Managing public health in the army through a standard community health promotion council model.
... any combination of health education and related organizational, political, and economic interventions designed to facilitate behavioral and environmental changes conducive to the health and well-being of the Army community. (1) (p6)
Community health promotion councils are designed to manage a coordinated approach to local public health at Army installations and integrate health promotion and disease prevention into the Army's business practices. Because CHPCs are essential to the Army's strategy to address public health concerns, there is a strong need to document and evaluate the evidence supporting their effectiveness. (2) Therefore, this study:
1. Describes the need for a CHPC model to coordinate the Army public health system.
2. Outlines the CHPC model and the evidence that informs its development.
3. Reports the results of initial studies of CHPC effectiveness.
4. Establishes an agenda for future research.
THE NEED FOR ARMY COMMUNITY HEALTH PROMOTION COUNCILS
Within most public health systems, the various components are typically owned and operated by different organizations such as schools, hospitals, and community health departments. Integration among these elements in the public health system is defined by their ability to agree on overall objectives, freely share information, and plan and implement complementary activities in the context of an agreed upon overall health response plan. (3) Research shows that effective coordination among stakeholders in public health allows public health systems to achieve their mission, address health problems and respond to economic and performance demands. (4) For example, integrating stakeholders within a public health system resulted in a dramatic rise in funding for single-disease or population-group-specific programs such as immunizations, malaria, and HlV/AIDS. (5)
Conversely, a fragmented approach to public health leads to duplication of services, conflicting recommendations to fix problems, medical errors, misunderstanding or lack of awareness of the true causes of problems, increased costs, public health errors, and ultimately poorer population health. (6) The Institute of Medicine reports that failures in system capabilities are often a result of how public health services are organized and delivered across communities. (7,8) Systemic errors occur, including poor reporting and communication of population health trends rather than technical failures. (9,10) These concerns led the field of public health to a wide-spread acknowledgement of a need for strong and integrated services within public health systems. (11)
Research demonstrates that integration within a public health system is largely driven by the extent to which there are clear processes and a strong governing body regulating the interaction of agencies and organizations. Further, effective governance involves bringing constituents together and facilitating their actions within the system to accomplish system-wide goals. The system should document and disseminate how the various components of a public health system function; provide their constituents with information about the evidence supporting programs, policies, services, and the effectiveness of other public health practices; and ensure the access of target populations to those services. (12) The information collected through the public health system and its governing body allows the effective allocation of resources, maximizes the collective impact of public health practices within the system, and allows public health stakeholders to methodically identify system strengths and weaknesses. (13)
Similarly, Army installations operate with interdisciplinary, complex systems that affect the health and well-being of the Army communities. For example, Army installations are governed through traditional, functional chains of command. Generally, these functional lines are mission or tactical operations (war-fighting, Soldier training and development, strategic operations); garrison operations (programs, services, facilities); and medical operations (healthcare services). The functional areas create many unique and overlapping systems within the overall Army public health system. The functional chains of command have the tendency to stovepipe and create natural silos. This is an efficient approach to ensuring leadership and accountability in achieving specific, clearly-defined missions. However, it creates obstacles and inefficiencies in addressing complex public health issues that require a multidisciplinary approach.
An example: suicide is a major, current public health concern in the Army. However, the ability to prevent suicide in the Army is within the purview of multiple commands and Army agencies. The Medical Command (MEDCOM) employs behavioral health providers that treat behavioral health disorders among Soldiers, (14) the Army G1 (the Chief of Staff for Manpower and Human Resources) develops and administers a suicide prevention program and other programs that affect risk factors associated with suicide, such as the Army Substance Abuse Program, (15) and the Army G3/5/7 (the Director of Strategy, Plans, and Policy) administers Comprehensive Soldier Fitness, a program designed to train Soldiers to become more psychologically resilient. (16,17) These programs have complementary missions, but had no formal forum to coordinate their approach to suicide prevention at an installation level. (18) Therefore, Army installation CHPCs evolved to bring representation from different stakeholders to the same table to develop efficient, coordinated approaches to public health concerns without reducing the autonomy of existing systems or disturbing the functional chain of commands in the Army organizational structure. In other words, the goal of the CHPC is to build a public health infrastructure and public health system that efficiently and systematically promotes health and prevents disease within the existing Army organizational structure on an installation.
The standard CHPC model, illustrated in Figure 1, is marked by 3 critical features. First, the CHPC is chaired by the highest level of leadership on an Army installation (the installation's senior commander). The senior commander champions and leads the CHPC, and provides the authority to influence the programs, policies, and environments that affect the health of the installation's population. Second, the CHPC is organized and managed by a health promotion operations team. The health promotion operations team consists of a health promotion officer (HPO) and a health promotion research assistant (HPRA). The health promotion operations team consists of members of the senior commander's full time staff and is responsible for facilitating the CHPC and ensuring it is consistent with Army regulations and meets the standards developed by the Army Institute of Public Health of the USAPHC. The health promotion team provides subject matter expertise on the public health process to the senior commander's staff and ensures coordination and fidelity to the standard process. This includes ensuring that the CHPC identifies health needs through systematic data collection, sets priorities through a health promotion strategic plan, oversees the development and implementation of health promotion programs and policies to address these priorities, and oversees the evaluation of the effectiveness of programs and policies. The third critical feature of the standard CHPC model is centralized management through the USAPHC. The USAPHC is a subordinate command to MEDCOM and oversees the administration of public health in the Army. It also collaborates with other Army oversight agencies such as the US Army Forces Command, US Army Training and Doctrine Command, the Army Materiel Command, the Army Installation Management Command, as well as other Army senior leaders such as deputy chiefs of staff of the Army and assistant secretaries of the Army to address the Army's public health concerns. Through centralized management, HPOs, CHPCs, and senior commanders are able to remove barriers to healthier communities through USAPHC's influence over programs and policies that are set at higher, strategic levels of the Army. Furthermore, USAPHC's direct oversight of the CHPCs ensures that the CHPCs adhere to an evidence-informed program framework.
Currently, USAPHC funds health promotion officers and health promotion research assistants at Army installations that adhere to the standard CHPC model. The HPOS and HPRAs are located at 12 posts across the continental United States: Aberdeen Proving Ground, MD; Fort Bliss, TX; Fort Bragg, NC; Fort Carson, CO; Fort Campbell, KY; Fort Drum, NY; Joint Base Lewis-McChord, WA; Fort Polk, LA; Fort Hood, TX; Fort Irwin, CA; Fort Riley, KS; and Fort Stewart, GA. Fourteen other installations in this evaluation have established CHPC processes but do not have a designated health promotion officer or health promotion research assistant.
EVIDENCE IN FORMING THE CHPC MODEL AND PROCESS: COMMUNITY COALITIONS
The CHPC standard model is rooted in community coalition action theory (19) and other research on effective community health coalitions. A community coalition is defined as:
... an organization of individuals representing diverse organizations, factions or constituencies within the community who agree to work together to achieve a common goal. (20) (p1)
The functions of community coalitions are generally to increase capacity through collaboration, help communities build social capital to apply to social and health issues, and to serve as catalysts for change and movement towards desired outcomes (eg, policy change). (21)
The community coalition approach grew out of multiple lines of research. For example, public health research indicates that public health problems are complex and rooted in a society's social and ecological context and should be addressed from multiple directions by multiple actors in the community. Therefore, community coalitions aim to create synergy and opportunities for collaboration to address public health problems across multiple sectors. (22) Community coalitions seek to empower communities to advocate for their own health and wellness, which is consistent with research demonstrating that a population's health is more likely to improve when the community itself is engaged and invested in the community coalition process. (23) Furthermore, better health in a community is more linked with the community health system characteristics (eg, health behaviors and environmental factors in the community) than the performance of the healthcare system (eg, accessibility of healthcare). (24) Finally, community coalitions that aim to advocate for policy changes are supported by research demonstrating that the most effective strategies to improve the public's health result from changes in policy. (25) Research on community coalitions indicates that coalitions can positively attect health indicators such as lead poisoning, adolescent pregnancy, infant mortality, motor vehicle accidents, and tobacco use. For example, the Community Trails Project (a collaborative partnership) contributed to a 10% annual reduction in alcohol involved automobile crashes. (26) Also, the Community Intervention Trial for Smoking Cessation contributed to increased quit rates among light to moderate smokers. (27) Additional case studies from 20 community coalitions indicate that they have a strong and positive impact on organizational change including leveraging financial resources, developing programs, changing policy, increasing collaboration, increasing community engagement, involvement, and strengthening an organization's health promotion structure. (28)
Not all community coalitions are equally effective. (28) Research consistently finds that the effectiveness of community coalitions is affected by multiple factors. For example, a review of 26 studies concerning community coalition effectiveness found that 5 factors predicted community coalition success in at least 5 studies. These factors include formalization of rules and procedures, leadership style, member participation, membership diversity, agency collaboration, and group cohesion. (29) Coalition leadership is a recurring predictor across several reviews. For example, a study of 10 coalitions formed as a part of the America Stop Smoking Intervention Study for Cancer Prevention highlights the importance of good coalition leadership. (30)
These case studies revealed that task-focus, good communication, quality action plans, and dedicated staff time were related to measures of community coalition effectiveness such as membership satisfaction, successful action plan implementation, and resource mobilization. (30) Other studies suggest that coalition success is facilitated by a supportive organizational climate, ability to affect community norms, power to influence policy, and ability to develop and advocate for primary prevention resources within the community. (31) Finally, diverse membership, a clear strategic vision, effective conflict resolution processes, a theory-driven approach to the community coalitions, the ability of coalitions to evaluate their effectiveness, and dedicated and competent staff all contribute to the success of community coalitions. (21)
The 3 critical features of the standard CHPC model ensure that many of the indicators of coalition and public health system effectiveness are present in the Army CHPC model. The Army CHPC model is wellpositioned to have an affect on policy. The senior commander at an Army installation has the authority to develop, disseminate, and enforce policies that affect the public health. For example, a senior commander at one Army installation learned that Soldiers were experiencing adverse effects from polypharmacy (the prescription of 5 or more medications) because providers were not receiving warnings when placing prescriptions through the electronic profile and pharmacy system. (32) The senior commander used the CHPC to convey this issue to the Army hospital commander who ensured warnings to prevent polypharmacy were added to the system.
The Army CHPC model also places a strong emphasis on formalization of rules and policies and can ensure these rules are executed through centralized management. Each standard CHPC is required to execute the prescribed model with specific deliverables, including reports of change in public health programs, practices, and policies; annual survey of CHPC effectiveness; report on adherence to the program framework; annual strategic plan; annual marketing plan; annual working group action plans; annual community profile; annual community resource guide; and quarterly program status reports. Health promotion officers provide these deliverables to centralized managers at the USAPHC who ensure the installation health promotion team adhere to the program framework and Army Regulation 600-630 Another characteristic of effective coalitions, staff dedication time and expertise, is the primary reason for the HPO position. The HPOs are hired based on their competence in Army culture, leadership, and business management skills, and are trained to appreciate their public health role in improving community health as they collaborate with local and USAPHC public health professionals in areas of surveillance, community health, program planning, implementation, and evaluation.
In summary, the standard CHPC model has several of the core components of an effective community coalition; dedicated staff time and support, formalized rules and procedures, oversight to ensure quality action plans, and power to affect policy and advocate for primary prevention resources through the senior commander. Nonetheless, there are currently no published studies testing the effectiveness of the standard CHPC model. Because the standard CHPC is becoming a key strategy for promoting health and preventing disease and injury within Army populations, additional study to evaluate the model is critical. In an effort to evaluate the standard CHPC model, USAPHC is establishing a process for evaluating and monitoring the model to ensure quality, satisfaction, fidelity, and impacts. The next sections establish the study design, participants, and results.
The purpose of this study is to test a foundational assumption of the CHPC effectiveness theory: the 3 features of a standard CHPC model--a CHPC chaired by a strong leader, ie, the senior commander; a full time health promotion team dedicated to the process; and centralized management through the USAPHC--will lead to high quality health promotion councils capable of providing a coordinated approach to addressing public health on Army installations.
Evaluation Questions and Study Design The study employed 2 evaluation questions:
1. Do CHPCs with centralized management through the USAPHC, alignment with the Senior Commander, and a Health Promotion Operations Team adhere more closely to the evidence based CHPC program framework than CHPCs without these 3 features?
2. Do members of standard CHPCs report that participation in the CHPC leads to a well-coordinated approach to public health at the installation?
The study addressed the first question with a single factor (CHPC type), 2-level (standard CHPC vs. nonstandard CHPC) evaluation design with CHPC program adherence as the outcome variable. A past evaluation of CHPC effectiveness conducted by the Office of the Secretary of Defense for Health Affairs showed that the effect of the critical features of the standard CHPC model was moderated by the amount of time a CHPC had been established. * Therefore, the amount of time a CHPC had been operating was included as an additional predictor of program adherence.
The study addressed the second question through a survey that measured members' perceptions that the CHPC led to a more coordinated public health system.
Program adherence was measured through an instrument called the "structure process evaluation tool" (SPET). The SPET is a 58-item self-assessment for CHPC leadership (HPOs, centralized HPO managers, and CHPCs) to measure the extent to which the CHPC is meeting the requirements set forward in Army Regulation 600-63.1 It includes items such as "Does the installation have a CHPC that meets quarterly?" and "Does CHPC membership include representatives from each of the following: medical tactical, community, local?"
Perception of public health coordination is measured through the CHPC Effectiveness Survey. The Effectiveness Survey is a 20-item assessment administered yearly to CHPC members to assess the extent to which they perceive the CHPC as achieving its objectives and member satisfaction. In this assessment, participants respond to items regarding member satisfaction such as "in general, how would you rate the overall functioning of the HPO position at your installation" on a scale from 1 (Strongly Disagree) to 5 (Strongly Agree).
However, only 5 of these items are directly relevant to members' perceptions that the CHPC is achieving a more coordinated public health system. Therefore, only these items were analyzed to address evaluation question 2. The items include:
* The CHPC identified gaps in existing resources for needs/risks.
* The CHPC uses data to identify community needs/ risks.
* The CHPC assesses existing resources for overlaps.
* The CHPC develops action plans for identified priorities.
* The CHPC facilitates relationships and networking between garrison, medical and tactical assets.
Participants and Procedure
The SPET and Effectiveness Survey are completed annually between July and September of the Army fiscal year by all HPOs or a member of the CHPC (for installations without the standard CHPC model). The results of the SPET were aggregated across 6 years (2007-2012) and represents responses from 11 installations with the standard CHPC model and 18 installations without the standard CHPC model. There were a total of 83 (N=83) responses to the SPET. The CHPC Effectiveness Survey was completed once per year for 6 years (2007-2012) by the CHPC membership only where there is a standard CHPC model (N=454). This study was reviewed by the US Army Public Health Review Board and all tools and methods were validated as approved methods of public health practice. The study did not require Institutional Review Board approval as all methods and data collected were a part of standard public health practice for community health promotion councils in the US Army.
Evaluation Question 1
Ordinary least squares regression was used to determine the extent to which the 3 critical features of the CHPC model and time operating positively predicted program adherence. The results revealed that both time ([F.sub.(5,76)] = 25.02, P <.0001) and the 3 critical features of the standard CHPC model ([F.sub.(1,76)] = 28.40, P <.0001) independently predicted program adherence. Contrary to prior research, however, the relation between adherence to the standard CHPC model was not moderated by the time that had elapsed since the CHPC began meeting ([F.sub.(1,76)] = 0.06, P = .81). (33) These results are displayed in Figures 3 and 4.
Evaluation Question 2
Data from the CHPC Effectiveness Survey were analyzed with descriptive statistics measuring the extent to which members perceived the standard CHPCs as achieving the goal of integrating the Army installations' local public health systems. The survey results indicated that members responded on the positive side of the scale. In other words, members generally agreed that participating in the standard CHPC model is associated with a more coordinated approach to addressing public health at the installation. Figure 5 presents the results of this analysis.
These results provide preliminary evidence that the Standard CHPC Model may lead to a more coordinated approach to public health and may assure that CHPCs follow an evidence-informed design. This data supports the standard CHPC Model where the Army senior commander provides strong leadership; the health promotion team drives the process with expertise and coordination; and centralized management ensures a standardized approach to policy and procedure execution is maintained through evidence of delivery. This is consistent with past research demonstrating that community coalitions and public health systems that have strong leadership, dedicated staff time and expertise, influence over policy, governance and oversight, and formalized rules and regulations function more effectively than those without. (3,4) It also demonstrates the feasibility of implementing an evidence-informed approach to community coalitions in an Army environment. The Army model is not only supported by methodologies described in the literature, the evidence from the process validates those same methodologies and contributes to the body of knowledge on the effect of coalitions on public health process management in communities.
The findings in this study are limited by several factors. Because the SPET is a self-report and completed by HPOs who are motivated to appear successful in developing an effective CHPC, the data from the SPET may be biased. However, this study assumes that participants in the study representing nonstandard CHPCs are also motivated to adhere to the regulations for installations CHPCs. Most likely, this bias is present in both standard and nonstandard CHPCs. At this time, the CHPC effectiveness survey is only completed at installations with a standard CHPC. Therefore, there is no way to compare whether or not standard CHPCs perform better on this survey than nonstandard CHPCs.
AN AGENDA FOR FUTURE RESEARCH
The studies support the link in the effectiveness theory between the 3 critical features of the standard CHPC model and a better coordinated approach to public health. However additional evaluation studies are needed to substantiate the effect of the standard CHPC model on community health and wellness and efficient resource management. Reviews of past research suggest that traditional program evaluation methods are often inadequate to capture the effect of community coalitions on population health. (21) For example, there are only 12 standard CHPCs in the Army. At the community level, there are many outside influences that affect population health and it is difficult to account for all potential confounders that may cloud the effects of standard CHPCs. Thus, traditional research designs and tests of statistical significance may be underpowered to detect the direct effect of a CHPC on community health and wellness.
However, evaluations of the effect of specific policy, program, and environmental changes initiated through CHPCs could potentially demonstrate the positive effects of the standard CHPC on population health and wellness. For example, one CHPC implemented an additional wellness service which was associated with a decrease in Soldiers' body mass index and increased help-seeking behaviors. ** According to an annual report provided to USAPHC, the CHPCs implemented 1,050 similar actions and initiatives during fiscal year 2012 that aimed to improve community health and wellness and more efficiently manage public health resources at an installation. Using program evaluation methodologies to assess the impact of these individual initiatives may dramatically increase the evidence to support the effectiveness of the standard CHPC model, as well as provide greater insight into what programs, policies, and environmental changes will effect health promotion and disease prevention in the Army.
The standard Army CHPC model evolved to meet a need for better coordination within the Army public health system and presents a key strategy to achieving better health among Soldiers and their Families, retirees, and civilians. Based on past research and the studies presented here, the standard Army CHPC model is poised to positively affect the Army public health system, community health and wellness, public health resource management, and ultimately military readiness. The potential effect of the Army CHPC model, together with the opportunities it presents for interesting and revealing evaluation studies, suggest an exciting future for the study of public health management in the Army.
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(30.) Kegler MC, Steckler A, Mcleroy K, Malek S. Factors that contribute to effective community health promotion coalitions: A study of 10 Project ASSIST coalitions in North Carolina. American Stop Smoking Intervention Study for Cancer Prevention. Health Educ Behav. 1998;25(3):338-353.
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Anna F. Courie, RN, MS
Moira Shaw Rivera, PhD
Allison Pompey, DrPH, CPH
* Internal military document not readily accessible by the general public.
** Internal military document not readily accessible by the general public.
Ms Courie is a Health Promotion Policy and Operations Project Officer, Army Institute of Public Health, Health Promotion and Wellness Portfolio, Health Promotion Operations Program, US Army Public Health Command, Aberdeen Proving Ground, Maryland.
Dr Rivera is a Public Health Scientist, Army Institute of Public Health, Health promotion and Wellness Portfolio, Public Health Assessment Program, US Army Public Health Command, Aberdeen Proving Ground, Maryland.
Dr Pompey is a Program Evaluator, Army Institute of Public Health, Health promotion and Wellness Portfolio, Public Health Assessment Program, US Army Public Health Command, Aberdeen Proving Ground, Maryland.
Figure 1. Three critical features of a standard community health promotion council. Standard Community Health Promotion Council Model Chaired by Organized and Centrally the senior managed by managed by commander the health the US Army promotion Public team Health Command Figure 5. Perceptions of community health promotion council members that the council effectively coordinates the public health system in 2012. Total possible score for each question is 5 points (N = 454). The CHPC facilitates relationships 4.06 and networking between garrison, medical and tactical assets. The CHPC uses data to identify 3.99 needs. The CHPC identifies gaps in 3.80 existing resources. The CHPC develops action plans 3.72 for identified priorities. The CHPC identifies overlaps in 3.64 existing resources. Note: Table made from bar graph.
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|Author:||Courie, Anna F.; Rivera, Moira Shaw; Pompey, Allison|
|Publication:||U.S. Army Medical Department Journal|
|Date:||Jul 1, 2014|
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