Okay, it's 1 30 Eastern. Good afternoon. Welcome to Preventive Medicine Grand Rounds for February 3rd, 2021. My name is Antonio Neri from the Division of Scientific Education and Professional Development.
The Preventive Medicine Grand Rounds is sponsored by the CDC's Preventive Medicine Residency and Fellowship and the Health Resources and Services Administration Bureau of Health Workforce. The PMRF provides 12 and 24 month full-time longitudinal service learning opportunities with senior public and population health leaders for physicians, veterinarians, and nurses who have completed the epidemic intelligence service at CDC or have equivalent public health experience. We use Adobe Connect for the audio and presentation but use the chat box to pose and answer questions.
Note that you can pose questions via the question box at any point during the lecture. and the speaker will work on answering them at their discretion. Those captioning is available at the webinar link in the box at the side. Continuing Education credits are available for the live course up to one month after the presentation date, and for the recorded version, up to two years from the date of the presentation through the CDC Training and Continuing Education online portal.
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I'm especially excited to have our speaker come today. I've followed her for a number of years in her work at the Prevention Research Centers at Emory. And Dr. Michelle Kegler is going to present on a topic called Application of Theory to Designing and Evaluating Public Health Interventions at Multiple Levels of the Socio-Ecologic Framework.
Before we start, Dr. Kegler, I did want to announce to the people listening our Population Health Training in Place Program, which is meant to build the workforce capacity for population health and public health agencies, similar to a little bit of what you and Michelle Carvalho did at Emory. The applications for that program are open. We're looking for people who are mid-career professionals, who are physicians, veterinarians, nurses, and have a master's in public health or whose terminal degree is a master's in public health. At public, private, and academic centers, we're looking to expand their scope of skills on policy analysis and program evaluation in the rubric of population health improvement. You can see our website, which we will post here in the near couple minutes about.
for our application period for the PHTIP program. But let's welcome our speaker, Dr. McKay. Thank you, Tony.
So hi, everyone. My main goal with this presentation today is to convince, if you're not already convinced, that is, that theory has an important place in public health practice and isn't just abstract. with minimal utility.
So I'm going to attempt to do that by giving you some concrete examples of how I've used theory over the years. Really at the intersection of academic and public health practice. So hopefully this will be interesting to you.
The general plan for today is to just give a quick overview of theory and public health and kind of where we are today. And then jump right into some concrete applications where we'll talk about how we can use theory to understand a public health problem, to design an intervention at different levels of the social-ecologic framework as well as multi-level interventions, and then just some suggestions for how theory is useful in evaluating interventions. I'm going to stop periodically throughout the talk and take questions and answers, so feel free to be typing in your questions. questions as we go.
So first of all, why use theory? And in my mind, theory is just a useful tool for helping us think about public health problems in a systematic way. And so theory can help answer questions like why are people in organizations behaving in a certain way?
For example, the question at the bottom, why are men less likely to wear masks? in the coronavirus pandemic. What should we learn before we actually design an intervention? What short-term outcomes should we target?
How will the short-term outcomes lead to intermediate outcomes? What's the causal pathway of change? How should we actually design an intervention? What strategies should we use and how do we create those strategies?
And then what should we measure to know if and how a program is working? And I think theory can help to answer all of those questions. So this is a formal definition of theory.
It's the idea of a set of interrelated concepts, definitions, and propositions that present a systematic view of events or situations. And importantly, theory specifies relationships among constructs or variables in order to either explain something or predict something. So theories are abstract on purpose.
The idea is that you can take that theory and apply it in different settings and the general constructs and relationships will hold across behaviors and situations. They can be testable, should be able to generate hypotheses from them, and then design a study or an evaluation to see if the theory actually was helpful. There's kind of two Go-to resources in my field, and when I say my field, I'm talking about public health education and health behavior. One is Karen Glanz's health behavior book.
The fifth edition is out now, 2015. It's used in a lot of MPH classes, so those of you that have MPHs, I bet many of you use that book. And then there's also a little sort of like cliff notes of theory called Theory at a Glance. National Cancer Institute put it together.
It's getting kind of old now, but it still has the basic theories that we go to a lot in health behavior, health education. So there have been multiple systematic reviews over the last decade or two on which of our theories get used most often. And the same ones always pop up to the top, which and we can talk about why that is.
But they're generally health belief model, theory of planned behavior, social cognitive theory, social support, diffusion of innovation, and then the social ecologic model. So health belief model and theory of planned behavior are usually at the individual level. Social cognitive theory crosses levels, but is heavily at the individual level. It does have some environmental components, so it gets used a lot. Social support is at the interpersonal level.
of a social-ecologic framework, diffusion of innovations, can be more community level, and then social-ecologic level, of course, covers all, social-ecologic model covers all levels. So one question that my students ask pretty often, and I've thought about some, is whether the terms theories, models, and frameworks are interchangeable. If you look in this list of theories, you see that some of them are models, health belief model and social-ecological model. The answer is technically no. However, the terms get used very loosely.
So often models and frameworks do not specify the relationships between constructs. So if you think about the social ecologic model, which I'm assuming many of you are familiar with, it's down in that right-hand corner, it specifies that there's these levels and they're nested. So you have individual level factors, interpersonal, organizational, community, and public. policy, but it doesn't identify constructs within those levels and it doesn't talk about relationships across the levels.
So in that sense it is a model or a framework. Another model that we're going to look at today is the Consolidated Framework for Implementation Research and it's similar in that it just has these buckets but doesn't actually specify variables within those buckets. Well it does specify the variable. variables, but it doesn't talk about how they interact with each other.
So that's consistent with a model or a framework. That said, not all theories specify relationships either. So if you think about critical race theory, multiple streams or agenda setting or community capacity, those are all helpful theoretical perspectives that don't necessarily identify constructs and relationships among the constructs. And probably it depends on what field they come from.
Critical race theory comes from law originally. Multiple streams agenda setting comes from political science and community capacity is from our field. So the first example I want to jump into is using theory to understand a public health problem. And the example I'm going to give is actually a doctoral dissertation from one of my doctoral students who's at CDC, Dr. Candice Hunter.
She's now in the National Center for Environmental Health and just joined the lead group, I believe. And she did her dissertation on soil testing for heavy metals in community gardens. Community gardens can be built in brownfields, empty lots, and sometimes the soil is tested for heavy metals and sometimes it's not. So she was interested in that.
And specifically, she chose to use the theory of plant behavior. Here's her. publication that summarizes this.
So the aim of her study, and it was a mixed method study, was to investigate factors that may contribute to heavy metal soil testing among U.S. community gardeners. She used theory of plant behavior, which I'm going to run through. Well actually I'm going to spend a little more time on this theory and then when I get to other theories I'll go faster, but the idea here is that This theory applies to behavior that is planned, that someone is actually cognitively thinking about doing or has an intention to engage in the behavior. So behavioral intention is really important in this theory.
In this context that would mean, yes, I intend to get my soil tested for heavy metals before the next growing season. And then you can see that the big constructs that influence behavioral intention are attitudes, subjective norm, and perceived behavioral control. And I'm going to explain a couple of those in more detail with this example. So attitudes toward behavior, that would be the extent to which the behavior is viewed positively or negatively.
So in this case, it's, yeah, soil testing for heavy metals is a good thing, or it's not a good thing. And that construct is a good thing. is comprised of behavioral beliefs and then evaluation of those beliefs. And so behavioral beliefs is the beliefs that the behavior will lead to an outcome. So in this case, soil testing will lead to the outcome of detecting soil problems.
It could also lead to the outcome of raising liability issues. For example, if the community garden is at a school site or at a senior center. Some folks don't want to know if there's heavy metals in it because it raises liability issues. And then evaluating those outcomes and whether they're good or bad.
So detecting soil problems might be good. Raising liability concerns might be bad in someone's mind. Subjective norms is the idea that people have perceptions of what others expect them to do.
So in the community gardening example, it's thinking about whether the people that are influential in that setting expect you to test your garden for heavy metals. Sorry about that. My phone's in the background.
So in terms of, and that's comprised of normative beliefs and motivation to comply. And so this involves the perceptions one thinks key people reference. have about how they should behave.
So in this case, it might be the garden leader, it might be public health agencies, it might be an extension agent, and how I think they expect me to behave related to soil testing or not, and then whether I care with what they think, which is the motivation to comply. And then the logic for perceived behavioral control is similar, and it has control beliefs and the strength of those beliefs. And that focuses on kind of facilitators and barriers, and I'll illustrate that in a second.
So in order to implement this theory in this context, Candice began with an elicitation phase. And when you apply the theory of planned behavior, it does begin with an elicitation phase. And this is an open-ended qualitative phase where you're trying to really understand everything I just went through in a particular context.
So the behavioral beliefs, the normative beliefs. the important influential people that are setting behavioral expectations and social norms with respect to a specific behavior in that context. And so Candice did five focus groups with community garden leaders here in Atlanta, and she found some interesting things. So the positive behavioral beliefs were that soil testing for heavy metal can identify problems and take action, which allows you to take action in advance. It can give you peace of mind.
It can verify soil quality from purchased or donated soil. It can help satisfy certification needs, and it can save time and money. If you know that your soil is in good shape, you don't need to do anything, which can save time and money. However, there are some downsides to testing soil from different perspectives.
So the liability issue I already mentioned, if there's high level of contaminants. in the soil and those are discovered, there are costs associated with that. Remediation, soil replacement, or even shutting down the garden. There's a fear of scaring people away from gardening.
If you emphasize the fact that there might be lead in the soil, people might be scared to garden and there are positives of gardening. So it's sort of this balancing act. There might be a perceived lack of need to do it. You might believe that raised beds preclude the need for soil testing. There's time and resources needed to collect, ship, and receive the sample results.
And then there might be concerns about the accuracy, the sensitivity, how to do the sampling, etc. that are influencing behavior. And so she found other interesting things like who are the people that set norms about soil testing. She learned that it was often the garden leaders, extension agents were particularly important in this setting, as well as CDC and EPA giving advice in this area were also influential. So with theory of planned behavior, the first step is this qualitative piece so that you understand all of these constructs in detail among your specific population, your specific behavior, your specific context. And then there's pretty clear guidance on how to turn the qualitative findings into quantitative measures.
Dr. Hunter went ahead and did that, and then she partnered with the American Community Gardening Association and was able to get 500 gardening leaders from across the country to complete her survey. And here I'm just showing a little snippet of her findings, but this was a logistic regression showing the extent to which these factors were associated with. intent to get your soil tested for heavy metals in the next growing season.
So all in all, this study helped to understand why some people test their soil for heavy metals and why some people don't and provided good insight into potential targets for intervention. So she was able to identify specific beliefs people have about gardening, pro and con. She was able to identify influential people and organizations that shape norms and she was able to identify barriers and facilitators to soil testing so if you were designing an intervention you would know what sort of persuasive messages to give to change people's behavior you would know who to reach out to as role models and social influences influencers like extension agents and leaders of the gardens And you would also identify some concrete barriers in facilitators as well as beliefs about those barriers in facilitators, but you might be able to actually make some environmental changes that make the behaviors easy for people to engage in.
So I think that's a nice concrete example of how theory can be really helpful in designing while understanding a public health issue and then give strong hints on how to go about designing an intervention. to make a difference in this area. I'm going to go through another example, and then I'm going to pause for questions.
This next one is an intervention that we've designed at the Emory Prevention Research Center. It's called Smoke-Free Homes, Some Things Are Better Outside. And we used social cognitive theory and the trans-theoretical models, stages of change.
And I'll show you how we applied. each of those, but first I want to give you just a second of context. So we all know exposure to secondhand smoke has gone down dramatically in the last couple decades, which is great.
It's now illegal in almost every setting except private homes. So that means that the home is now a major source of exposure, particularly for children who spend a lot of time in the home. And the last time And Haines was used to publish serum cotinine, which is a biomarker for secondhand smoke exposure. There were some significant problems that... still exist.
So children had a relatively high, well, relatively high prevalence of children who were still exposed to secondhand smoke, 40.6 percent, and this was 2011 to 2012. And there were significant racial disparities, with African Americans more likely to have serum, cotinine, or secondhand smoke exposure relative to whites. In fact, it was more than double. And there are also...
disparities in smoke-free homes. So there's research that shows if you have a smoke-free home, you're less likely to be exposed to secondhand smoke. And there are significant disparities in who has a smoke-free home by both socioeconomic status and race. So all that to say it's an important area to work in.
And we had... Earlier in my career, we had gotten a grant from National Cancer Institute to do a qualitative study where we interviewed over 100 households about how they went smoke-free, how they established household smoking bans, or why they hadn't established household smoking bans, whether they had tried, what the family conversations were, what kind of disagreements they were having, what process they went through, etc. So we had a pretty deep qualitative understanding of smoke-free homes. Before we decided to develop an intervention.
Our intervention, we purposefully wanted to keep it simple. We knew that we wanted it to be easy to deliver in a range of settings. We were particularly aware that if we had greater reach, that is, if more of our partners could implement it, we would have greater potential for public health impact.
Even if The impact was modest. We know in public health that if we can disseminate things broadly, that modest impact can have a huge effect if we reach enough of the population. So we tried to keep a simple intervention that consists of three mailings and a coaching call, and it takes six weeks to deliver. We used social cognitive theory, and stages have changed.
So one of the... core components of social cognitive theory is this idea of reciprocal determinism, that personal factors like knowledge, self-efficacy, skill, environment, both physical and social, and behavior all interact with each other and each influences the other. There's also a list of specific constructs which I'll show you how we operationalize those in a minute. But the second theory we used is stages of change, which is a part of the trans-theoretical model. This is the idea that change is a process.
And we knew that actually from talking to families about how they created a smoke-free home. And so this theory categorizes people into pre-contemplation, not yet thinking about changing the behavior, contemplation, thinking about it in the next six months, but not actually doing it. Preparation, I'm going to change the behavior in the next 30 days and I'm taking steps to get ready. Action is changing the behavior, maintaining the behavior, and then potentially relapsing or staying in the maintenance phase. So you're in one of those stages with respect to any given behavior and then as health educators we try to shift you to the next stage except for relapse.
So we decided to use those theories. first of all, social cognitive theory, because it includes both individual factors and environmental. So we know that knowledge, skills, attitudes, self-confidence, self-efficacy are important factors, but we know that they're not enough and that the environment also needs to be supportive of creating the change.
And I like that social cognitive theory really acknowledges the environment. It doesn't acknowledge it a whole lot. do reading about it, but for our purposes it's there and so that's enough.
And you can think about it in terms of physical or social or built. It also gives ideas for how to go about intervening in those various factors which is really helpful. And then stages of change, we knew from our smoke free home qualitative work that creating a household smoking ban was a process and so it seemed like a good fit.
So I won't spend much time here, but this is taken from theory at a glance, and I just wanted to show you that these concepts in social cognitive theory, I mentioned reciprocal determinism already. Each of them also provides hints on how to intervene, labeled potential change strategies here. So some of the other important concepts are behavioral capability, which is a nice one. That's a combination of knowledge and skills.
Expectations, the anticipated outcomes of a behavior, self-efficacy, confidence. Social cognitive theory highlights the importance of role modeling. and then reinforcement and provides, as I've mentioned, change strategies to affect those different constructs.
And so we, and I think this is a nice way to design interventions that are theory-based, is to think through what are the theoretical constructs that we're trying to change. And I think about those as intervention targets. And so with our smoke-free homes intervention, we were trying to give people new knowledge and new skills for negotiating a smoke-free home or for smokers to actually change their behavior and start going outside.
We wanted to shift people's outcome expectations so they expected largely positive outcomes from having this home smoking ban. We wanted to give both non-smokers and smokers that were in the program the self-control. to create this change.
We wanted to change the physical environment so there were cues for going outside to smoke and to make it easy to go outside to smoke. We wanted the social dynamics in the home to support household smoking bans and we wanted to shift people through the stages. And so then we thought about, okay, how are we going to change those theoretical constructs?
And so when we were developing our educational materials, we were very conscious about the different pieces and how they would potentially change those theoretical constructs. For example, we have a photo novella that role models a family going smoke-free, and by role modeling that, it gives knowledge and skills related to how to do this within your family context. We have a list of reasons to create smoke-free.
free homes, some related to non-smokers, some related to children, some related to pets, some related to the smoker, him or herself. That's an attempt to shift outcome expectations. We have a challenges and solutions booklet based on our quality work, which really gives excuses people have for not smoking outside and suggestions for why that excuse isn't that great or how to overcome it, which can build self-confidence.
in overcoming these barriers. We provide stickers and signs and pledges and encourage people to create a space outside for their smoking, so changes to the physical environment. The coaching session really supports households in gearing up to have a family talk about creating a smoke-free home and the coach reinforces that, so that's kind of the social environment.
And then we use persuasion and goal setting in that coaching call as well as the written materials to shift people across the stages. So just real quickly, here's some of the materials. So if you look closely, our tagline is some things are better outside. If you look closely at that, you can see some things that are better outside. So we tried to keep it kind of light and fun rather than bashing the smoker and making them feel bad about their behavior.
And I think that's partly why we were successful. We have a five-step guide to creating a smoke-free home. It's a little hard to see what the steps are, but they roughly correspond to the stages of change from the trans-theoretical model.
Our coaching call is pretty short. It averages about 15 minutes in each stage based. And so the coach figures out where they are in terms of creating a smoke-free home, and then does some goal-setting and reinforcement and persuasion based on the stage to try to get them to take it to the next stage.
Here's the photo novella I mentioned, which is a family who has a son who's coughing. They go to the pediatrician. The pediatrician says, is anyone smoking in your home? The mom says, yeah, my mom has.
And then... The grandma doesn't want to stop smoking in the home and then eventually they are able to work through it. So it role models the change of solutions and challenges booklet I already mentioned. And then here we have a window cling, so a potential change to the physical environment in terms of an environmental cue, stickers, and then just some more information. So quickly, once we had the intervention developed, and we developed it through actually CDC funding as part of the Cancer Prevention and Control Research Network and pilot tested it.
And that positioned us to get a very large grant for us from the National Cancer Institute. We were part of the State and Community Tobacco Control Research Network. And that allowed us to do a series of randomized controlled trials. So we started with an efficacy trial. And by that, we mean ideal circumstances.
So in this case, that meant that Emory staff were delivering the intervention. We were... collaborating with United Way of Greater Atlanta, 2-1-1. And I'll tell you what 2-1-1 is in a second because I know some people don't know that usually. Then we did an effectiveness trial with North Carolina, 2-1-1.
And by effectiveness, we mean more real world. And so in that case, the 2-1-1 staff, so no longer academic staff, but practitioners associated with 2-1-1 delivered the intervention. They also had a...
different population. They had more white residents than we did here in Atlanta, and they had more rural, so beginning to diversify the participants. And then we did a replication trial in Houston area, and that was even more diverse, bringing in the Latino population. And again, it was the 2-1-1 staff that delivered the intervention.
After that, we did a national dissemination through a grants program to 2-1-1s across the country. Right now, this is just an aside, but I'm trying to write a grant to get money to test a version of it that we developed for American Indians. So 211, this has nothing to do with theory, is like 911 or 411. They're typically run by United Ways across the country. They're an information and referral system that connects people to social services.
in their community. And so people that need help, and they're getting tons of calls right now during COVID, as you might imagine, people that are having a hard time paying utilities, need to know where a local food pantry is, want to figure out how to get on SNAP, can't pay their rent. All of the social support infrastructure that a community has is cataloged by 211, and you can call.
or go to the website or text them and they can tell you how to connect to local resources. And so there's over 200 of these across the country. There's at least one in every single state and they get about 16 million callers a year. So they're a really nice partner for public health and public health I think is starting more and more.
They've promoted flu shots and some of them are helping with the pandemic right now. So I mentioned we did a randomized controlled trial here in Atlanta, and I'm just going to show you a couple slides of that. To be eligible, the participant, well, they would call 211, and then 211 would deal with the reason or the purpose of the call.
And then they would say, we're collaborating with Emory on the smoke-free home study. Can we tell you a little bit more about it? Eligible participants were smokers or non-smokers who lived with a smoker.
They had to allow some smoking in the home, and they had to live with a nonsmoker or a child. So there needed to be someone in the household to protect, and all our materials were in English. We collected data at baseline three months and six months, and we validated self-reported smoke-free home with air nicotine monitors.
This is the population that we were able to recruit here in Atlanta. It's largely women that call 211. In Atlanta, heavily African-American, so we had 83% black. You can see that education, the biggest group had a high school education.
There was a chunk that had some college and some that didn't have high school degrees. And you can look at income was very, very low. So annual household income over half were living on $10,000 or less.
And we had 80% smokers. So just quickly showing you that they like the materials. Close to 95% said they found the materials somewhat or very helpful. These were the steps we wanted them to take as a result of our theory-informed intervention strategies, and you can see that a decent percent did them.
So came up with why they wanted a smoke-free home, had a family talk. 93% did that, which we viewed as really important and probably the driver of the changes, and then a decent percentage, signed the pledge, posted the pledge, put up signs, used stickers, and then we didn't emphasize cessation much, but we did provide the information and a percentage of the smokers called the quit line. So it worked. So no one had a smoke-free home at baseline.
The first green line there is the percent that had a full household smoking ban at three months. So in the intervention, it was 30% control, it was 14.9%. And then this doesn't happen very often, but I think because the social norms are so strong around not exposing your loved ones to secondhand smoke, that we actually saw an increase between three and six months. So by six months, 40% had a smoke-free home in the intervention and 25% control. So this was a significant difference between intervention and control.
We got the same results essentially. in North Carolina, in Houston, and in the National Dissemination Trial. So it's been tested multiple times and is now listed on National Cancer Institute's research-tested intervention programs.
So our team is big. We're a lot of people involved here at Emory. And then we had University of Texas, University of North Carolina, Wash U, consultant from San Diego State, and then we had the 4211s. We had the State Health Department tobacco control programs.
in those partnering states and we had a TTAC here at Emory involved. Okay, so here's my first stopping point. And I'll answer questions, kind of general questions about theory, and then if you have any specific questions about these two examples.
So let me see if I can... Quick to expand question. I'd be curious to hear what you have found to be the biggest misconception about theory from public health practitioners. Conversely, what sorts of things can we do to make theory more useful for practice? Yeah, my take on this, and I might be wrong, but my take on this is sometimes the way we teach it, in schools of public health is we just have people memorize the theories and they don't understand deeply enough that they're practical and when they actually get a job they'll be able to use them in different ways so I think more concrete examples and I know a lot of teachers are trying to teach in that way but it does But I think in a lot of people's minds, theory is just abstract and doesn't have utility in the day-to-day practice for public health practitioners.
Also, I think right now we're pushing, generally I support this, but I think there are some downsides. We're pushing evidence-based interventions so heavily that practitioners are more often taking canned interventions or approaches that are on a list of best practices from CDC or some other agency and implementing them without thinking through behind the scenes of why is it that this program works, which I think then makes theory feel less useful, even though there usually is some theory behind the scenes. So I don't know. I'm just sort of kind of a brain dump on that question. It seems there are a lot of these behavior change approaches, I'm reading the next one, that involve positive reinforcement or other positive-based factors.
CDC Tips for Smokers campaign is well known and seems to come more from a shock, fear, negative reinforcement approach. Both approaches seem to be effective. Can you speak to the nuance of how or why both strategies can work?
Yeah, I'm not all that up on communication theories, but I know there are some There's been research on fear arousal. I think it has shown. I wish that I could have a communication theorist talk.
But I think You know, we are trying to convince people in some of our theories, like health belief model, which I know pretty well, that they are susceptible, that disease can be severe. And so we're targeting those constructs that are theory informed with fear based messages. I believe, and again, this isn't my area at all, but I think that we're viewing that as acceptable as long as there's a solution. So the CDC Tips for Smokers campaign, the solution, of course, is call your quit line, and then there's all the support infrastructure that's there.
So you can scare people, but you have to provide the support afterwards. So that's kind of my view on how those fear-based messages work. They still target theoretical constructs and then follow that kind of the chain of logic from different theoretical perspectives. I'm going to do a couple more here.
So, are you aware of any effective theories or frameworks for addressing some of the misinformation? Oh, this is a really important question. Addressing some of the misinformation that has become amplified through social media and other platforms. We could really use the answer to that right now.
I think if we looked at some of the communication theories, we could understand. why that's happening, how to counter it. I feel like we're stuck on that right now.
If anyone has the answer, type it in. You know, I don't know if us doing our own campaigns with different kinds of messages would be enough to counter that because the way communication theories work is, you know, it starts out as broad information. for the public, but then when it becomes personalized with people in your networks, it's much more impactful.
And that's what social media is able to do. So it's really tapping in, in a, we might think, a negative way to these communication theories. So the theories might be right, but how we use them to advantage, I think, is a great question that I can't completely answer. Completely agree with the need for more concrete examples to bridge theory to practice.
What steps could local or state health departments take to incorporate theories into their public health program planning beyond just following those canned evidence-based practices that you mentioned? I think for me, the... A good place to make this connection for practitioners is in program evaluation and logic models.
So I'm going to circle back to that at the end of the talk because I think it is important for practitioners, even if they are taking these canned or evidence-based approaches, they need to adapt them to their particular settings. So they need to understand how they work, what we often call those core elements or core ingredients, what those are. And those are usually theory-based. And so understanding those and how. how to adapt the strategies but keep those theoretical constructs or core elements central, I think would help.
And then developing logic models or figuring out how to evaluate interventions, I think also helps people think about theory and know that there's theory underlying what they're doing. The questions are coming in. I'll take one more and then I'll go to the next. section and then come back to these I haven't answered. What are your thoughts on mixing and matching pieces of different theories together to fit an intervention?
I love that question. I'm a big believer in mixing and matching but not everyone is. So there's kind of two camps there. One is that you dilute the power of a theory if you don't use all of it but I'm being a public health practitioner before I became an academic. And a lot of our planning models stress understanding the public health problem first.
And usually when we do a thorough community assessment, we learn, okay, there's determinants at all different levels, right? There's policy determinants, there's environmental determinants, there's individual level determinants. And as I'll talk about in a bit, our theories generally don't cover all the determinants.
And so I personally believe in taking theories that map onto different determinants or at least different levels, and that many of our interventions do need to be multilevel, which. means some mixing and matching. However, if one theory like with the smoke-free homes, their social cognitive theory did a pretty good job. So we were able to pretty much stick with that just throwing in stages of change. All right, I'm going to stop there, but I see Michelle Carvalho has the next question on my list, so I'll be able to find that spot.
Okay. Let me check the time. Okay, all right, this is a quick one. I wanted to give an example of using theory to design and evaluate a community level intervention. So this is a project that we have going on right now.
It's an international project called Gather. It's in Georgia, the country, and Armenia. So the project is Georgia and Armenian teams for healthy environments and research.
And here we're using a theory I developed with Fran Butterfoss called Community Coalition Action Theory. So just quick acknowledgement to our partners. We're working with the CDC in Georgia.
We're working with the NIH in Armenia and the American University in Armenia. And then my co-PI is Carla Berg, and she left Emory and went to George Washington. University a little while ago.
So this study is a community randomized control trial to examine the impact of local coalitions, so a public health intervention strategy, and the ability of local coalitions to promote adoption and enforcement of smoke-free policies. We're trying to advance community coalition action theory as well as local policy. public health practice by assessing how community context and coalition factors influence impact.
We're trying to contribute to the evidence base for informing public health practice in low and middle income countries, and then building research capacity for our partners and us too. So I'm not going to spend a lot of time on this particular theory. It's based on my dissertation research and Fran Butterfrost's dissertation research. So we came together to pull this theory together in the early 2000s based on what we call practice proven propositions. Having both worked in public health, consulted with a lot of community coalitions, as well as being up on the theory underlying community coalitions, we decided to develop this theory.
And so real briefly, you can see that community context influences everything. Coalitions usually start with a lead agency or a convener group. They then expand membership with a focus on diversity across sectors and populations.
They establish processes, leadership, and staffing coalition structures. If done well, coalition members are actively engaged. They pool their resources.
This creates collaborative synergy. When there's collaborative synergy, then the community assessment and planning are higher. quality, implementation of strategies is higher quality, and the strategies are at multiple levels.
This leads to changes in policy systems environments, which we label community change, which leads to health and social outcomes, as well as increased community capacity and coalition cycle through stages. And as I'm sure many of you on the call know, there's community coalitions in almost every community now across the U.S. working on some sort of public health. health issue. We have a bunch of propositions.
I'm just going to show a couple. So this is the community context proposition. Coalitions are heavily influenced by context in the community throughout all stages of coalition development. So for each box in the model we have a company propositions which are kind of like hypotheses for coalition membership. We're hypothesizing more effective coalition's results when the core group expands to include a broad constituency of people who represent diverse interest groups and organizations.
So the GATHER project, as I mentioned, is a community randomized trial. We've identified 14 municipalities in each country, randomized them into intervention and control. And the local public health. So that would be like a local health department here.
Serves as the lead agency and plays the role of convener of the coalition. So they've actually formed the coalitions. In these 14 communities, we have done a series of trainings for the local public health staff and coalition members on how to conduct situational assessments, how to make strong coalitions, how to do action planning. We taught them smart objectives and logic models and strategy selection.
They're having annual meetings to problem solve and learn. new skills, share success stories. So it's a pretty typical public health intervention, at least in the public health world I'm in, which is chronic disease prevention, health promotion. And then the local national public health people at the CDC or NIH are providing the technical assistance with monthly calls. So how did we use theory in this particular project?
Basically, it informed our training agenda. So we use theory to figure out what do we need to teach them in order to build. So about broadening membership, taught them about coalition processes that work well, communication, decision-making, how to structure coalitions, how leaders and staff should facilitate coalitions, how to create collaborative synergy, best way to do a community assessment, you know, each of the... parts of the theory really helped guide our training and this is a picture of the training in Armenia.
This is just the kind of work that they're doing. This was particularly important, well I don't know, important, interesting because these are former Soviet countries and they don't have a long history of democracy or people coming together at the local level to try to change their communities. Much more used to a top-down approach doing what the centralized government tells them to do.
So we're really curious about where this, if this very American approach to doing public health would work in former Soviet countries. And I can't, well, we're, our study's a little messed up because of COVID and because they passed national laws to create smoke-free environments, which is great from a public health point of view. But it does mean that we've had to shift gears a little bit to focus on enforcement and then closing gaps where smoking is still allowed, like in taxis and some bars. And Armenia hasn't implemented those yet.
And then the theory is also really helpful in evaluating the effort. So we've been able to take each construct from the theory, leadership, communication, collaborative synergy, community change, secondhand smoking. exposure as the health outcome.
And again, you know how I showed how we use social cognitive theory and map our strategies. Here we're taking the theoretical constructs and mapping our measures. And so we have coalition member surveys, we have key informant interviews, we have document review like their action plans and their progress reports, and we're able to map all of that information to particular theoretical constructs in community coalition action theory.
So it's providing a lot of... Nice structure, structure for the project. And I want to go through this one quickly.
So that was an example of a community-level intervention and using community-level theory. This next one is blending theory in a multi-level intervention. This was really the first big study I did that used theory. after I got my DRPH. So we used the health belief model, the theory of reason action, social network theory, community capacity, and social ecologic model in this project.
So this was in Oklahoma. That was my first faculty position was in Oklahoma. The northeast corner of Oklahoma used to be one of the largest lead and zinc mining regions in the world. So this is Ottawa County. It's a terrible legacy of contamination on Indian land.
And so there are mine tailings, which the locals call chat, filled with heavy metals, arsenic, cadmium, as well as lead. There's hundreds and hundreds of acres, millions and millions of tons. The Quapaw Nation. owns much of the land. There are eight other tribes in the area and the Cherokee Nation is right below this part of the state.
It's a Superfund site and it was a Superfund site for water when we began the project and there are multiple sources of lead. It's in the dust, it's in the soil, it's in the chat, and it's in what they speak. I don't need to tell this group that that's a problem. When we did this study, this was before CDC had lowered the threshold of what's considered threshold of action for lead, which I think is now at 5 or even lower, but at the time it was at 10. So with a threshold of 10, we had lead poisoning at 26%. So if we had used a lower threshold, it would have been 50, 60, 70%.
of people that had elevated blood blood levels or children. So here's just to show that it's acres and acres. Anything you can see that's not greenish brown is a chat pile.
Here's a picture I took when I had a better camera. I was back there a couple years ago with my iPhone and so this is what the chat piles look like. They're really from the road just for a sense of scale. hundreds of feet high.
When we started the project people were living in and among the chat piles and it was a recreational destination kind of like the sand dunes of Colorado I like to say except this gravelly consistency with heavy metals in it. We were funded by National Institutes of Environmental Health Sciences. Our goal was to decrease elevated blood lead levels and change preventive behaviors and associated beliefs in American Indian children and their caregivers, and then to increase the capacity of the tribes.
So we used theory and three main ways to inform our general intervention approach. We were outsiders. We were down in Oklahoma City.
We were, I was a northerner. And. We were white, and so there were a lot of lines that we had to cross. We were city, they were rural.
And so we needed an intervention approach that would allow us to get involved with the community pretty quickly. We wanted to use theory also to identify steps in the behavior change process. What short-term outcomes should we target? We knew the longer-term outcomes. And then what variables do we want to measure in our evaluation?
So we landed on LA. Health advisor intervention where we recruit individuals who serve natural helping roles in their social networks. So these are people whom others turn to naturally for advice, emotional support, tangible assistance. So they occupy key spots in the interconnected social networks in a community.
There is a theory, natural helper model. that posits that this approach creates linkages between the lay helping system and the professional support system, and each benefits from the others. So we asked the tribes, we explained what a natural helper was, and then we asked each of the tribes to identify five people that would be good lay health advisors, and we recruited them and trained them to be our lay health advisors.
They call themselves the Society of Clan Mothers. This is what they did. I'm going to go quickly. They attended this training. They had monthly dinner meetings rotated among tribal headquarters.
They developed an action plan. They had work groups for different projects. They did all kinds of activities. I'll show you in a minute. We did have them fill out a form every month as part of the process evaluation.
They received a stipend. We collectively developed policy-related objectives. It was pretty clear. that we couldn't just focus on individual behavior change.
We had to deal with the structural issues that people were living in in the midst. And so we wanted to pass or make progress in passing an ordinance to restrict the sale of CHAT. We wanted the legislature to support EPA's Superfund cleanup. We wanted the daycares to implement prevention curricula. We wanted Indian Health Service to routinely screen and tell parents their child's lead levels.
And we wanted to make it easier for tribal members to follow the proper house cleaning techniques, which involved HEPA vacs. And so we wanted those to be available to the tribal offices. These are just the general behaviors that CDC and EPA advise in a lead-contaminated environment.
So lots of hand-washing, face-washing. We had to throw in, play in grass or paved surfaces because of the... Chat was in the roads and in the parks and everywhere, so where children played was important. Blood load testing once a year, a healthy diet, and then certain kind of house cleaning. So our clan mothers and clan fathers educated people through social networks, sponsored interactive booths, developed educational materials, gave presentations, pilot tested the curriculum, supported youth.
So we didn't teach the clan mothers and clan fathers theories, but for the most part we could apply theory on top of what they were doing, but we didn't push that in any way. Here are the policy things they worked on, passing tribal resolutions to support policy change, letters to the editor about policy change, organizing petitions and showing up at county commissioners meetings to demand changes, pushing this Ottawa Reclamation Authority, which is this weird government entity that had meetings that public was allowed into, but no one knew when they were. Clan mothers went to those meetings, made demands, and then educating decision makers about the need for a Superfund match and other policy-oriented changes.
So we used a lot of theories in this project. So we were using social network and social support theory as the basis for the lay health advisor approach. The idea that key individuals play natural helper roles and these networks are linked. We used the health belief model to figure out, okay, we say we want to change behaviors.
What do we mean by that and how are we going to do that? So there we took ideas from health belief model, perceived susceptibility, perceived severity, barriers, benefits, and self-efficacy are the ones we targeted. It was a challenging situation because people, parents...
and grandparents, elders had grown up there in the lead contaminated area and they didn't believe originally that it had a health effect. They didn't feel that they had been affected by the lead poisoning and then you know it's hard to tell people that they probably were. So anyway we had to overcome a lot of a lot of things like that and so we used theory to figure out what exactly are we trying to persuade people to believe. Theory of reasoned action. I was uncomfortable only with health belief model because I knew there was a strong social element.
Health belief model acknowledges that only indirectly, and so we wanted to target subjective norms that became normative to try to prevent lead poisoning and engage in these behaviors. For community capacity, obviously we wanted to strengthen the tribe's capacity to deal with this issue, and community capacity isn't quite a theory. It's a list of constructs.
But it was helpful in figuring out what exactly do we mean when we say we want to strengthen tribal capacity. And then the social ecologic framework helped us think about everything altogether. How are we changing individuals, social networks, organizations, community, and policy? We had a very crude, sorry the lines aren't showing up, but a pretty crude conceptual model. for the project.
You can look down at the bottom and you can see that we had identified changes that we wanted to see that some of them are theory-based, some of them are just practical at each level of the social-ecologic framework. We did see success. That was the study.
A lot of my real-world studies get kind of messed up because Superfund, which of course was super important, they were bulldozing front and backyards and putting in clean soil. So it was a little hard for us to figure out what was the intervention versus our intervention versus the huge environmental change. But that was in just a small part of the community, and we were looking broader.
And we were able to look at American Indians or Native Americans versus whites in the same geographic area. And so we did see significant decreases in blood blood levels, increases in the behaviors that we were targeting, some of them. And then changes in the constructs from the health belief model, perceived susceptibility, perceived benefits, and self-efficacy.
We also had policy successes. I guess there was one. I don't know why this isn't showing up, but just to kind of bring the end of the story to light, it did become... The Superfund effort was expanded and that led to a voluntary buyout and then eventually the federal government bought the heart of the Superfund area out and so now nobody lives there.
The problem was just too big. to fix with smaller remediation efforts. They just had to buy out the area, fence it off, and that's kind of where it is right now.
This is one of our outcomes for tribal capacity, and so we use social network theory to show that there was strengthened capacity. And so one of the dimensions of community capacity is inter-organizational networks. We did a network analysis at the beginning of the... project, so this was in the 90s. It's maybe a little hard to see, but you can see some of the tribes aren't in the social network at all.
This was a social network specific to collaborating on lead poisoning prevention. There was one tribe that was sort of the gatekeeper between the public health agencies and the environmental agencies on the left and the tribes on the right. And then fast forward.
to 2005 and you can see that all the tribes are actively networked in, dealing with how to address the LID problem in the area and the public health agencies and the environmental health agencies are right in the mix interacting with all of the tribes. And so we were viewing that as an indicator of strengthened community capacity. This is what it looks like now in the... heard of the Superfund area. There used to be a house here.
So this was an example of how social ecologic theory, social ecologic framework and theory align. I think theories can provide additional detail for what to target and how within each level of the social ecologic framework. So there's theories related to public policy, there's theories related to community capacity to community readiness to community coalitions. So at each of the levels you can identify specific theories. So getting back to the question about can you pick and choose from different theories, this is another example of how to combine theories.
Put, apply different theories to different levels if you have a complex intervention like this one was. And then theory can also help to understand how the levels interact with each other. Although, This is an area for growth. I don't think our theories do a great job of that right now, of helping us understand how the different levels interact with that.
When you try to think through study designs that do that, it's very complex because of the unit of analysis issues. So, I'm going to stop again and see if there are any questions. I'm just going to take a few. There seems to always be interest in demonstrating health outcomes through evaluation. How can we better communicate to partners that evaluation outcomes link back to theory?
Yeah, that's a nice question. And in my mind, some of the public health outcomes we're interested in take a while to achieve. This is one of our arguments for using logic models, but I think it's also an argument for using theory.
If you can specify your theory of change, and I'm using theory in a different way there, your model of change, which can be informed by theory, I think it becomes obvious that before you get to behavior change or before you get to policy change or before you get to environmental change, there's shorter-term outcomes that are worth measuring to see if our logic for how to create change holds, and that's a really nice place for theory to apply and to convince practitioners and partners that it's worth thinking through the process of change, our models and theories of change, and how social and behavioral science theory can contribute to that. I'm following back to the... Earlier, Jane, regarding social media, it struck me that the strategies that social media used to keep viewers engaged provide an environmental-based reinforcement.
Yeah, I mean, I'm kind of new to Instagram, and I like to see how many likes I get. I don't have many followers. But anyway, definitely, they're feeding that need we have for social reinforcement, I think. shares and likes and all of that.
So that's a really good point and I'm 100% sure that that would fit in with some of our theoretical models. I'm going to kind of jump to the bottom. What are strategies you recommend to maintain momentum through years three through five regarding community level coalitions? Often I feel the natural enthusiasm subsides or challenges impact morale to make it successful. Yeah, I mean that's a whole training on community coalitions, how to maintain a coalition over time and a lot of the coalitions in our communities were set up.
10, 15, 20 years ago. And so people are getting kind of worn out if they're not re-energized. I think success fuels success.
That would be my main answer there. And then coalitions often recycle to take on new issues when they get new grants. And I think just acknowledging maybe the stages of development, it's okay to regroup, lose some members, refocus yours.
strategies and things like that. But Fran Butterfoss, she's close to retiring, but she does trainings on community coalitions. And I think that's the area where she provides quite a bit of guidance.
Let's see, regarding community coalition action theory, is there evidence, is there general guidance, evidence based? Recommendations regarding the ideal size of coalition membership. Thank you. I would say not exactly, but we do recommend and research shows that if you have a subcommittee structure, work groups working on particular issues, that you're more likely to be successful.
And so if you have a giant coalition, you know, 60, 70 people, it's really critical that folks get engaged. And so you usually need to do that by having smaller groups, and work groups are really nice. nice way to do that either each work group takes on a subtopic or an initiative and that can and that can keep people engaged this is the last one I'm going to take for this section and then we got one more pretty quick section you mentioned not influencing clan mothers based on theory but that you were able to map theory on top of what they were already doing generally speaking What do you feel comes first, the theory or the intervention design?
In practice, it feels as though the intervention comes first and then a theory that fits is identified. What do you recommend when there are pieces that do not fit into an existing theory or when an intervention doesn't seem to be supported by a theory? Yeah, I think about that some because I don't always map. I don't always start with the theory because I'm, I mean, these theoretical concepts are so ingrained in me now that, you know.
I'm able to identify the theory that matches with a lot of things that we do. So that's an interesting question. I think it's true. As I've mentioned, I'm a big believer in mapping the change process. I found that when practitioners or academics, for that matter, are creating interventions, sometimes an intervention can feel off.
I just feel like, oh, that won't work. And a gentle way to help people think about theory and think about the likelihood of something working, those sometimes go hand in hand, is to have them talk through how do you think that change is going to work. So, you know, a big one is health fairs or awareness campaigns and never moving beyond that. You can go through a process where you have them think out loud about how. Like a lot of our communities in Georgia and Armenia are doing flash mobs.
And so we had to think, okay, there's nothing wrong with flash mobs, but how are flash mobs going to get you to tobacco control policy change? And so help kind of work with them to connect the dots. That might be a first step. There's nothing wrong with awareness, but think through how awareness leads to an outcome that you're interested in. So that's only somewhat answering that question, but I think that's a good question.
All right, I'm going to do my last little section. We have 15 minutes left. This one, I'm going to skip some of the slides, I think, but this is my last example, and this was a collaboration that we did with American Cancer.
society to try to increase cancer screening and safety net systems. and we had a big team on this. They funded safety net systems, by that I mean federally qualified health centers and some large urban hospital systems to implement evidence-based practices to increase cancer screening.
It was a five million dollar initiative that gave grants of 40 to 80k. So this is a lot like CDC funded projects, except I think you often give bigger dollars. And they did have an evaluation team that did an evaluation. So they did site visits to nine of the grantees, and then they brought us in because they wanted to do something a little more sophisticated in terms of data analysis and get a peer-reviewed publication.
So this example is actually going to answer the last person's question about how sometimes things are done without theory, and then you can put theory on the back end, which is actually what we did here. So these are from the community guide that CDC supports, so evidence-based practices for increasing cancer screening. This is the site visits that ACS did, and they did key informant interviews with leaders, program implementers, in each of these nine systems that they visited.
So they had multiple interviews in each setting. This is just to show that each of... the safety net systems did a different combination of intervention strategies. So again, this is real similar to a lot of the work CDC does where you provide a menu for your grantees and grantees select which items on the menu they want to implement. And then we were able to, this was crude, but we were able to categorize implementation into high, medium, and low based on whether their goals were met, how many people they were actually able to screen.
And then we had a likelihood of sustainability indicator in there as well. So our study goal was to identify factors that explain the variation in levels of implementation. So some, why was it that some were high, some were medium, and some were low? We decided to use this theoretical framework, which is really hot right now in the world of implementation science, consolidated framework for implementation.
I think I mentioned this at the beginning of the talk, saying that it had five buckets. And so here you can see the buckets, process, intervention characteristics, outer setting, inner setting, characteristics of individuals. So this is a theoretical framework that helps us understand when we have an evidence-based intervention, or actually an innovation, but it's more specific to evidence-based interventions, and it gets implemented. What affects the quality of that implementation? And you can see the constructs within each of these buckets.
So like under outer settings, it's patient needs and resources. This was developed by the VA, has a real health care focus. When I use it in public health, I just say client needs or population needs resources, cosmopolitanism, peer pressure, external policies and incentives.
Inner setting. structural characteristics, networks and communication, culture, implementation, climate. So lots of constructs within each of these domains.
So we were able to qualitatively code the transcript using those constructs and then we rated the constructs within each case by magnitude and valence. So by magnitude was how many of the people interviewed in that setting talked about peer pressure. or talked about whether the intervention was trialable or not.
Could it be pilot tested? And then the valence, was that viewed as a positive or negative impact on implementation? And then we look for patterns across the nine cases. So we came up with the matrix like this. So green was high level, yellow was medium, red was low.
You can see the theoretical constructs on the left. And then we rated each, as I just mentioned, by magnitude and valence. So just to zoom in, then we did what we called pattern matching, looking for patterns across cases.
And here you can see that there seemed to be a pattern and that the high-performing sites viewed the intervention as pilot testable. They could try out parts of it, learn from it, try it again, which is theoretically called trialability. And the lower levels of implementation, folks did not view the intervention as trialable, more than they actually do any of that sort of process implementation. And so that was a distinguishing factor is what we called it between the high and low performing sites. So we were able to identify a few of those, whether the intervention was adaptable, trialable, leadership engagement, attention for change, access to information, formally appointed implementation leaders, and et cetera.
So in this case, the laying a theory on top of already collected data. allowed us to make sense of the information in a more meaningful, systematic way. This is my last point.
I've mentioned logic models a couple times, so I just wanted to close with how do theories and logic models align? So this is back to the Tribal Lead Poisoning Prevention Project, and I don't know how to highlight in Adobe Connect, but if you look at the short-term outcomes in the blue boxes, You can see theoretical constructs there. So you can see increased belief that children are susceptible.
That's health belief model. Increased belief that children are susceptible. Increased belief that elevated blood levels are harmful. So that's severity. So these are constructs from health belief model.
And you can see if you're familiar with how logic models work of how it's really the short-term outcomes that link our children. activities to our longer-term outcomes, which are usually changes in policies, environments, and behaviors. So that's kind of the sweet spot for the utility of some of our theories, I think.
This is just another example. I'm not going to get into this project, but we're doing an evaluation of Two Georgias Initiative. It's a coalition-based health equity initiative in rural Georgia. And here in red, you can see how we use theory.
community capacity theory to figure out, okay, we say that the initiative is going to increase community capacity for equity. What does that mean? How do we measure that? And the theory helped us get specific about that by emphasizing skills, leadership opportunities, networks, resources, and critical reflection. And so we're trying to measure each of those as part of our evaluation of that initiative.
So just some closing thoughts here. What's next for theory? I think about this some, partly because I teach the PhD theory class in our program.
So I have smart young people that I have conversations with with regularly. So I feel like we need greater testing of theories or conceptual models that pull from multiple theories that cross levels of the social-ecologic framework. So I showed you in some examples of, you know, how we use theories at specific levels, but there aren't that many theories that actually cross levels.
There are some, but we know in public health that the problems are complex. They're influenced by determinants at multiple levels, so having our theories kind of catch up to that, I think, is really important. There's a strong desire in the field to put more energy into these statistical methods called mediation and structural equation models to look at the whole. Instead of looking variable at a variable at a time, map out the causal pathway that's supported by theory and then test that statistically to see if all the interconnections work as you hypothesized or as the theory would predict and then We just don't have that many theories at the higher levels of the social-ecologic framework. So when I look for community theories or policy change theories, there's a few, but it feels like we need more work done in that area.
Okay, that's it. Maybe take, I was told it was okay to end early, but I'll just look at the list of questions and see if there's a couple more that we should. So weird for you all just to be little lines in the attendee box. I appreciate your pragmatic approach.
That must have been the combining theories one. If you perchance get time, can you talk about the guide to community services and how if you aim to address gaps or strengthen specific areas? I can answer that, but not really from a theory perspective.
Our smoke-free homes intervention, well, that might be, that's the U.S., that's preventive services. So Community Guide to Preventive Services, I think of that as associated with the Community Guide. Again, I think just more evidence for the environmental interventions, I think we often have to label them promising practices because they are. hard to study. It's hard to show change at the higher levels of the social-ecologic framework, so just more work in that area.
I think more work on social determinants of health. I know the cancer division has a call out right now to begin to understand racism and its role in social determinants of health and interventions that influence the social determinants of health. I feel like that's an area where the field and in general.
I'll contribute to the extent that I can, but we need to be moving more concretely and we are pilot testing some work in through our Emory Prevention Research Center to try to create community change related to policy and systems change using community organizing as opposed to community coalitions, even though I love community coalitions. And I'm gonna Close with this question. Can you talk about how your smoke-free homes programs is interfaced with the HUD smoke-free rules? Yeah, that's a good question. So I didn't get into this, but as part of that same funding, we were, we had, it was a big grant.
It was like $7 million. So we were able to do some work that directly coincided with HUD's work. And so we interviews, we interviews, interviewed early adopters of smoke-free policies in public housing.
affordable housing in Georgia and North Carolina. And so we were able to gather really deep understandings of the change process. Our smoke-free homes project, however, is family by family by family. So it's not what CDC is advocating in terms of policies at the apartment or the higher multi-unit housing level. However, we think, and we're writing this into the proposal I'm working on now with some tribes.
that we could soften up communities or decision makers by first implementing our smoke-free homes program, which would get specific families units to go smoke-free, and then in very resistant settings that might convince decision makers that, yes, they can actually implement these policies where it is still voluntary. So the HUD rules, as whoever wrote that question probably knows, is just conventional housing. And so there's some other types of public housing and lots of affordable housing that's not covered by those rules. And some decision makers are still resistant to going smoke-free, and some are very open to it. Tribal governments, the tribal partners I'm working with, it's variable.
But a common refrain is we can't go smoke-free. People, you know, it's not fair. People are too resistant. And so we're going to start.
We'll see how it goes with our smoke-free homes intervention adapted for tribes and then see if that can change community readiness to go at a higher level for higher level policy change. Okay, well it's three o'clock. So thank you everybody. Thank you so much, Dr. Kegler, for just the breadth and depth of your experiences and presenting those. We really, really appreciate it.
We will get back together on March 3rd for the next Preventive Medicine Grand Rounds. Thanks again, Dr. Kegler. Take care. Stay strong. Sure.
It was fun. Bye, everyone.