Making Strides in Public Health: Spotlight on Dr. Ross Brownson
by Sheryl Monks
“[A] really important part of Public Health 3.0 is having new partners in new disciplines. Not just rounding up the usual suspects of the health sector but thinking about economists or the agricultural sector or the school sector or city planning. And universities often have departments that focus on those disciplines… [S]ome of the biggest strides we can make in public health are going to come from disciplines outside of public health. [W]e spend too much time in our own health silos and not enough time in other ones.”
This month, we shine the spotlight on JPHMP editorial board member Dr. Ross C. Brownson. Dr. Brownson has been a member of the editorial board since 2007. He is a leading expert in chronic disease prevention and in the area of applied epidemiology, and is regarded as one of the great intellectual, educational, and practice leaders in the field of evidence-based public health. Dr. Brownson has a joint appointment with Washington University’s School of Medicine in the Department of Surgery and the Siteman Cancer Center. JPHMP Spotlight Ross Brownson
Brownson directs the Prevention Research Center, a center that develops innovative approaches to chronic disease prevention through translational research. He leads a large number of other research and training projects funded by a broad array of federal and foundation sources, including the National Institutes of Health and the Centers for Disease Control and Prevention.
I had the opportunity to speak with Dr. Brownson about his career journey. Listen to the podcast or read the interview below.
Read the transcript:
Sheryl Monks: Your background is in chronic disease prevention and applied epidemiology with an emphasis on the translation of research to policy. Can you briefly describe some of the roles you’ve held, including your role as Director of the Prevention Research Center in St. Louis?
Dr. Brownson: Sure, yeah. I’ll go back into the time of graduate school and preface with a short description of that. I went to graduate school in Colorado at Colorado State University, and then my former department chair then had become a division director with the Missouri State Health Department in Jefferson City, Missouri, and he called me one day and said I’ve got an open job for a cancer epidemiologist and if you’d like to come out, I think it’d be a good fit for you. So I sort of took a chance and moved, at that time, to Columbia, Missouri, and worked there with the Missouri State Health Department for 8 years. I started in a small office of three people as a cancer epidemiologist, and by the end, had a division of chronic disease prevention and health promotion of over 75 people. So we had a lot of growth. It was sort of the glory days of rapid growth, of federal funding and state funding in chronic disease prevention and health promotion. In 1994, I headed to St. Louis University to become a department chair there with the School of Public Health, and spent 14 years there. Then moved to Washington University here in St. Louis in 2008 and have been here ever since and really focused on the work of our Prevention Research Center that is focusing on several different domains: 1) building leadership capacity in state and local public health agencies, 2) working on work with obesity in built environment research to understand how the community environment influences risk of obesity, and 3) then under the broad heading of implementation science, trying to understand how we more rapidly and efficiently translate scientific evidence into public health practice and policy.
“Surprising to a lot of people, rural communities of 10,000 people and less have the very lowest rates of physical activity. It’s a preconceived notion to a lot of people that there’s a lot of day-to-day physical activity in smaller communities, but that’s just not what the data show.”
Sheryl Monks: What are some of the projects the PRC is working on?
Dr. Brownson: We’re focused really on trying to improve public health practice, address health disparities in disadvantaged communities, and move science to practice. PRC has about 15 active projects. We have really interesting projects going on in state health departments for addressing the concept of what we call mis-implementation. What that means is how often health departments are implementing programs that are ineffective and ought to be stopped, or are not implementing effective programs that should be either started or scaled up. We’re working on that project first to get a lay of the land and then doing a systems science approach called agent-based modeling, which will identify certain modifiable ways that we can reduce what is essentially the waste of resources at the state health department. We’re working a lot with local health departments here in Missouri, 12 health departments, where we’re trying to build capacity, build leadership, and scale up evidence-based decision making reciprocity. And then we have a project in rural Missouri that’s focusing on a multilevel intervention approach to promoting physical activity in six rural communities in southeast Missouri. Surprising to a lot of people, rural communities of 10,000 people and less have the very lowest rates of physical activity. It’s a preconceived notion to a lot of people that there’s a lot of day-to-day physical activity in smaller communities, but that’s just not what the data show. We’re trying to really focus on the disparities that exist in a number of rural communities around the region here in Missouri and Illinois.
Sheryl Monks: What are some of the behavioral, environmental, and other factors that contribute to chronic disease, such as obesity, particularly in these rural communities?
Dr. Brownson: That’s a complicated question. There are many intersecting factors. When you think of things in a multilevel ecologic context, and you have at the top the broad community environment and the policies, and then in the middle you have organizations where people work or where they worship or where they go as gatherings. That leads to the idea of interpersonal factors, the social support people get, all the way down to the individual. So there are usually four or five layers of factors across those different levels that influence activity or the lack of activity. So if you think of physical activity as the example, zoning policy influences whether people have sidewalks or how communities are built… the built environment in a community: are there walking trails? Are there sidewalks? Are there a lot of green spaces where people can walk or bike or spend time in nature? And then the organizations: does the workplace where you work everyday support physical activity in the policies and incentivize that? At the interpersonal level it might be do your family and friends do physical activity together? Do you enjoy it? Do you encourage family members and friends to do physical activity? And then the individual can be all the way from genetics, to their gender, their race, sort of the individual determinants of physical activity that are influenced by all these other levels. So it’s a complicated set of factors, and what we try to do for effective intervention is intervene at all these levels, but it’s especially at the broader community and policy levels that influence chronic disease risk.
“[I]t might be that a researcher looks at the world in a certain way, that we want the members of our state to be more healthy. A policy maker might look at it in a different way. They might think, well, health is okay, but we want to look at ways that are going to save our state money. So the message has to be, how do we get a health message out, but how do we layer it and segment it in a way that that message is tailored to how the policy maker might view the world?”
Sheryl Monks: A lot of your work focuses on understanding the way policy makers receive and understand information so that we might be better able to share evidence-based research that will positively affect public health policy. Can you speak a little about your article “Getting the Word Out: New Approaches for Disseminating Public Health Science,” which appears in the March 2019 issue of the Journal of Public Health Management and Practice? What are some of the lessons or best practices for disseminating research? JPHMP Spotlight Ross Brownson
Dr. Brownson: Yes, that’s a good question. I guess I would start by saying that we ought to try to think and act not like a researcher but like someone in another field, so a communicator, someone who really knows how to reach various audiences. The piece we did there was sort of giving some background on what leads to effective communication and dissemination, and that starts with a model from the 1940s that looks at the source of information, the audience you’re trying to reach, the message you’re trying to convey, and then the channel, which is how you convey that message. So for policy audiences, it might be that a researcher looks at the world in a certain way, that we want the members of our state to be more healthy. A policy maker might look at it in a different way. They might think, well, health is okay, but we want to look at ways that are going to save our state money. So the message has to be, how do we get a health message out, but how do we layer it and segment it in a way that that message is tailored to how the policy maker might view the world? So that’s where we start. We start by getting the people to think first of all about who their audience is, how they receive information, what information resonates with them, what information for policy makers is relevant to their constituents or the people who elected them if it’s an elected official, and then going from there. And we often reach out to communications experts or political scientists or others who are not necessarily researchers but have a good idea about how to reach policy makers, and those are a few of the lessons that we put forth in the article you mentioned.
Sheryl Monks: You’ve said before that some of the barriers to the uptake of research to practice are lack of incentive, workforce preparedness, and leadership decision making, among other things. You’re a coauthor of an article in the July 2019 issue of JPHMP, “Organizational Supports for Research Evidence Use in State Public Health Agencies.” Can you speak a little about the study’s objective and findings? JPHMP Spotlight Ross Brownson
Dr. Brownson: Yes, I’m certainly glad to do that. This study was a layered on study from a larger project, and one of our students, Hengrui Hu, led the analysis. It was about almost 900 workers in the state health department. Hengrui did what he called a latent class analysis, which is an advanced statistical method of taking information.. and so the outcome we were looking at is what leads toward use of science and research information in decision making, in this case, in the state health department? And what the latent class analysis allowed him to do was to group employees into four distinct groups that predicted whether people do or don’t use science in their day-to-day work. And I won’t go into all the groupings, but what we found out is there were certain critical factors, things we call organizational support, that really predicted the use of research information in state public health. Those are things like having access to information. That might be having a portal where you can go find the latest information. Whether someone’s supervisor expects them to use information from research sources in their day-to-day work. And then the broader concept of what we call participatory decision making. Especially on important decisions that are going on in a state health department, do supervisors/do leaders engage the employees in learning about and making those decisions? And those things look like they’re organizational factors, some people call it the climate and culture of an agency, and not only in this study but in a number of other studies, they look to be very important toward more quickly moving research to practice in state and local public health agencies. JPHMP Spotlight Ross Brownson
“[R]ural health departments face what we call the dual burden in public health. And dual burden just means that they face some of the highest health risks… in other words, the highest disparities occur in small, rural communities, and they also tend to have the challenge of having lower resources.”
Sheryl Monks: Let’s talk about health department accreditation and another recent article in JPHMP, “Public Health Agency Accreditation Among Rural Local Health Departments: Influencers and Barriers.” Why are smaller, rural health departments less likely than micropolitan health departments to seek accreditation? And why is this important to understand? JPHMP Spotlight Ross Brownson
Dr. Brownson: Yeah, that’s an excellent question. So rural health departments face what we call the dual burden in public health. And dual burden just means that they face some of the highest health risks… in other words, the highest disparities occur in small, rural communities, and they also tend to have the challenge of having lower resources. So they’re not having hundreds and hundreds of staff. They maybe don’t have a school of public health outside their door where they can get intern students or they can hire people. So right off the bat, there are some really unique challenges that rural, low-density populations face. The study you mention came from the NACCHO Profile Survey, so it’s a nationwide survey that we’re able to stratify by the size of the jurisdictions, and we found that there are some unique barriers and challenges that these small, rural health departments face, that in a way aren’t rocket science… they kind of make sense. There’s a fee for accreditation, so a fee can be a barrier and challenge to a rural health department. They tend to have smaller staff sizes and tend to be understaffed. And they may not have some of the technical disciplines that are required to fulfill accreditation. And then sort of the entry point of this is that accreditation is a voluntary process where a health department has to perceive a benefit, and it appeared from this article and others is that the perceived benefits of accreditation are lower among some of the rural health departments than they are in more urban and suburban settings. So it’s really important to understand these and begin to think about how accreditation can be tailored, how rural health departments can be supported in the accreditation process so that they can essentially be on an equal playing field with other health departments across the US.
Sheryl Monks: What role does the academic health department play in achieving Evidence-Based Public Health or Public Health 3.0? JPHMP Spotlight Ross Brownson
Dr. Brownson: The emphasis in Public Health 3.0 is sort of the underpinning that we have more knowledge and tools than ever before and we’re in a position to apply those in new and exciting ways, yet we have large inequalities. So there’s a distinct emphasis in Public Health 3.0 on the social determinants of health. So as we think about this linkage between practice and the academic world — in particular, the formal academic public health department — I think there are a number of ways it can connect and further the idea of evidence-based decision making. One is that universities are good at analytic disciplines like epidemiology and finding data; understanding where health risks occur, where disparities occur; what some of the influences are in driving and what the resulting interventions might be to address some of the key elements from Public Health 3.0; [and] building better data skills that cross over between health departments. If anybody’s health departments have lots of data that are in need of analysis and dissemination, often universities, whether it’s a public health training program, a program in community health, or a program in a different discipline, can often help with those data skills. Then I think also a really important part for Public Health 3.0 is having new partners in new disciplines. Not just rounding up the usual suspects of the health sector but thinking about economists or the agricultural sector or the school sector or city planning. And I think universities often have departments that focus on those disciplines. And I always argue that really some of the biggest strides we can make in public health are going to come from disciplines outside of public health, and we spend too much time in our own sort of health silos and not enough time in other ones. And I think this idea of building stronger academic-practice linkages can really foster new disciplines and new players coming to the table to address these health issues. JPHMP Spotlight Ross BrownsonWe're focused really on trying to improve #publichealth practice, address #health disparities in disadvantaged communities, and move #science to practice. -- Ross Brownson on @JPHMPDirect Click To Tweet
Sheryl Monks: This year marks the 25th anniversary of the Journal of Public Health Management and Practice. How long have you been a member of the JPHMP editorial board? What has JPHMP meant to you as it relates to your work?
Dr. Brownson: Yeah, so that’s exciting. Twenty-five years, so that should be the silver anniversary. I hope everyone gets to have a little piece of silver to remember that. I joined, I believe, in 2007, so I’ve been on the editorial board for about a dozen years. I’ve known about the journal ever since it started twenty-five years ago. I’ve been in public health that long. I think the unique and special part of the Journal is, number one, that it’s really a go-to source for rigorous science, but rigorous science that’s relevant to state and local public health practitioners, looking for topical areas, intervention science, new emerging health issues that are relevant, timely, and actionable for public health practice. I think that’s probably the biggest thing. The Journal has been, for my work, for the work of my teams, an ideal venue for a lot of our work as we’ve talked about. Other times, our work is just trying to improve public health practice, and that’s essentially what the Journal is trying to do as well. And I think the other thing the Journal has done that’s a little different than a lot of other journals is they’ve done some really timely and unique theme issues that are showcasing hot topics, emerging areas, collaborative work between practitioners and academics and people working in non-governmental organizations, that I think is a little different than a lot of other journals and really tends to highlight things that are especially relevant to those out working in day-to-day pubic health. JPHMP Spotlight Ross Brownson
Sheryl Monks: Is there anything you’d like to add?
Dr. Brownson: Yeah, there are a couple things I was thinking about. One, I think we still don’t have as much activity in the Journal in publishing from practitioners. So I think if I was going to add something it would be for us to find ways to better engage practitioners in publishing their work. For the people working in the ivory towers of academia, the publication is the kind of coin of the realm. It’s necessary for people to advance in their careers. And that’s not really the case for people out working in practice. So finding ways to link practice and academics; as we’ve talked about, a good example of that is the academic health department that I think will move it forward. I know the Journal is moving more and move on open access on a number of the articles, and I think the open access movement is a really exciting movement for the future because we find that one of the biggest reasons why practitioners don’t read journals, like the Journal of Public Health Management and Practice, is they don’t have access to a library where they can read the journal articles. I think that is an important thing for us to focus on going forward. And then I think also just focusing on a number of the emerging topics that the Journal has been focusing on, like climate change, or how technology can be a bigger part of public health practice and intervention, and then how we address the growing inequalities in the US and other parts of the world. I think those are all important and exciting things as we move forward and look forward to the next 25 years.
Thank you, Dr. Brownson. JPHMP Spotlight Ross Brownson
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Sheryl Monks is the Editorial Associate of the Journal of Public Health Management & Practice. She manages JPHMP Direct.