207. 5. Wandersman A, Duffy J, Flaspohler P, et al. Bridging the gap between prevention research and practice: the interactive systems framework for dissemination and implementation. Am J Community Psychol. 2008;41(3-4): 171---181. 6. Dodson EA, Baker EA, Brownson RC. Use of evidence-based interventions in state health departments: a qualitative assessment of barriers and solutions. J Public Health Manag Pract. 2010;16(6):E9---E15. 7. Jacobs JA, Clayton PF, Dove C, et al. A survey tool for measuring evidence-based decision making capacity in public health agencies. BMC Health Serv Res. 2012;12:57. 8. Noonan RK, Wilson KM, Mercer SL. Navigating the road ahead: public health challenges and the interactive systems framework for dissemination and implementation. Am J Community Psychol. 2012;50(3-4): 572---580. 9. Glasgow RE, Vinson C, Chambers D, et al. National Institutes of Health approaches to dissemination and implementation science: current and future directions. Am J Public Health. 2012;102(7):1274---1281. 10. LaPelle NR, Luckmann R, Simpson EH, Martin ER. Identifying strategies to improve access to credible and relevant information for public health professionals: a qualitative study. BMC Public Health. 2006;6:89---102. 11. American Public Health Association, Council on Linkages Between Academia and Public Health Practice. Core competencies for public health professionals. 2009. Available at: http://www.phf.org/programs/council/ Pages/default.aspx/competenciesinformation.htm. Accessed September 2, 2012. 12. Centers for Disease Control and Prevention, University of Washington’s Center for Public Health Informatics. Competencies for public health informaticians. 2009. Available at: http://www.cdc.gov/InformaticsCompetencies. Accessed September 2, 2012. 13. LaPelle N. Simplifying qualitative data analysis using general purpose software tools. Field Methods. 2004;16 (1):85---108. 14. Crabtree BF, Miller WL. Doing Qualitative Research in Primary Care: Multiple Strategies. 2nd ed. Newbury Park, CA: Sage Publications; 1999. 15. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. Thousand Oaks, CA: Sage Publications; 1994.
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16. Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-Based Public Health. London, UK: Oxford University Press; 2003. 17. Brownson RC, Fielding JE, Maylahn CM. Evidencebased public health: a fundamental concept for public health practice. Annu Rev Public Health. 2009;30:175---201. 18. Jacobs JA, Jones E, Gabella BA, Spring B, Brownson RC. Tools for implementing an evidence-based approach in public health practice. Prev Chronic Dis. 2012;9:E116. 19. Colorado Department of Public Health and Environment, Prevention Services Division. Colorado Obesity Integration Project. 2012. Available at: http://www.coprevent. org/search/label/OIP. Accessed September 2, 2012.
The Impact of Childhood Mobility on Exposure to Neighborhood Socioeconomic Context Over Time Elisabeth Dowling Root, PhD, and Jamie L. Humphrey, MPH
We used the 1998–1999 Early Childhood Longitudinal Study— Kindergarten Cohort, with data collected in kindergarten, first, third, fifth, and eighth grades, in a descriptive analysis of associations between early childhood residential mobility frequency and neighborhood context changes. We found that children who move frequently appear initially to move into higher-socioeconomic-status neighborhoods but eventually move back to lower-socioeconomicstatus neighborhoods, exposing frequent movers to diverse neighborhood contexts. These findings have implications for policy and research that seeks to link neighborhood context to health. (Am J Public Health. 2014;104:80–82. doi:10.2105/ AJPH.2013.301467)
In 2011 approximately 12% of US children aged 5 to 17 years changed residences.1 Previous research has associated frequent
residential mobility with numerous adverse and long-term educational, behavioral, emotional, and mental health issues; physical health outcomes; and inconsistent or lacking preventive health services.2,3 As children move, they are also exposed to new neighborhood environments.4 Although the literature on neighborhood context and health suggests that residential socioeconomic status (SES) has an impact on a wide range of health outcomes,4---12 most studies that examine these dynamics are conducted with cross-sectional study designs because longitudinal data are largely unavailable. In fact, very little literature even examines how children’s neighborhood contexts change over time. This knowledge gap compromises our ability to study and understand the impacts of neighborhood on children’s health over time because we do not know (1) whether children move to neighborhoods with similar or different socioeconomic characteristics and (2) whether children who move frequently maintain consistently upward or downward trajectories in neighborhood SES with each subsequent move. Using a nationally representative longitudinal data set, we examined how often children moved during early childhood and the socioeconomic contexts of neighborhoods children move to and from over time. The findings from this study have implications for future research examining the impact of neighborhood environments on health.
METHODS We drew data from the Early Childhood Longitudinal Study—Kindergarten Cohort (ECLS-K), maintained by the National Center for Educational Statistics.13 The ECLS-K is a nationally representative longitudinal study of 21 410 children in the United States who began kindergarten during the 1998---1999 school year. Five waves of data were collected, in kindergarten, first, third, fifth, and eighth grades. The National Center for Educational Statistics established a complex process for following children who changed schools so researchers could study the effects of mobility on child well-being. Details of the survey methods, including attrition and sample limitations, are described in materials available as a supplement to the online version of this article at http://www.ajph.org and elsewhere.14
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Residential mobility was assessed at each wave of the study by the parent interview question, “Why did you move?” Families were categorized as “stayers” if they did not indicate a change in residence at any point during the study period, “movers” if they changed residences 1 time, and “frequent movers” if they changed residences 2 or more times. The ECLS-K provided census tract of residence for each wave except fifth grade, which we linked to measures of neighborhood SES derived from the 2000 US Census and the 2005--2009 American Community Survey. We developed 3 indices of neighborhood SES—the Townsend and Carstairs Indices and the Centers for Disease Control and Prevention’s Index of Local Economic Resources—and 3 single variable measures—percentage below the federal poverty line, percentage with a college education, and median household income.12,15---17 We compared the mean values of neighborhood SES indicators for stayers, movers, and frequent movers by using analysis of variance tests in SAS version 9.3 (SAS Institute, Cary, NC). We applied survey weights to all estimates using the jackknife method.
RESULTS After we applied sample weights, 18 950 children were included in the analyses. Between kindergarten and eighth grade, 22.9% of families moved once and 6.3% moved 2 or more times. At baseline, movers and frequent movers lived in lower SES neighborhoods compared with stayers for all SES measures (Table 1). Over time, both movers and frequent movers in the ECLS-K sample moved to higher SES neighborhoods, although frequent movers appear to move back to lower SES neighborhoods during their final move (Figure 1 and materials available as a supplement to the online version of this article at http://www.ajph.org). Additional results can be found in the online supplemental material.
DISCUSSION This study provides evidence of significant movement and change in neighborhood context over time among children in the ECLS-K. Perhaps the most novel finding relates to the diversity of experiences among frequent movers who appear initially to move into higher SES
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