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Public Health Today:A National PerspectivePam Aaltonen, PhD, RNpresident@apha.org or aaltonen@purdue.edu

My public health journey;what’s yours?

Minneapolis, MNCrookston, MN

Tulsa, OK

Champaign, IL

Lafayette, IN/

Kayenta, AZ

Why public health?

Pivotal experience?Grad School

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Objectives (continuing education)

• Explore APHAs national advocacy priorities

• Identify strategies to enhance the generation and use of practice-based evidence

• Explore the importance of context in use of practice-based evidence

Nothing to disclose

Agenda• Introduction

• PH History IQ

• National Advocacy

• Evidence-based public health

• Sources of evidence/best practices (handout)

• APHA work/resources

• Conclusion/summary

• Exercise (for later)

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Greetings from APHA

• Georges Benjamin, MD - APHA Executive Director

• Betty Daniels, PhD, RN - APHA Executive Board Chair

• Illinois ARGC (Affiliate Representative to the Governing Council) Mark Stevens

• Many APHA leaders (42) including past presidents Iris Shannon and Linda Rae Murray; potential for another

For your calendar

Philadelphia, November 2-6, 2019

APHA Live

individual or group

Students/Early Professionals

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Watch for 2nd Annual APHA Policy Conference, 02.12.20

Public Health Under Siege: Improving Policy in Turbulent Times, 2019

Public Health IQ

• 1872 APHA founded by _______ , NYC Surgeon

• Honored at APHA meeting in 1921, age 98

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August 1, 1884 Letter• Sister in Chicago writing to report

on brother Virgil’s illness … by August 15th had died of what disease?

Upton Sinclair’s The JungleExposed what industry in Chicago?

1906 book led within a year to:

• Federal Meat Inspection Act

• Pure Food and Drug Act

• Dr. Harvey Wiley• “Poison Squad”

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• Illinois’s first mobile TB unit initiated in what year?

• 1968 Illinois Public Health Association dues were ___.

• WIC initiated in Illinois: 1960s, 1970s or 1980s?

• First full-time county health department (1922) … which county?

• Who is this individual?

What famous public health document/diagram is celebrating 25 years?

• de Beaumont Foundation survey: Tweak

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APHA Strategic Plan

Why so important to be strong advocate …

• Intersection of forces

• Decision making by & for public health initiatives often complex, iterative, nuanced

Social

Political

Cultural

Economic

PH

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APHA’s Advocacy Priorities

• Affordable Care Act: Universal Coverage/Health Care Costs

• Prevention & Public Health Fund

• Funding for CDC & HRSA (much returns to states)

• Climate Change/Clean Air Act (EPA)

• Pharmaceutical Costs

• Addiction (opioids, …)

Firearm Safety Advocacy

• February Summit 2019: ACS, AAP, APHA, ABA, …

• Dickey Amendment (1996): none of the funds made available for injury prevention and control at CDC may be used to advocate or promote gun control• Put us BEHIND

• Responsible gun ownership; engage gun owners

• 30% suicides by firearm (2/3 gun deaths are suicides)

• Higher caliber bullets …↑ damage, fractures

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Additional Discussions• ACES

• Violence/Hatred

• Upstream actions: Food Insecurity, Affordable Housing, Education Systems, etc.

• Science-Based Regulation/Deregulation

• Industry Influence

• Global issues such as Ebola, Antibiotic Resistance … One Health

• Health Equity

Illustrating Inequity• Life Expectancy Calculated by Where Live• 2018 NYU study: largest gap in country in Chicago• Streeterville Neighborhood (90 years) vs Englewood Neighborhood (60 years)

• Gap Between Rich & Poor ↑• ~ 15 years gap for men

• ~ 10 years gap for women

• ~ 1/3 of difference explained by risky behaviors

• social determinants of health/population health

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RWJ Graphics

Siddiqui, N., et al. (2018) The HOPE Initiative [Health Opportunity and Equity]Robert Wood Johnson Foundation Texas Health Institute & Virginia Commonwealth University Center on Society and Health

http://www.nationalcollaborative.org/our-programs/hope-initiative-project/

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Measure (overall) IllinoisRank Score

USAGoal

Measure (overall) IllinoisRank Score

USAGoal

Adult Health Status (good or excellent) 32 49 75% Low Assault Rate (counties < 283/100,000) 39 45 100%

Mental Health Status (not good) 12 10 5% Low Rape Rate (counties < 36.9/100,000) 20 82 100%

Child Health Status 38 84 97% Low Robbery Rate (counties < 52.1/100,000) 27 45 100%

Premature Mortality (death rate, 24-64) 18 349 260 Home Ownership 27 69 81%

Infant Mortality (rate) 23 6.9 2.4 Housing Quality (no severe problems) 33 84 94%

Low Birth Weight (< 2500 grams) 32 8.5 5% Air Quality: Particulate Matter(% counties meet standard)

36 7 100%

Livable Income (> 250% federal poverty level) 20 65 89% Low Liquor Store Density (< 1.736/10,000) 17 99 100%

Affordable Housing (< 30% monthly income) 33 66 87% Food Security (not living in food desert) 12 92 97%

Post-secondary Education 23 61 83% Access to Primary Care (< 2000:1) 29 80 100%

Connected Youth (school or working) 24 94 100% Access to Psychiatric Care (< 30,000:1) 20 78 100%

Preschool Enrollment 6 54 76% Health Insurance Coverage 20 87 97%

Employment (> 16 years of age) 37 90 98% Affordable Health Care (no delay due to $) 19 87 95%

Low Poverty Concentration (< 20% poverty) 25 80 100% Usual Source of Care (have provider) 18 83 92%

Low Murder Rate (counties < 5.1/100,000) 39 50 100% Colorectal Ca Screening (50-75 yrs) 38 64 80%

28 Indicators … much more depth in report … share with collaborators

• Definition of Terms

• Common Goals and Interests

• Understanding of Inequities

How Realistically Going to Accomplish?

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The Public Health Advantage!

We’re experienced collaborators

Partnering with Extension• Community gardens at LHD

• Other areas of collaboration in Indiana:

Opioids, Heart Healthy, CollaborativeResearch, Revising 4-H Materials

• Illinois Extension … pre-diabetes course

Purdue Extension collaboration with rural counties: https://www.youtube.com/watch?v=yijGfb5fnwA

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Multi-Sector Partnerships

Direction, alignment & commitment

Preliminary goal(s) of partnershipsCommon groundWhat each brings & does NOT bringBoundaries of workCheckpointsMeasures & outcomes (short/long term)

▪Chief Health Strategist

▪Foundations funding demonstration projects

▪Time can be challenging

Perhaps Best Served by Cross-Jurisdictional Activities?

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7 local health departments (10 counties)

Funding from RWJ Foundation (2015)

o Sharing Expertise, Leadership, Knowledge

o Linked Services

o Addressing social determinants ofhealth

o Workforce Training

o Community Health Assessment

o Emergency Preparedness

o Focused Advocacy

o Chief Health Strategist (PH 3.0)

https://malph.org/sites/default/files/303%20Hirschenberger.pdf

https://www.michigan.gov/documents/mdhhs/NMCHIR_Bright_Spots_final_641389_7.pdf

Community Engagement

National Academy for Medicine call for deliberate actions on all levels … federal, state, local

• Graphic … sectors to engage

• Anchor Institutions• Universities/Hospitals

• Community Health Clinics/Local Health Departments

• The Democracy Collaborative

www.demoracycollaborative.org

National Academy of Medicine Model, https://nam.edu

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Notes from the Road▪ Work with, not for communities

▪ Listen

▪ Earn Trust, change happens at speed of trust

▪ Communities have different priorities, ask!

▪ Nothing for us without us (Chicago project)

▪ Facilitate, don’t take over; PH doesn’t have to be in the lead

▪ Ask others to join at beginning stage not just when need theirstories or want photo opportunity

▪ Partner with Faith-based organizations

Infrastructure: Public Health WorkforceGraduate Degrees Awarded to US citizens by CEPH-Accredited Schools & Programs

Race/Ethnicity 1992 (%) 2004 (%) 2016 (%)2016 Total US

Pop

Total 3,240 (100) 5,224 (100) 11,490 (100)

White 2,433 (75) 3,157 (60) 6,131 (53) 61.7%

Asian/Pacific Islander 180 (6) 753 (14) 1,614 (14) 5.4%

Black/African American 208 (6) 628 (12) 1,296 (11) 12.4%

Hispanic/Latino 257 (8) 392 (7) 1,130 (10) 17.7%

Unknown 136 (4) 294 (6) 927 (8)

American Indian/Alaska Native 26 (0.8) 30 (0.6) 49 (0.4) 0.7%

Two or More Races NA NA 343 (3) 2.1%

Leider, J. et al. (2018), Public Health Reports, 133(6) 729-737.

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Health Care WorkforceEnrollment in Baccalaureate Nursing Programs & Schools of Medicine by Race/Ethnicity

Race/Ethnicity

2017 Medicine

Enrollment1

%

2016 BSN Enrollment2

%

2016 Total US Pop

Total 88,546 190,214

White 52.8 67.7 61.7%

Asian/Pacific Islander 21.8 8.3 5.4%

Black/African American 7.0 9.7 12.4%

Hispanic/Latino 6.5 11.0 17.7%

Unknown 1.3 -- --

American Indian/Alaska Native 0.2 0.5 0.7%

Two or More Races 8.2 2.7 2.1%

1AAMC, 2017 (US Citizen)2AACN, 2017

Evidence-based/Evidence-informed Practice

• 1992 Evidence Based Medicine (Guyatt et al., 1992)

• 2003 IOM Report: …take action based on evidence

• Information or facts systematically obtained in manner that is replicable, observable, credible & verifiable for use in making judgments or decisions (Bose, 2013)

Guyatt, Cairns, & Churchill (1992). Evidence-based medicine: A new approach to teaching the practice of medicine. JAMA,268(17), 2420-2425

Committee on Assuring the Health of the Public in the 21st Century, (2003). The futureof the public’s health in the 21st century. Washington, DC: Institute of Medicine

Bose, (2013). The evidence project overview, CDC. https://www.cdc.gov/violenceprevention/pdf/evidence_project_overview2013-a.pdf

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Public Health Accreditation Board Standards & and Measures (v 1.5, 2013)

• Domain 10: Contribute to and Apply the Evidence Base of Public Health

• 10.1 Identify and use best available evidence for making informed public health practice decisions

• 10.2 promote understanding and use of current body of research results, evaluations and evidence-based practices with appropriate audiences

• Public Health National Center for Innovations, https://phnci.org/• Innovations Playbook (phnci.org)

IDPH

ChampaignChicagoCookDuPageKaneKendallLakePeoriaSt. ClairTazewellWinnebagoWheaton

How linked to the Evidence?

How Health Departments Learn About Research Findings?

How Researchers Perceive They MostEffectively Reach Practitioners

1. Professional associations (APHA, IPHA, …) 1. Journal articles

2. Seminars/workshops 2. Face-to-face meetings

3. Email alerts 3. Media interviews

4. Journal articles 4. Press releases

LEAD Public Health, Prevention Research Centers

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Use of Evidence Hits Stumbling Block

• 1,234 (8.29.2019); IL 9

• Anti-vaccinators/Vaccine Hesitancy

• # religious objectors rising

• # philosophical objectors in states where option also rising

• National Academy of Medicine Congressional Mandate: build out science

Steve Breen/San Diego Union-Tribune

Would this help?

Retirement Plan(s)

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Evidence in practice …▪Positive impact

▪Finite resources used wisely

▪Demonstrates value to funders & accountability to public

Balance with …▪Being innovative

▪Anticipating conflicting information, lack of information, need to act

Use of Evidence in Decision Making (EBDM), 2015 Local Health Department Study

• 25.7% applied research findings

• 22.3% used Guide to Community Prevention Services

• 60.9% completed community health assessment

• 49.5% participated in community health improvement planning

Lovelace, Aronson, Rudison, Labban, Stah, & Smith (2015). Laying the groundwork for evidence-based public health: Why some local health departments use more evidence-based decision-making practices than others. American Journal of Public Health, 105(S2), S189-S197.

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Lovelace et al., cont. • States with decentralized LHD ↑ EBDM

• Size of jurisdiction strongest predictor of use of EBDM

If not using evidence, is it that we don’t…▪ Have the evidence?

▪ Able to efficiently & effectively secure the evidence?

▪ See how best to apply to own practice?

▪ Sufficient forums for dialogue among researchers andpractitioners?▪ If we want more evidence-based practice, we need more practice-based

evidence (Lawrence Green, DrPH, UC San Francisco)

▪ Shorten timetable from research to action

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How might APHA help?

• Science Board

• Searchable database

(since 1948; many archived)

• This 2017 policy has 49 references

Opportunities to disseminate research & best practices

• Annual meetings

• Publications

• Advocacy materials

Written for practitioners?

Include implications for practice?

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Getting the science right ...

• Mid-July 2018, USA delegation “browbeats” WHO to back down on breastfeeding resolution (corporate influence)

• Sugar-sweetened beverages (corporate influence)

• June 2018, NIH concludes $100 M Harvard trial biased by extensive interactions between researchers and alcohol industry (duh)

• Toxicdocs: Columbia University and City University of NY, www.toxicdocs.org (Millions of Pages of Previously Classified Documents)

Evidence and Policymakers • Not role of policy makers to second guess the evidence, but to

• Weigh evidence

• Establish priorities

• Allocate resources

(Dannel Malloy, 2019)

• How do policymakers weigh evidence?• Understanding of process insufficient

• Costs, complexity, risks, flexibility, relevance

• Collect data from many sources (some conflict with OUR agenda)

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Sifting Through the Resources• Government

• Academies

• Foundations

• Universities

• Associations

Handout … make point to go to unfamiliar site

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Academy Health

• Supports production and use of evidence to inform policy and practice (generators)

• Wide range of publications

https://www.academyhealth.org/sites/default/files/publications/files/publications/TDguidePHSR.pdf

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Why Investing in Public Health so Challenging?

• > requirements for cost-saving

• Head-to-head with other health system components

• Belief in long run prevention cost more than treatment• Live longer, use more health care $ (shorter period of senescence at end of life?)

• Timeframe … mismatch with funding cycles of 3-5 years• My administration bears costs, next reaps benefits

• Interest group influence

• Identifiable victim effect

• Evidence alone does NOT drive health policy

Painting a portrait or a landscape?

• Portrait: detail about individual or event

• Landscape: broader view, shared responsibility … need for collaboration

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Speak for Health Initiative• Strength in collective voice

• Join Generation Public Health

• Action Board key player

PODCASTS

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Monthly Newsletter

Are there topics like to see addressed?

Illinois featured stories

Share copy with others before recycling

Resources

APHA, www.apha.org

• Fact Sheets

• Webinars

• Collaborative Publications

• Annual Meetings

• Get Involved if not already

Affiliates/Sections/SPIGS/Forums/Caucuses

Student Assembly

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Key PointsUse/generate/share evidence (publication, presentation, editorials, …)

Translate findings for others

Evaluate & address policy and system barriers to use of best available evidence

Exploit your state’s/community’s/system’s health & other assets

Respond to community’s self-identified priorities (bring the evidence)

• Nothing About Us Without Us (IL project)• Work with communities, listen• Facilitate, don’t have to always lead

Continue work of cultivating relationships

Foster cultural connections, strengthen cultural awareness/sensitivity

Create spaces in which to discuss … issues are complex and intertwined

Create networks of belonging and support … establish trust, build momentum (change happens at the speed of trust)

Use evidence to assist in achieving health equity … a strategic priority & moral imparity

What would you like me to take back to APHA?

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Recommended Reading List from affiliate visits …• Kendi, I. (2017). Stamped From the Beginning: The Definitive History of

Racist Ideas in America

• Villanueva, E. (2018). Decolonizing Wealth: Indigenous Wisdom to Heal Divides and Restore Balance

• Westover, T. (2018). Educated: A Memoir

• Meacham, J. (2018). The Soul of America: Battle for Our Better Angels

• Vance, JD. (2018) Hillbilly Elegy: A Memoir of a Family and Culture in Crisis.

• Metzl, J. (2019) Dying of Whiteness: How the Politics of Racial Resentment is Killing America’s Heartland

Questions

Share work for The Nation’s Health Columnaaltonen@president.apha.org

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Extra Slides

Exercise: Collaborating for Public Health Action

Find a partner and ask the following 3 questions. Listen closely to your partner’s story, encouraging as much detail as possible. Think of it as initiating a conversation that will provide a foundation for future collaborations. Take notes and then share your notes with the person you interviewed.

Switch roles and complete the same three questions.

Question 1: What inspires you to work in the field of Public Health?

Question 2: Think back through your career and share a time when you felt you were most effective and engaged.Describe how you felt and what made this possible.

Alternative Question 2: If a student, consider in what class(es) you feel you have been most successful? Explore why you feel this way.

Question 3: What legacy do you hope to leave when you conclude your public health career?

Group Discussion

Themes or similarities that may have emerged? How might you capitalize on each others strengths to accomplish your goals?

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Learning Opportunity

CDC VetViolence … Understanding Evidence-Based Decision Making

https://vetoviolence.cdc.gov/apps/evidence/

Health Equity Institute Video

• https://www.youtube.com/watch?v=ZPVwgnp3dAc

• Length: 3.24 minutes

• Share with your colleagues on your board of health

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