From the Schools and Programs of Public Health THE ACADEMIC HEALTH DEPARTMENT: ACADEMIC–PRACTICE PARTNERSHIPS AMONG ACCREDITED U.S. SCHOOLS AND PROGRAMS OF PUBLIC HEALTH, 2015 Paul Campbell Erwin, MD, DrPH Jenine Harris, PhD Roger Wong, MPH, MSW Christine M. Plepys, MS Ross C. Brownson, PhD
Partnerships between public health academia and public health practice are valuable for providing students with opportunities to apply classroom theory and knowledge to real-world settings, for providing academicians with practice-based research opportunities, and for providing practitioners with opportunities to enhance skills and knowledge through workforce development and to strengthen the evidence base of public health.1–3 The Council on Education for Public Health (CEPH) requires evidence of practice engagement as part of the academic accreditation process.4 The Public Health Accreditation Board’s (PHAB’s) voluntary program for national accreditation includes metrics for assessing the extent to which public health departments are working collaboratively with educational programs to strengthen the workforce and to identify and use the best available evidence for making informed public health practice decisions.5 Although academic–practice partnerships can take many forms, the term “academic health department” (AHD) has received renewed interest.6 An AHD is described as a formalized relationship “between an academic institution and a governmental public health agency which provides mutual benefits in teaching, research, and service, with academia informing the practice of public health, and the governmental public health agency informing the academic program.”1 Most of what is known about AHDs comes from case studies; for example, a special issue of the Journal of Public Health Management and Practice in 2014 consisted of 17 articles illustrating the scope of AHDs.7 In 2015, an attempt was made to assess the larger landscape of AHDs through a survey of more than 300 members of the Academic Health Department Learning Community,6 which includes academicians, practitioners, and others interested in the AHD concept.2 Although that 630
study could not accurately estimate the prevalence of AHDs, results indicated that almost one-third of the AHDs described had been established for more than 10 years, two-thirds were engaged in joint research activities, and respondents placed a high value on improving the competencies of students and faculty. To continue developing the evidence base on AHDs, including their characteristics and functions, and to provide a better estimate of the prevalence of AHDs, we surveyed CEPH-accredited schools and programs of public health. METHODS We refined a survey instrument previously validated for use in assessing characteristics of AHDs2 to focus on the academic perspective of AHDs. Briefly, development of the survey instrument was based in part on an analysis of the gap in knowledge between what is known about AHDs and what is needed to document the added value of AHDs and was structured on domains of AHD relationship characteristics, including the use of formal written partnership agreements, functions of the AHD, and potential and experienced benefits of the AHD.2 The survey also included questions about public health practice partners and types of engagement activities (e.g., field practice sites for students, joint research, workforce development), as well as questions on PHAB accreditation-related activities. Survey validation included cognitive response testing with eight experts in public health academia and practice who were familiar with the AHD concept. After several iterations of survey refinement, a final survey was loaded into a Qualtrics® online platform,8 and an electronic link was distributed in February 2015 through the Association of Schools and Programs of Public Health (ASPPH) to its 95 members and directly to the 61 CEPH-accredited programs of public health that were not ASPPH members, thereby targeting all 156 CEPH-accredited schools and programs of public health. For ASPPH members, the survey link was sent to the director or associate dean of the office of public health practice if one was known; otherwise, the survey link was sent directly to the dean or program director, who was asked to either respond to the survey or forward it to an appropriate colleague. For non-ASPPH members, the survey link was sent directly to program directors. Surveys were completed online; four followup reminders were sent, and respondents had a total
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of two months to respond. After survey data were collected, additional data on academic institutions (e.g., whether or not the institution offers a doctor of public health [DrPH] degree) were made available through ASPPH. We analyzed data using Stata® version 12.09 and used descriptive statistics such as frequency distributions, measures of central tendency, and measures of variability. For bivariate analyses, we used Wald c2 tests, t-tests, and Pearson’s tests of correlation. RESULTS The survey was distributed to 156 academic institutions: 53 CEPH-accredited schools of public health and 103 CEPH-accredited programs of public health. Of the 156 institutions, 117 (75%) completed the survey, of which 67 (57%) identified the school or program they represented. Of the 117 institutions, 64 (55%) indicated having an AHD; the mean number of public health practice partners was 3.8 (standard deviation [SD] 5 5.4, range: 1–30). We found no significant differences in the presence of an AHD (p50.61) between programs of public health (n542) and schools of public health (n522). Likewise, we found no significant differences in the presence of an AHD (p50.57) between public schools or programs of public health (n544) and private schools or programs of public health (n520). We found no significant differences in the number of graduates (p50.37) or the years of CEPH accreditation (p50.46) between schools and programs that had an AHD and schools and programs that did not. Having an AHD was not significantly associated with offering a DrPH degree (p50.73). Of the 64 AHDs, 46 (72%) had formal written partnership agreements. To determine whether or not these relationships differed between AHDs with a formal agreement and those without, we classified each participant as not having an AHD, as having an AHD without a formal agreement, or as having an AHD with a formal agreement. Using this new variable, we still found no significant relationship between AHD formalagreement status and having a partnership (p50.86), whether a school or a program (p50.86), number of graduates (p50.72), years of CEPH accreditation (p50.45), or offering a DrPH degree (p50.76). Types of connections In addition to most AHD partnerships having formal written partnership agreements, 21 partnerships shared personnel, 10 partnerships shared financial resources, and nine partnerships shared physical facili-
ties. Of the 46 schools or programs of public health with formal written partnership agreements, 32 had a memorandum of understanding or a memorandum of agreement, 19 had a contract, 10 had a letter of agreement, and eight were unsure or had another type of formal written partnership agreement. The most commonly shared personnel types were researchers (n515), followed by managerial staff members (n510), other (n57), health-care providers (n53), and clerical workers (n52). Of the partnerships, most (n548, 75%) included public health education and training. Additionally, 42 of 64 (66%) participants indicated their AHD partnerships had joint research projects. Only nine of 64 (14%) partnerships shared the provision of public health services. Types of engagement The 64 academic institutions that had an AHD were engaged with health departments in numerous ways (Figure 1). The AHDs frequently facilitated the PHAB accreditation prerequisite of conducting a community health assessment (CHA): 33 of 64 (52%) academic partners indicated their AHD facilitated a CHA, and, on average, these academic partners worked with two to three (mean 5 2.4, SD52.4) public health practice partners. The most common type of engagement for public health practice partners was hosting trainees, interns, or volunteers (n557, 89%). For academic partners, faculty and staff members were most engaged in consulting roles for AHDs (n546, 72%) for specific projects. Academic partners were least engaged in supporting AHDs in the development of service learning courses (n532, 50%). Although the differences were small, a higher percentage of AHDs with formal agreements, compared with AHDs without formal agreements, were engaged in each activity. Benefits of the AHD relationship When asked about the degree to which they had benefited from the AHD relationship in 14 areas, participants rated all but three of the areas at a median score of 4 on a scale of 1 to 5, where 1 was no benefit and 5 was an extremely large benefit. The three benefits with lower scores were increasing capacity for performing core public health functions (median 5 3.5), improving access to quality care for the uninsured and underinsured (median 5 3.0), and improving the competencies of faculty (median 5 3.5). We found a significant positive relationship (all p,0.05) between perceived importance of each benefit and actual experience of the benefit. The strongest correlations between perceived importance and experienced benefits were
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Figure 1. Percentage of academic partners engaging in education, research, and service activities with public health practice partners in academic health departments at 64 CEPH-accredited U.S. schools and program of public health, 2015a
a The PHP partner is the governmental health agency participating in the partnership. The AP is the academic institution (accredited school or program of public health) participating in the partnership. The AHD is the name or label given to the academic–practice partnership. The error bars indicate 95% confidence intervals.
CEPH 5 Council on Education for Public Health PHP 5 public health practice AP 5 academic partner PHAB 5 Public Health Accreditation Board AHD 5 academic health department
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related to education, including improving the competencies of students (r50.58, 95% confidence interval [CI] 0.55, 0.61, p,0.001) and enhancing career opportunities for public health graduates (r50.58, 95% CI 0.54, 0.61, p,0.001) (Figure 2). The benefit with the weakest correlation between perceived importance and experienced benefit was in improving the competencies of public health practitioners (r50.31, 95% CI 0.26, 0.35, p,0.001). Although the correlation between perceived importance and experienced benefits of AHDs was high for improving student competencies (r50.58), modest for improving faculty competencies (r50.39, 95% CI 0.35, 0.43, p50.008), and lowest for improving competencies of public health practitioners (r50.31, 95% CI 0.26, 0.35), 60% of academic institutions working with AHDs believed that improving faculty competencies was moderately to extremely important, 73% thought improving student competencies was important, and 72% believed that improving public health practitioner competencies was important. DISCUSSION The key finding from this study was the estimated prevalence of AHDs in accredited schools and programs of public health: slightly more than half of respondents indicated having such a relationship with one or more public health practice partners. Even limiting the definition of an AHD to only those with formal written agreements resulted in a prevalence of 39%. The most common activities of these AHDs revolved around education for students, with two-thirds of respondents also indicating collaborative research activities. As a reflection of these activities, the highest correlation between perceived and experienced benefits of the AHDs was related to students: improving student competencies, enhancing career opportunities for public health graduates, and preparing public health graduates for entry into the workforce. We found no differences in having an AHD when we compared accredited schools of public health with accredited programs of public health. Although this finding may be counterintuitive, given the larger resources of most schools, we did not attempt to measure overall volume of outputs and outcomes. Other than differences in volume, we would not expect to find differences in AHDs between schools and programs, because no a priori reason for such differences exists. Although our analyses were limited by small numbers, we found a tendency for AHDs with formal written agreements to be more engaged than AHD partnerships without formal written agreements. The estimated prevalence (55%) of AHDs in accred-
ited schools and programs of public health closely matches results from a survey of participants in the Academic Health Department Learning Community, which included both academicians and practitioners, in which 59% of respondents reported an AHD.2 For the public health practice component of academic–practice relationships, the National Association of County and City Health Officials’ 2008 Profile of Local Health Departments indicated that approximately 20% of local health departments nationally reported that staff members serve as faculty (i.e., regular, adjunct, or guest) at an academic institution, and approximately 15% indicated that faculty or staff members from an academic institution had served as consultants for the local health department.10 In addition to academic–practice relationships that may meet the definition of AHDs, such relationships also exist under other arrangements (e.g., through the Public Health Training Centers11 and Public Health Practice-Based Research Networks).12 We did not assess the relationships between AHDs and these other academic–practice arrangements. The level of engagement between public health academia and public health practice reflected in this study can be celebrated as a success in moving the public health discipline closer to accomplishing what the Institute of Medicine (now National Academy of Medicine) recommended in its landmark The Future of Public Health report on the establishment of such linkages “so that significantly more faculty members may undertake professional responsibilities in these [public health practice] agencies, conduct research there, and train students in such practice situations.”13 The isolation of academic institutions from practice described by the Institute of Medicine, although not completely resolved, at least appears via our study to be substantially lessened. The implications of this study are framed by a fundamental question posed by Quill and Aday in 2000: How well are these partnerships suited to the current and future problems of public health?14 And, closely related, how will such partnerships influence the forces of change likely to be experienced in public health practice?15 We believe at least three relational considerations are most relevant: students’ preparation when entering the workforce and navigating the Affordable Care Act, collaborative research and evidence-based public health (EBPH), and the enhancement of competencies and requirements for CHAs. We focus on these three considerations because AHDs may add value to these areas and because both academia and public health practice have been and will continue to be engaged in addressing these three topics. The Affordable Care Act is not only making its
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Figure 2. Correlations between perceived importance and actual experience of academic health department benefits from academic partners and public health practice partners at 64 CEPH-accredited U.S. schools and programs of public health, 2015a
a The mean benefit score indicated the perceived value of a benefit, where 1 was no benefit and 5 was an extremely large benefit. The error bars indicate 95% confidence intervals.
CEPH 5 Council on Education for Public Health
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presence known in public health practice, it is affecting relationships between public health and clinical medicine, especially concerning changes in health services delivery.16 Increasing the number of people who have health insurance, either through the market Exchanges or Medicaid expansion, has resulted in improvements in self-reported coverage and access to primary care and medications.17 Health departments are now implementing third-party billing and using electronic health records more frequently than in the past. Many organizations that partner with health departments, including accountable care organizations, have already been operationalizing these and related activities as new delivery systems are being established. Thus, whether the public health graduate finds employment in a governmental public health agency, nonprofit, or for-profit health sector, learning new methods in management and administration that will be relevant to the Affordable Care Act can be enhanced through AHDs. EBPH, defined as the integration of science-based interventions with community preferences to improve population health,18 has become increasingly important as practitioners seek to enhance the efficient use of scarce resources; however, the evidence for what works in public health practice is relatively thin. Brownson et al.19 have recently identified limitations to current approaches for generating evidence for public health policy and practice, among which are several limitations that can be addressed through AHD-supported collaborative research: • Lack of relevant study designs for certain public health issues • Imbalance between internal and external validity • Lack of data on implementation • Generation of the evidence base in high-resource settings • Limited focus on health equity Practice-based research, which occurs through AHDs, (1) provides opportunities to enhance the relevancy of research questions and, by proxy, study designs themselves; (2) improves the potential for external validity because the real-world settings of public health practice are more generalizable than narrowly focused, highly controlled research laboratories; and (3) expands the possibilities for understanding barriers to implementation, including issues related to fidelity, when evidence-based programs or activities are scaled up.20 Additionally, because health departments often have a particular focus on and presence in low-resource communities, practice-based research through AHDs can
provide opportunities to build capacity in settings that are different from the typical high-resource settings of most research. These opportunities can in turn increase the focus on health equity. Finally, the AHD serves as the setting in which the competencies of students, faculty, and the public health workforce can be strengthened for conducting highquality CHAs. The national voluntary accreditation process through PHAB requires that health departments conduct a CHA as a prerequisite for accreditation.5 In addition, the Affordable Care Act, through the Internal Revenue Service, established new requirements for nonprofit hospitals to conduct CHAs as a part of their community benefit;21 moreover, hospitals are required to partner with public health departments to accomplish this requirement.22 More than half (52%) of the academic institutions in this study that reported having an AHD also said that conducting the CHA was enhanced by conducting it through the AHD. The finding of a large gap between perceived importance and experienced benefit for improving the competencies of practitioners indicates that AHDs’ potential to strengthen workforce development has not been fully realized. Workforce development is yet another appropriate connection to both PHAB accreditation and EBPH. Domain 8 of the PHAB standards focuses on maintaining a competent public health workforce.5 In a recent analysis of evidence-based decision making, practitioners reported the highest competency gaps in the areas of economic evaluation, communicating research to policy makers, evaluation designs, and adapting interventions.23 One possible approach to addressing these gaps is for academicians to facilitate and expand training for practitioners in EBPH, for which there are well-documented national, state, and local models of implementation.24,25 Importantly, the first major component of EBPH is conducting community assessments. Academicians, through AHD relationships, can be key to resolving these competency gaps. Limitations This study had several limitations. First, data were selfreported and came from the perspectives of academicians involved in AHDs. No attempt was made to verify the data or perspectives with public health practice partners in these AHDs. Second, the survey was limited to accredited schools and programs of public health, although the literature indicates that many disciplines—from nursing and medicine, to environmental science and allied health professions—have developed academic–practice partnerships.1 Finally, the data were cross-sectional and indicated associations only; as such, they cannot be interpreted as causal.
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CONCLUSION Academic–practice partnerships, or AHDs, are prevalent across accredited schools and programs of public health. Such relationships bode well for preparing public health graduates to enter the workforce in the era of the Affordable Care Act and for strengthening the evidence base of public health through practicebased research. For AHDs to make a greater impact on workforce development, opportunities for improving practitioners’ competencies can be realized through a focus on CHAs and EBPH training.
6.
7. 8. 9. 10.
This study was approved by the Institutional Review Board at the University of Tennessee, Knoxville. Paul Campbell Erwin is Professor and Head of the Department of Public Health at the University of Tennessee, Knoxville, Tennessee. Jenine Harris is an Associate Professor at Washington University in St. Louis, George Warren Brown School of Social Work, Prevention Research Center in St. Louis, St. Louis, Missouri. Roger Wong is a doctoral student at Washington University in St. Louis, George Warren Brown School of Social Work. Christine Plepys is Director of Data Analytics at the Association of Schools and Programs of Public Health, Washington, D.C. Ross Brownson is the Bernard Becker Professor of Public Health at Washington University in St. Louis, George Warren Brown School of Social Work, and at the School of Medicine, Division of Public Health Sciences and Alvin J. Siteman Cancer Center, and Codirector of the Prevention Research Center in St. Louis. Address correspondence to: Paul Campbell Erwin, MD, DrPH, University of Tennessee, Department of Public Health, 1914 Andy Holt Ave., Knoxville, TN 37996; tel. 865-974-5252; e-mail .
11.
©2016 Association of Schools and Programs of Public Health
20.
REFERENCES 1. Erwin PC, Keck CW. The academic health department: the process of maturation. J Public Health Manag Pract 2014;20:270-7. 2. Erwin PC, Barlow P, Brownson RC, Amos K, Keck CW. Characteristics of academic health departments: initial findings from a cross-sectional survey. J Public Health Manag Pract 2016;22:190-3. 3. Neri EM, Ballman MR, Lu H, Greenlund KJ, Grunbaum JA. Academic-health department collaborative relationships are reciprocal and strengthen public health practice: results from a study of academic research centers. J Public Health Manag Pract 2014;20:342-8. 4. Council on Education for Public Health. Accreditation criteria and procedures [cited 2015 Sep 30]. Available from: http://ceph.org /criteria-procedures 5. Public Health Accreditation Board. Standards and measures, ver-
12. 13. 14. 15. 16. 17. 18. 19.
21. 22. 23.
24.
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sion 1.5. 2014 [cited 2015 Apr 22]. Available from: http://www .phaboard.org/wp-content/uploads/SM-Version-1.5-Board-adoptedFINAL-01-24-2014.docx.pdf Public Health Foundation. Academic health department learning community [cited 2013 Jan 2]. Available from: http://www.phf.org /programs/AHDLC/Pages/Academic_Health_Department _Learning_Community.aspx Novick LF, Morrow CM. The academic health department: antidote to antipathy. J Public Health Manag Pract 2014;20:267-9. Qualtrics. Qualtrics survey research suite. Provo (UT): Qualtrics LLC; 2014. StataCorp. Stata®: Release 12.0. College Station (TX): StataCorp; 2011. National Association of County and City Health Officials. 2008 national profile of local health departments. Washington: NACCHO; 2009. Also available from: http://www.naccho.org/topics/infrastructure /profile/resources/2008report/upload/NACCHO_2008_Profile Report_post-to-website-2.pdf [cited 2013 Jun 18]. Department of Health and Human Services (US), Health Resources and Services Administration. About public health training centers [cited 2015 Oct 16]. Available from: http://bhpr.hrsa.gov/grants /publichealth/trainingcenters/about University of Kentucky. Public health practice-based research networks [cited 2016 Apr 22]. Available from: http://www.public healthsystems.org/pbrn-sites Institute of Medicine. The future of public health. Washington: National Academy Press; 1988. Quill BE, Aday LA. Toward a new paradigm for public health practice and academic partnerships. J Public Health Manag Pract 2000;6:1-3. Erwin PC. Forces of change. Am J Public Health 2015;105:836. Leider JP, Castrucci BC, Russo P, Hearne S. Perceived impacts of health care reform on large urban health departments. J Public Health Manag Pract 2015;21 Suppl 1:S66-75. Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in selfreported insurance coverage, access to care, and health under the Affordable Care Act. JAMA 2015;314:366-74. Kohatsu ND, Robinson JG, Torner JC. Evidence-based public health: an evolving concept. Am J Prev Med 2004;27:417-21. Brownson RC, Diez Roux AV, Swartz K. Commentary: generating rigorous evidence for public health: the need for new thinking to improve research and practice. Annu Rev Public Health 2014;35:1-7. Milat AJ, King L, Newson R, Wolfenden L, Rissel C, Bauman A, et al. Increasing the scale and adoption of population health interventions: experiences and perspectives of policy makers, practitioners, and researchers. Health Res Policy Syst 2014;12:18. Pub. L. No. 111–148 (2010 Mar 23). Internal Revenue Service (US). Form 990, schedule H. 2011 [cited 2012 Apr 12]. Available from: http://www.irs.gov/pub/irs-pdf /f990sh.pdf Jacob RR, Baker EA, Allen P, Dodson EA, Duggan K, Fields R, et al. Training needs and supports for evidence-based decision making among the public health workforce in the United States. BMC Health Serv Res 2014;14:564. Gibbert WS, Keating SM, Jacobs JA, Dodson E, Baker E, Diem G, et al. Training the workforce in evidence-based public health: an evaluation of impact among US and international practitioners. Prev Chronic Dis 2013;10:E148. Jacobs JA, Duggan K, Erwin P, Smith C, Borawski E, Compton J, et al. Capacity building for evidence-based decision making in local health departments: scaling up an effective training approach. Implement Sci 2014;9:124.
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Partnerships between public health academia and public health practice are valuable for providing students with opportunities to apply classroom theory and knowledge to real-world settings, for providing academicians with practice-based research opportunities, and for providing practitioners with opportunities to enhance skills and knowledge through workforce development and to strengthen the evidence base of public health.1–3 The Council on Education for Public Health (CEPH) requires evidence of practice engagement as part of the academic accreditation process.4 The Public Health Accreditation Board’s (PHAB’s) voluntary program for national accreditation includes metrics for assessing the extent to which public health departments are working collaboratively with educational programs to strengthen the workforce and to identify and use the best available evidence for making informed public health practice decisions.5 Although academic–practice partnerships can take many forms, the term “academic health department” (AHD) has received renewed interest.6 An AHD is described as a formalized relationship “between an academic institution and a governmental public health agency which provides mutual benefits in teaching, research, and service, with academia informing the practice of public health, and the governmental public health agency informing the academic program.”1 Most of what is known about AHDs comes from case studies; for example, a special issue of the Journal of Public Health Management and Practice in 2014 consisted of 17 articles illustrating the scope of AHDs.7 In 2015, an attempt was made to assess the larger landscape of AHDs through a survey of more than 300 members of the Academic Health Department Learning Community,6 which includes academicians, practitioners, and others interested in the AHD concept.2 Although that 630
study could not accurately estimate the prevalence of AHDs, results indicated that almost one-third of the AHDs described had been established for more than 10 years, two-thirds were engaged in joint research activities, and respondents placed a high value on improving the competencies of students and faculty. To continue developing the evidence base on AHDs, including their characteristics and functions, and to provide a better estimate of the prevalence of AHDs, we surveyed CEPH-accredited schools and programs of public health. METHODS We refined a survey instrument previously validated for use in assessing characteristics of AHDs2 to focus on the academic perspective of AHDs. Briefly, development of the survey instrument was based in part on an analysis of the gap in knowledge between what is known about AHDs and what is needed to document the added value of AHDs and was structured on domains of AHD relationship characteristics, including the use of formal written partnership agreements, functions of the AHD, and potential and experienced benefits of the AHD.2 The survey also included questions about public health practice partners and types of engagement activities (e.g., field practice sites for students, joint research, workforce development), as well as questions on PHAB accreditation-related activities. Survey validation included cognitive response testing with eight experts in public health academia and practice who were familiar with the AHD concept. After several iterations of survey refinement, a final survey was loaded into a Qualtrics® online platform,8 and an electronic link was distributed in February 2015 through the Association of Schools and Programs of Public Health (ASPPH) to its 95 members and directly to the 61 CEPH-accredited programs of public health that were not ASPPH members, thereby targeting all 156 CEPH-accredited schools and programs of public health. For ASPPH members, the survey link was sent to the director or associate dean of the office of public health practice if one was known; otherwise, the survey link was sent directly to the dean or program director, who was asked to either respond to the survey or forward it to an appropriate colleague. For non-ASPPH members, the survey link was sent directly to program directors. Surveys were completed online; four followup reminders were sent, and respondents had a total
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of two months to respond. After survey data were collected, additional data on academic institutions (e.g., whether or not the institution offers a doctor of public health [DrPH] degree) were made available through ASPPH. We analyzed data using Stata® version 12.09 and used descriptive statistics such as frequency distributions, measures of central tendency, and measures of variability. For bivariate analyses, we used Wald c2 tests, t-tests, and Pearson’s tests of correlation. RESULTS The survey was distributed to 156 academic institutions: 53 CEPH-accredited schools of public health and 103 CEPH-accredited programs of public health. Of the 156 institutions, 117 (75%) completed the survey, of which 67 (57%) identified the school or program they represented. Of the 117 institutions, 64 (55%) indicated having an AHD; the mean number of public health practice partners was 3.8 (standard deviation [SD] 5 5.4, range: 1–30). We found no significant differences in the presence of an AHD (p50.61) between programs of public health (n542) and schools of public health (n522). Likewise, we found no significant differences in the presence of an AHD (p50.57) between public schools or programs of public health (n544) and private schools or programs of public health (n520). We found no significant differences in the number of graduates (p50.37) or the years of CEPH accreditation (p50.46) between schools and programs that had an AHD and schools and programs that did not. Having an AHD was not significantly associated with offering a DrPH degree (p50.73). Of the 64 AHDs, 46 (72%) had formal written partnership agreements. To determine whether or not these relationships differed between AHDs with a formal agreement and those without, we classified each participant as not having an AHD, as having an AHD without a formal agreement, or as having an AHD with a formal agreement. Using this new variable, we still found no significant relationship between AHD formalagreement status and having a partnership (p50.86), whether a school or a program (p50.86), number of graduates (p50.72), years of CEPH accreditation (p50.45), or offering a DrPH degree (p50.76). Types of connections In addition to most AHD partnerships having formal written partnership agreements, 21 partnerships shared personnel, 10 partnerships shared financial resources, and nine partnerships shared physical facili-
ties. Of the 46 schools or programs of public health with formal written partnership agreements, 32 had a memorandum of understanding or a memorandum of agreement, 19 had a contract, 10 had a letter of agreement, and eight were unsure or had another type of formal written partnership agreement. The most commonly shared personnel types were researchers (n515), followed by managerial staff members (n510), other (n57), health-care providers (n53), and clerical workers (n52). Of the partnerships, most (n548, 75%) included public health education and training. Additionally, 42 of 64 (66%) participants indicated their AHD partnerships had joint research projects. Only nine of 64 (14%) partnerships shared the provision of public health services. Types of engagement The 64 academic institutions that had an AHD were engaged with health departments in numerous ways (Figure 1). The AHDs frequently facilitated the PHAB accreditation prerequisite of conducting a community health assessment (CHA): 33 of 64 (52%) academic partners indicated their AHD facilitated a CHA, and, on average, these academic partners worked with two to three (mean 5 2.4, SD52.4) public health practice partners. The most common type of engagement for public health practice partners was hosting trainees, interns, or volunteers (n557, 89%). For academic partners, faculty and staff members were most engaged in consulting roles for AHDs (n546, 72%) for specific projects. Academic partners were least engaged in supporting AHDs in the development of service learning courses (n532, 50%). Although the differences were small, a higher percentage of AHDs with formal agreements, compared with AHDs without formal agreements, were engaged in each activity. Benefits of the AHD relationship When asked about the degree to which they had benefited from the AHD relationship in 14 areas, participants rated all but three of the areas at a median score of 4 on a scale of 1 to 5, where 1 was no benefit and 5 was an extremely large benefit. The three benefits with lower scores were increasing capacity for performing core public health functions (median 5 3.5), improving access to quality care for the uninsured and underinsured (median 5 3.0), and improving the competencies of faculty (median 5 3.5). We found a significant positive relationship (all p,0.05) between perceived importance of each benefit and actual experience of the benefit. The strongest correlations between perceived importance and experienced benefits were
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Figure 1. Percentage of academic partners engaging in education, research, and service activities with public health practice partners in academic health departments at 64 CEPH-accredited U.S. schools and program of public health, 2015a
a The PHP partner is the governmental health agency participating in the partnership. The AP is the academic institution (accredited school or program of public health) participating in the partnership. The AHD is the name or label given to the academic–practice partnership. The error bars indicate 95% confidence intervals.
CEPH 5 Council on Education for Public Health PHP 5 public health practice AP 5 academic partner PHAB 5 Public Health Accreditation Board AHD 5 academic health department
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related to education, including improving the competencies of students (r50.58, 95% confidence interval [CI] 0.55, 0.61, p,0.001) and enhancing career opportunities for public health graduates (r50.58, 95% CI 0.54, 0.61, p,0.001) (Figure 2). The benefit with the weakest correlation between perceived importance and experienced benefit was in improving the competencies of public health practitioners (r50.31, 95% CI 0.26, 0.35, p,0.001). Although the correlation between perceived importance and experienced benefits of AHDs was high for improving student competencies (r50.58), modest for improving faculty competencies (r50.39, 95% CI 0.35, 0.43, p50.008), and lowest for improving competencies of public health practitioners (r50.31, 95% CI 0.26, 0.35), 60% of academic institutions working with AHDs believed that improving faculty competencies was moderately to extremely important, 73% thought improving student competencies was important, and 72% believed that improving public health practitioner competencies was important. DISCUSSION The key finding from this study was the estimated prevalence of AHDs in accredited schools and programs of public health: slightly more than half of respondents indicated having such a relationship with one or more public health practice partners. Even limiting the definition of an AHD to only those with formal written agreements resulted in a prevalence of 39%. The most common activities of these AHDs revolved around education for students, with two-thirds of respondents also indicating collaborative research activities. As a reflection of these activities, the highest correlation between perceived and experienced benefits of the AHDs was related to students: improving student competencies, enhancing career opportunities for public health graduates, and preparing public health graduates for entry into the workforce. We found no differences in having an AHD when we compared accredited schools of public health with accredited programs of public health. Although this finding may be counterintuitive, given the larger resources of most schools, we did not attempt to measure overall volume of outputs and outcomes. Other than differences in volume, we would not expect to find differences in AHDs between schools and programs, because no a priori reason for such differences exists. Although our analyses were limited by small numbers, we found a tendency for AHDs with formal written agreements to be more engaged than AHD partnerships without formal written agreements. The estimated prevalence (55%) of AHDs in accred-
ited schools and programs of public health closely matches results from a survey of participants in the Academic Health Department Learning Community, which included both academicians and practitioners, in which 59% of respondents reported an AHD.2 For the public health practice component of academic–practice relationships, the National Association of County and City Health Officials’ 2008 Profile of Local Health Departments indicated that approximately 20% of local health departments nationally reported that staff members serve as faculty (i.e., regular, adjunct, or guest) at an academic institution, and approximately 15% indicated that faculty or staff members from an academic institution had served as consultants for the local health department.10 In addition to academic–practice relationships that may meet the definition of AHDs, such relationships also exist under other arrangements (e.g., through the Public Health Training Centers11 and Public Health Practice-Based Research Networks).12 We did not assess the relationships between AHDs and these other academic–practice arrangements. The level of engagement between public health academia and public health practice reflected in this study can be celebrated as a success in moving the public health discipline closer to accomplishing what the Institute of Medicine (now National Academy of Medicine) recommended in its landmark The Future of Public Health report on the establishment of such linkages “so that significantly more faculty members may undertake professional responsibilities in these [public health practice] agencies, conduct research there, and train students in such practice situations.”13 The isolation of academic institutions from practice described by the Institute of Medicine, although not completely resolved, at least appears via our study to be substantially lessened. The implications of this study are framed by a fundamental question posed by Quill and Aday in 2000: How well are these partnerships suited to the current and future problems of public health?14 And, closely related, how will such partnerships influence the forces of change likely to be experienced in public health practice?15 We believe at least three relational considerations are most relevant: students’ preparation when entering the workforce and navigating the Affordable Care Act, collaborative research and evidence-based public health (EBPH), and the enhancement of competencies and requirements for CHAs. We focus on these three considerations because AHDs may add value to these areas and because both academia and public health practice have been and will continue to be engaged in addressing these three topics. The Affordable Care Act is not only making its
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Figure 2. Correlations between perceived importance and actual experience of academic health department benefits from academic partners and public health practice partners at 64 CEPH-accredited U.S. schools and programs of public health, 2015a
a The mean benefit score indicated the perceived value of a benefit, where 1 was no benefit and 5 was an extremely large benefit. The error bars indicate 95% confidence intervals.
CEPH 5 Council on Education for Public Health
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presence known in public health practice, it is affecting relationships between public health and clinical medicine, especially concerning changes in health services delivery.16 Increasing the number of people who have health insurance, either through the market Exchanges or Medicaid expansion, has resulted in improvements in self-reported coverage and access to primary care and medications.17 Health departments are now implementing third-party billing and using electronic health records more frequently than in the past. Many organizations that partner with health departments, including accountable care organizations, have already been operationalizing these and related activities as new delivery systems are being established. Thus, whether the public health graduate finds employment in a governmental public health agency, nonprofit, or for-profit health sector, learning new methods in management and administration that will be relevant to the Affordable Care Act can be enhanced through AHDs. EBPH, defined as the integration of science-based interventions with community preferences to improve population health,18 has become increasingly important as practitioners seek to enhance the efficient use of scarce resources; however, the evidence for what works in public health practice is relatively thin. Brownson et al.19 have recently identified limitations to current approaches for generating evidence for public health policy and practice, among which are several limitations that can be addressed through AHD-supported collaborative research: • Lack of relevant study designs for certain public health issues • Imbalance between internal and external validity • Lack of data on implementation • Generation of the evidence base in high-resource settings • Limited focus on health equity Practice-based research, which occurs through AHDs, (1) provides opportunities to enhance the relevancy of research questions and, by proxy, study designs themselves; (2) improves the potential for external validity because the real-world settings of public health practice are more generalizable than narrowly focused, highly controlled research laboratories; and (3) expands the possibilities for understanding barriers to implementation, including issues related to fidelity, when evidence-based programs or activities are scaled up.20 Additionally, because health departments often have a particular focus on and presence in low-resource communities, practice-based research through AHDs can
provide opportunities to build capacity in settings that are different from the typical high-resource settings of most research. These opportunities can in turn increase the focus on health equity. Finally, the AHD serves as the setting in which the competencies of students, faculty, and the public health workforce can be strengthened for conducting highquality CHAs. The national voluntary accreditation process through PHAB requires that health departments conduct a CHA as a prerequisite for accreditation.5 In addition, the Affordable Care Act, through the Internal Revenue Service, established new requirements for nonprofit hospitals to conduct CHAs as a part of their community benefit;21 moreover, hospitals are required to partner with public health departments to accomplish this requirement.22 More than half (52%) of the academic institutions in this study that reported having an AHD also said that conducting the CHA was enhanced by conducting it through the AHD. The finding of a large gap between perceived importance and experienced benefit for improving the competencies of practitioners indicates that AHDs’ potential to strengthen workforce development has not been fully realized. Workforce development is yet another appropriate connection to both PHAB accreditation and EBPH. Domain 8 of the PHAB standards focuses on maintaining a competent public health workforce.5 In a recent analysis of evidence-based decision making, practitioners reported the highest competency gaps in the areas of economic evaluation, communicating research to policy makers, evaluation designs, and adapting interventions.23 One possible approach to addressing these gaps is for academicians to facilitate and expand training for practitioners in EBPH, for which there are well-documented national, state, and local models of implementation.24,25 Importantly, the first major component of EBPH is conducting community assessments. Academicians, through AHD relationships, can be key to resolving these competency gaps. Limitations This study had several limitations. First, data were selfreported and came from the perspectives of academicians involved in AHDs. No attempt was made to verify the data or perspectives with public health practice partners in these AHDs. Second, the survey was limited to accredited schools and programs of public health, although the literature indicates that many disciplines—from nursing and medicine, to environmental science and allied health professions—have developed academic–practice partnerships.1 Finally, the data were cross-sectional and indicated associations only; as such, they cannot be interpreted as causal.
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CONCLUSION Academic–practice partnerships, or AHDs, are prevalent across accredited schools and programs of public health. Such relationships bode well for preparing public health graduates to enter the workforce in the era of the Affordable Care Act and for strengthening the evidence base of public health through practicebased research. For AHDs to make a greater impact on workforce development, opportunities for improving practitioners’ competencies can be realized through a focus on CHAs and EBPH training.
6.
7. 8. 9. 10.
This study was approved by the Institutional Review Board at the University of Tennessee, Knoxville. Paul Campbell Erwin is Professor and Head of the Department of Public Health at the University of Tennessee, Knoxville, Tennessee. Jenine Harris is an Associate Professor at Washington University in St. Louis, George Warren Brown School of Social Work, Prevention Research Center in St. Louis, St. Louis, Missouri. Roger Wong is a doctoral student at Washington University in St. Louis, George Warren Brown School of Social Work. Christine Plepys is Director of Data Analytics at the Association of Schools and Programs of Public Health, Washington, D.C. Ross Brownson is the Bernard Becker Professor of Public Health at Washington University in St. Louis, George Warren Brown School of Social Work, and at the School of Medicine, Division of Public Health Sciences and Alvin J. Siteman Cancer Center, and Codirector of the Prevention Research Center in St. Louis. Address correspondence to: Paul Campbell Erwin, MD, DrPH, University of Tennessee, Department of Public Health, 1914 Andy Holt Ave., Knoxville, TN 37996; tel. 865-974-5252; e-mail .
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©2016 Association of Schools and Programs of Public Health
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