A weakness of many existing PHSSR activities has been public health prac-titioners’ lack of direct engagement in the design and conduct of this re-search, resulting in relatively low levels of research awareness and research use among them. Practitioners oft en cannot see how research fi ndings can be used to improve everyday public health decision making, and research-ers oft en fail to identify clear practice implications and feasible improvement strategies that fl ow from their scholarship. To address these issues, research-ers are beginning to use the concept of a practice-based research network (PBRN), with the goals of using practitioner input to develop and implement
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2 Infant mortality Heart disease Diabetes Cancer Influenza All-cause Alzheimers Injury
Figure 6.4. Estimated eff ects of a 10 percent increase in local public health spending on selected measures of preventable mortality, 1993–2005. Note: Vertical lines repre-sent 95 percent confi dence intervals for the estimates shown in the bar graphs. Source:
Data from Mays GP, Smith SA. Evidence links increases in public health spending to declines in preventable deaths. Health Aff . 2011;30(8):1585–1593.
new PHSSR studies and accelerating the translation of research fi ndings into new policies and practice strategies that improve health. A PBRN brings multiple public health agencies and research partners together to design and implement studies of population-based strategies that prevent disease and injury and promote health. Participating practitioners and researchers col-laborate to identify questions of interest, design rigorous and relevant stud-ies, execute feasible research eff ectively, and translate fi ndings rapidly into practice (fi gure 6.5). As such, PBRNs can expand the volume and quality of practice-based research needed for evidence-based decision making in pub-lic health.
PBRNs have been used successfully in the fi eld of health services re-search to study clinical innovations and test quality improvement strategies in community-based medical practice settings, largely with the engagement of practicing physicians and occasionally other health professionals.55–57 Build-ing on this model, the Robert Wood Johnson Foundation launched the Public Health PBRN Program in 2008.58 Like their counterparts in clinical research, public health PBRNs are particularly well positioned to test and evaluate strat-egies for accelerating the diff usion of evidence-based practices and policies
Common questions of
interest
Rigorous research methods
Data exchange Analysis and
interpretation Translation
applicationand Engaged practice
settings Research partners
Figure 6.5. Conceptual model for a public health practice-based research network.
across a variety of practice settings. The range of public health studies that can be conducted through PBRNs is wide and includes the following:
• Comparative case studies designed to identify problems or innovations in how public health activities are currently implemented in different practice settings.
• Large-scale observational studies designed to evaluate practice variation across local or state public health settings to identify opportunities to re-duce unnecessary, inefficient, or harmful variation.
• Intervention studies and community trials designed to test the effective-ness and cost-effectiveeffective-ness of new public health programs. Such studies may also test the effectiveness of quality improvement initiatives direct-ed at existing programs.
• Policy evaluations and natural experiments designed to monitor the ef-fects of key policy and administrative changes made at the state or local level, such as changes in laws and regulations, shifts in funding or staff-ing levels, and organizational restructurstaff-ing, such as service consolida-tion, regionalizaconsolida-tion, or decentralization.
These types of studies require the ability to measure public health activities and outcomes in real-world practice settings and to make valid comparisons across such settings and over time.
The Public Health PBRN Program currently supports twelve research net-works comprising local and state governmental public health agencies, com-munity partners, and collaborating academic research institutions. These networks are located in Colorado, Connecticut, Florida, Kentucky, Massachu-setts, Minnesota, Nebraska, New York, North Carolina, Ohio, Washington, and Wisconsin. In addition to these twelve, other public health PBRNs partici-pate as affiliate members and as emerging networks under development. The National Coordinating Center for the Public Health PBRN Program, located at the University of Kentucky, provides resources and technical assistance for the development and conduct of research projects. The center also organizes crosscutting and multinetwork research studies designed to evaluate and com-pare public health strategies implemented across diverse practice settings.
Research projects currently under way address a wide range of topics and delivery system issues. In the most general sense, all these projects focus on elucidating the causes or consequences of variation in the organization, fi-nancing, and delivery of public health services across communities. As such, the projects are designed to produce findings that will lead to a reduction in unwarranted variation and an improvement in the effectiveness, efficiency,
and equity of public health practice. Issues to be addressed by the participat-ing public health PBRNs include the followparticipat-ing:
• Variation in staffing levels among local public health agencies and the impact on the volume and quality of public health services delivered.
• Variation in the implementation and impact of regionalized public health delivery models that consolidate the operations of multiple small agencies to achieve economies of scope and scale.
• Variation in local health department approaches to communicable dis-ease reporting, and its impact on surveillance and disdis-ease control efforts.
• Impact of a comprehensive state public health reform law on the organi-zation and delivery of local public health services.
• Causes and consequences of variation in the local public health response to the H1N1 influenza outbreak.
• Impact of recession-driven funding reductions on the delivery of evi-dence-based public health programs and services.
• Effectiveness of quality improvement strategies for diabetes prevention delivered through local public health agencies.
• Effectiveness of public health agencies’ efforts to facilitate the adoption of evidence-based obesity prevention strategies by local community coalitions.
Although still relatively new, public health PBRNs show considerable promise in strengthening both the rigor and the relevance of PHSSR studies.