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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2005.083188
FRAMING HEALTH MATTERS |
William C. Livingood is with the Duval County Health Department, Institute for Health, Policy and Evaluation Research, Jacksonville, Fla, and the Department of Pediatrics, Health Science Center, University of Florida, Jacksonville. Jeffrey Goldhagen is with the Division of Community Pediatrics and the Department of Pediatrics, Health Science Center, University of Florida, Jacksonville. William L. Little is with the Sarasota County Health Department, Sarasota, Fla. Jennifer Gornto and Tao Hou are with the Duval County Health Department, Jacksonville.
Correspondence: Requests for reprints should be sent to William C. Livingood, PhD, Duval County Health Department, Institute for Health, Policy & Evaluation Research, 900 University Blvd, Jacksonville, FL 32211 (e-mail: william_livingood{at}doh.state.fl.us).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We identified, described, and defined models of academic institution–public health agency partnerships in Florida. The study involved a mixed-method research design using data collected from a survey of 67 county health department (CHD) administrators and directors in Florida, in-depth interviews of key informants, and reviews of relevant Florida statutes and other archival data providing context for the partnerships.
Fifty-one of the CHDs (76%) participated in the survey. Most reported formal agreements involving 50 different academic institutions. The partnerships were perceived to enhance the local public health system’s capacity. Recommendations focus on the need for a multitiered system for recognition of the partnerships and expansion of federal support for partnership beyond existing approaches.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Following the Institute of Medicine’s recognition of the importance of collaboration to the future of public health,1,2 partnerships between public health agencies and academic institutions have received increased attention. Most of the partnerships described, however, have been collaborations related to single specific issues or services.
Although these collaborative activities are wide-ranging (emergency preparedness,3,4 disease prevention and control,5–8 reducing health disparities,9 hospices,10 minority health,11 minority workforce recruitment,12,13 rural health,14,15 maternal and child health,16 environmental health,17,18 education, research, and service,19–23 and so on), they do not provide a holistic or systems view of academic institution–public health agency (academic–agency) partnerships. Most assessments of these relationships have been conducted by public health academic institutions and primarily reflect the faculties’ own reports of success,24–35 as do recent assessments involving schools of nursing36–44 and medicine.45–47 Third-party evaluation is rare, and little is known of what the leaders of health agencies think about the value of these partnerships to their organizations and to the health and well-being of the communities they serve.
The growing interest of schools of public health in these partnerships can be traced to the 1988 Institute of Medicine report The Future of Public Health, which concluded that "schools of public health have in recent years become somewhat isolated from the field of public health practice."1(p128) Schools of public health responded by focusing more on practice,48–50 but the notable academic partnerships that emerged have been with state health departments.51,52 Third-party assessment of academic institutions’ progress in forming partnerships with local public health agencies has not been optimistic. According to a recent study by the Health Resources and Services Administration on the public health workforce, "While there are a few examples of successful collaborations between schools of public health and public health agencies at the local level, schools of public health, in general, have done a poor job of partnering with these agencies."53(p4)
The "academic health department" concept,54 a robust model for collaborations between public health agencies and academic institutions, has reinvigorated interest and enthusiasm for expanded academic–agency partnerships.55 These collaborations are similar to the relationship between teaching hospitals and medical schools in academic medical centers. Teaching hospitals are well established in American society, with volumes of literature discussing their relationships with communities and academic institutions (see, for example, Meyer et al.56 and Naughton and Vana57). Applying the academic medical center model to public health, a health department would become a center for advanced public health practice where university faculty would serve as both public health agency staff and university teaching and research faculty. This model is well developed at the state level in New York and Arkansas by affiliations between the state departments of health and schools of public health, but its status at the local level is not as well defined. Keck’s54 description of partnerships that provide for joint appointment of faculty or staff appears to be fundamental to the emergence of this model for public health, but a paucity of literature limits insights into best practices, characteristics, or definitions of what constitutes an "academic health department."
In view of the increasing interest in academic health departments, and the scant data related to their development, we implemented this study in 2005 to define the current status of collaboration between academic institutions and local health departments. The study was catalyzed in part by the need for the Florida Association of County Health Officials (FACHO) to respond to questions from the Florida Department of Health (DOH) about the importance and legitimacy of these relationships. We attempted to (1) identify and describe models for academic–agency partnerships throughout the state, (2) assess health department directors’ perceptions of the impact of these partnerships on core public health functions, and (3) identify guiding principles or best practices for their development. The study involved a survey of all county health department (CHD) administrators and directors in Florida’s 67 counties, in-depth interviews of key informants on academic–agency partnerships, and a review of Florida statutes and other archival source material that define and govern the agencies and institutions involved in these partnerships.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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A mixed-method58 research design was used to collect and analyze data for this study. Mixed method refers to the use of both quantitative and qualitative methods of data collection and analysis. Quantitative and qualitative data were obtained separately, and the results were then combined by methods derived from metasynthesis analytic approaches,59,60 qualitative research methodologies for combining multiple studies. Because context is an essential component of metasyn-thesis and the interpretation of results, the circumstances under which the study was conducted were included in the analysis of both the survey and interview elements of the study. Three questions framed the research agenda:
- What models have emerged for academic–agency partnerships in Florida?
- What is the perceived value of academic–agency partnerships?
- Are there recommendations, principles, or best practices that can be identified to support the further development of academic–agency partnerships?
Data Collection
Data collection for the survey of county health officers was through an online survey accessible only through the Florida DOH intranet. The survey instrument was constructed from the notes taken during a discussion of potential research questions at a meeting of CHD officials. We then revised the survey questions with input from the FACHO leadership and placed them online using ASP (Active Server Page) and Microsoft Access 2000 (Microsoft Corp, Redmond, Wash).
CHD directors were contacted through the DOH e-mail system and invited to participate in the survey. The response rate was exceptionally high for online surveys: 76% (51 of 67) of CHDs participated in the survey, with the department director or administrator completing the survey in 90% of the cases and a designated official completing the remainder. Three officials completed faxed versions of the survey.
Survey Questions Asked in Interviews With Key Informants on Academic–Agency B Partnerships: Florida, 2005
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FACHO officials identified 7 key informants (not including themselves) whom they regarded as having been major leaders in the development of partnerships in Florida. An interview schedule (the sequence of questions, with examples of probes or follow-up questions) was developed in collaboration with the FACHO officials (see the box on this page). Interviews with the key informants were conducted over the phone. A research associate with a master of public health degree, located in the Duval CHD Institute for Health, Policy and Evaluation Research, conducted all but 1 of the interviews. Interviews were recorded and transcribed.
The archival records that we used primarily focused on the current legal foundations for public health and academic institutions in Florida. In particular, the statutes governing the institutions of concern to the study were reviewed. In addition to the statutory foundations for the institutions, the official Web sites for the governing authorities of academic institutions were reviewed for descriptions of the current status of those institutions.
Analysis
We analyzed the responses to the CHD officer survey data, primarily using descriptive statistical analytic tools provided by SAS version 8.2 (SAS Institute Inc, Cary, NC) and Excel 2000 (Microsoft Corp). Frequencies and percentages were calculated, and Excel was used to graph the data.
We analyzed responses to the in-depth interview questions using qualitative methods for summarizing narrative data. We analyzed and organized the narrative using predetermined thematic categories associated with the questions and then reanalyzed it using the themes that emerged from the data. Following categorization of the themes, the narrative was reread to identify the themes, and segments of the narrative reflecting the themes were abstracted electronically and placed in categories by theme. Each theme was then examined for consistency and contradictions. Preliminary analysis was conducted by the research associate who conducted the interviews.
Archival records, primarily Florida statutes and Internet information, were reviewed and analyzed for their relevance to local public health systems. The information was then summarized to provide descriptions of the different institutions and the legal mandates and enabling legislation that have influenced the development and evolution of the partnerships.
The metasynthesis was conducted through the use of analytic techniques derived from qualitative research,61–64 primarily thematic analysis. Critical themes that emerged from the different sources of data were identified. The data from all 3 analyses (Web-based survey, key informant interviews, and archival data) were then analyzed for information relevant to the themes. The data and narrative were examined for consistency and contradictions within each theme. The themes were then used to organize the results for the report and provide a foundation and framework for the conclusions. Two authors (W. L. and J. G.) and 2 FACHO officials triangulated data through analysis of interview notes, archival records, and survey data. Findings and conclusions required the approval of all 4 analysts.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We present the results of the meta-synthesis using the themes that emerged from the analysis as organizing constructs. The survey and in-depth interview results are presented in the context of the following themes.
Context and History
Florida has a well-organized system of public health that integrates state and local government. Each county has a local health department that is coordinated as part of a statewide system by the state’s DOH, an executive branch agency. The authority of the CHD to function in each county is established through a contractual agreement between the DOH and each county government, as stipulated by Florida statute. This system facilitates both effective coordination of CHDs on a statewide basis and local autonomy and decisionmaking to address local issues.
The unique arrangement authorizing each county to maintain a local health department that is responsive to local governments and communities has continued to evolve with respect to their relationship with the state-level coordinating agency (the DOH). By Florida statute, local governments approve the appointment of CHD directors and CHDs have separate budgets, but state legislation also makes clear that citizens’ interests are best served if CHDs are coordinated by the state DOH. Over the past several years, the DOH has increasingly centralized the administrative infrastructure required by CHDs to function (e.g., human resources, finance and accounting, information technology, and contracting). This evolving centralized infrastructure, which includes increased state control of local academic–agency partnerships, could impede the CHD’s capacity to respond to the contexts, issues, needs, and resources of the local communities they serve.
Florida’s post–secondary school academic structure includes both public and private institutions. Eleven institutions are listed by the Florida Department of Education as public institutions, and another 28 are listed as independent (private) colleges and universities that vary in enrollment. There are also 28 community colleges in the Florida community college system, many with multiple campuses (n = 52). These institutions are well integrated with the public university system.
Interviews with key informants revealed that the early partnerships between academic institutions and agencies developed out of concerns about inadequate training of the public health workforce. There was a "lack of formal public health training among workers at the health department." The partnerships emerged "through a realization that employees of the state health department had little to no formal public health training." They also "developed because of the importance of field experience for students seeking their MPH degree. There was a lack of field experience for public health professionals compared with nursing and medicine."
Florida has grown from 1 accredited public health program in the 1970s to 4 accredited programs and 1 accredited school in 2006. Additionally, 2 institutions are in the process of obtaining school accreditation, and 2 are obtaining program accreditation, which would make a total of 8 accredited public health institutions (1 program is converting from program to school, which will not affect the net number of institutions).
Nature of Agreements
Academic–agency partnerships can be traced to early collaboration beginning in southern Florida in the 1950s, leading to formal relationships between a CHD and the School of Medicine at the University of Miami in the 1970s. This early agreement focused on providing primary care physicians with public health training and MPH degrees. Since that time, partnerships have grown extensively, with most CHDs now having formal agreements with colleges or universities. Among the CHD directors and administrators responding to the online survey, 82% indicated that their department had formal relationships with academic institutions such as colleges or universities, including junior and community colleges.
Formal agreements primarily take the form of memoranda of agreements and contracts. Most survey respondents (88%) said that their CHD used memoranda of agreements as the primary means of establishing the formal agreements, although 29% also used contracts; many respondents (19%) indicated that their department had more than 1 type of formal agreement. Two respondents said that their CHD used the DOH statewide model agreement for internships as formal agreements.
Collaborating Academic Institutions
Many CHDs had relationships with multiple academic institutions. Of those reporting formal agreements, 21% reported relationships with 5 or more institutions, 29% with 3 or 4, 19% with 2, and 29% with 1 institution.
Fifty distinct academic institutions were identified by the CHDs with which they had formal agreements. Seventeen institutions were identified by more than 1 CHD. Three large public institutions had formal agreements with relatively large numbers of CHDs. The University of Florida was identified by 13 CHDs, the University of South Florida by 12, and Florida State University by 11. The University of North Florida, Nova Southeastern University, University of Central Florida, and University of South Alabama were identified by 5 or 6 CHDs. Another 10 institutions had agreements with 2 CHDs. The other 33 identified institutions (including 15 community colleges and 2 junior colleges) had an agreement with 1 CHD. Although most identified institutions were in Florida, 5 institutions were in other states, with the University of South Alabama being notable for agreements with 5 CHDs.
Academic Institutions’ Services to County Health Departments
Most CHD directors and administrators (55%) reported that they had formal agreements for academic institutions to provide services to their CHDs. Fifty-four percent of the 28 CHDs receiving such services reported that the academic institutions were paid for their services through a combination of various funding sources, including federal or state grants. Approximately 40 discrete services were identified; they included educational services (such as continuing education for staff), research services (such as evaluation or community assessments), health services (such as primary care), and capacity building of the local public health system (such as infrastructure development or faculty service on technical advisory committees; Figure 1
).
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County Health Department Services to Academic Institutions
Most CHDs provide education services to the academic institutions in the form of sites for field experience or adjunct faculty for teaching in the academic programs (Figure 1
). These academic programs cover an extensive range of disciplines. A substantial proportion of CHDs support development of capacity through consultative support for developing curricula or health policy. A few CHDs provide health services such as primary care or prevention of sexually transmitted diseases (STDs). Of agencies that reported providing services to academic institutions, only 6 were paid for those services. The CHDs provide considerably more educational services to the academic institutions than are received from them; however, CHDs receive research services from academic institutions while providing none (Figure 1). Many of the early efforts related to the development of academic partnerships focused on developing MPH programs and preventive medicine residencies. As the partnerships have evolved, recognition has grown that a broad range of academic disciplines could benefit, and that the public health system would profit from greater exposure of many health professions to public health training. According to 1 key informant, "Education should not be confined to physicians; we had a southeast training program for nurses, nutritionists, laboratory personnel." This expanded view of public health education is echoed in the Institute of Medicine report Who Will Keep the Public Healthy?2
Enhancement of Public Health Systems
Collaboration between CHDs and academic institutions is perceived to improve the public health system and increase the local community’s public health capacity to serve. "These partnerships are important to advancing not only the assessment of public health problems but coordinating the delivery system to deal with public health problems," said 1 key informant. HIV/AIDS was noted as 1 specific area of improvement that resulted from the partnerships.
"The relationship has grown and there are ongoing partnerships where the [county] health department works with the university to find the best people for the public health needs here. That has expanded beyond just the HIV service delivery side but into a joint collaborative research program that is mostly targeted for HIV, STD, and other communicable diseases," said 1 key informant. Credibility is also enhanced, another said: "There is credibility in publications with multiple agencies contributing (for example a publication where the collaborators are from the [county] department of health and a university). It gives it much more credibility."
The services provided by the CHDs to academic institutions are perceived as central to CHD functions. CHDs providing such services reported that the collaboration contributed to the public health system (95% of these CHDs), the mission of the health department (86%), and core public health functions (84%). The 55% of CHDs receiving services from academic institutions reported that the collaboration contributed to the public health system (100% of these CHDs), the mission of the health department (100%), and core public health functions (89%).
Research
With the public health community’s growing acceptance of the 3 core functions (assessment, assurance, and policy development) and 10 essential public health services (monitor, investigate, educate, mobilize, develop policies, enforce laws, ensure health care and services, ensure competent workforce, evaluate, and research), local health departments need to enhance their own research skills or acquire these skills through other means, such as partnerships with academic institutions. Public health measurement sciences such as epidemiology and biostatistics are essential to all 3 core functions and serve as a foundation for many of the essential services, including monitoring, evaluating, and conducting research.
A stereotypical view of research, in which academic institutions do research and CHDs implement programs, was often expressed. "We are primarily a research organization, and public health is much more a program implementation group, and so it kind of makes for a pretty nice partnership when it works well," said 1 key informant. "I don’t [see] the downside of that."
Others think that research should be shared by health departments and academic institutions. "There are people doing research in universities and health departments, and research going on that all entities should know about. It is important to keep up on the science," said a key informant. Regardless of whether or not research is a shared responsibility, partnerships are viewed as critical to the advancement of the science of public health: "State public health workers cannot do it alone; we must rely on community-based partners," said another key informant.
However, only 19% of CHDs responding to the survey reported that services provided by academic institutions included research services such as evaluation or community assessments. Some see the formal MPH and preventive medicine programs as a solution: "Training programs in preventive medicine are necessary to achieve the types of public health and services delivery research [that are needed]," said a key informant.
Barriers and Challenges
Despite the perceived benefits of these partnerships, they face barriers and challenges to implementation. Clearly, the partnerships must be perceived to be mutually beneficial. "[I] think the challenge and barrier is that there might be something about the partnership not being a good fit. Both groups have to have similar goals, and both groups have to benefit from the partnership," said a key informant. What comes first—the partnership or the enhanced staffing—is also an issue. "Generally speaking, one of the biggest challenges was getting qualified and educated staff at the health department," said another. The partnership aids in obtaining more highly qualified staff, but it is the highly qualified staff that also facilitates the partnership.
Other issues of concern included budgets, the arrangements for funding the partnerships, and liability. "The only problems we have had are with things that are out of our control and protecting our organization from liability issues," said 1 key informant. There is also a need for a clear vision and purpose: "Sometimes agencies don’t have a clear view of what they want done," said another.
Resistance to change at either the local or state level can be a major impediment to greater collaboration and diffusion of the academic health department model. "Problems with health departments—those without proper training are resistant to change," commented a key informant. The increasing centralization by the Florida DOH of the core functions and essential services of the CHDs might contribute to the expanded development of local capacities, but it could also pose a threat to innovation associated with the evolving models of academic health departments.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The importance of the discipline of public health to the nation’s well-being has received increasing recognition over the past 2 decades, albeit without increasing financial support for core infrastructure and services.65,66 The Institute of Medicine report The Future of Public Health concluded that "no community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection, which is possible only through a local component of the public health delivery system."1(p9)
The importance of local public health systems is also receiving increased attention following major disasters such as the attack on the World Trade Center; concerns about bioterrorism, bird flu, and severe acute respiratory syndrome (SARS); and the impact of the 2004 and 2005 hurricane seasons. However, the organizational approach to local public health systems varies widely throughout the United States, with some states maintaining highly centralized state structures, some relying on local government for organization and control, and others using a combination of approaches. Services vary extensively across the many types of agencies at the local level,1,67 and considerable concern has been expressed about the system’s capacity to meet emerging threats to the public’s health.65
The academic–agency partnerships can address the increasing demands on public health systems with sparse resources. Because states are pivotal to the organization of the public health system, it is important to understand how these partnerships are evolving within state systems. Ours is the first large-scale study to look at the evolution of these partnerships on a statewide basis. The use of heads of local health departments as the sources of data for this study provides the perspective of local health agencies rather than that of academic institutions. The study’s high response rate for a comprehensive sample of local officials is noteworthy when contrasted with the relatively low response rate for a "convenience" sample of agency officials found in another study of academic–agency parnerships.68 Combining survey questions and archival data provided a context for the analysis of the historical and current impact of sociopolitical influences on the evolution of these partnerships. In-depth interviews provided more detail on the benefits and the challenges to partnerships, and the survey data provided data on the prevalence of the partnerships and their characteristics.
Limitations
This study, which reflects a more systems-based assessment of academic–agency partnerships, has limitations, including its focus on a single state, albeit a large state with a comprehensive system of local health departments. The diverse and often fragmented nature of systems of local public health agencies limits generalization to other states. The targeted archival review, focusing on legal foundations and structures without attempting to review the historical evolution of each CHD or the extensive documents that might reflect state efforts to coordinate CHDs, is another limitation. A limitation of the key informant interviews was the focus on historical foundations, as perceived by key informants identified by FACHO officials. Because key leaders within FACHO currently involved with recently evolved partnerships (some of which are extensive) were not interviewed, some of the more extensive partnerships were not described.
This study provides evidence of extensive collaboration between academic institutions and local public health agencies in Florida, resulting in expanded capacity of local public health systems. Collaborations between CHDs and academic institutions began to emerge in the middle of the last century and are now pervasive throughout Florida, involving most CHDs and a large proportion of the state’s academic institutions. County health officials report that these relationships contribute to the local public health system, the mission of the CHDs, and the core functions of public health. Rather than being an economic burden to local communities, academic–agency collaboration can be a major economic asset to the local community. An economic impact study of an academic partnership involving 1 local health department (Duval County) reported that the partnership, rather than depleting local resources, generated resources and increased access to funding for the community.69
As public health faces such increasing challenges as the emerging global threats of infectious disease and bioterrorism and diminishing or stagnant resources, these local partnerships can enable the local public health system to leverage human and financial resources that otherwise may not be available to them. Potential benefits of these partnerships include expanding service capacities, developing and educating the public health workforce, providing real-life experience for health professions students, and facilitating the use of research by local communities as a tool for local public health problem solving. These local partnerships can also provide more competitive environments for attracting highly educated and experienced staff, and greater opportunity and accessibility to grant funding for local community programs and organizations.
The collaboration between academic and public health agencies in Florida comprises a broad range of activities that are relevant to the newly emerging model of the academic health department. Although not strictly defined, this model has been cited in the public health literature and recognized by the Institute of Medicine, particularly regarding recommendations for implementation55 of the Who Will Keep the Public Healthy? report.2 The promise and current evolution of the academic health department model challenge proponents to define and clarify the nature and characteristics of an academic health department within the broad range of academic–agency partnerships.
Although the academic health department concept is analogous in many ways to that of a teaching hospital, there are no comparable accrediting or regulatory bodies that maintain standards for defining or accrediting such a department. Consequently, which CHDs would qualify for this status, or whether there should even be a defined status, has yet to be determined. Given the model’s early stages of evolution, it may be premature to rigidly define it. Approaches to the recognition of academic health departments that encourage their emergence and innovation may be particularly valuable, especially considering the large number of academic institutions that could be involved and the tremendous variation in the size, resources, and community demographics of local health departments. A tiered approach that recognizes the continuum of academic–agency integration and partnerships and does not attempt to establish a single "ideal" definition could encourage and facilitate the development, diffusion, and sustainability of academic health departments.
Our study provides insight into how tiers or levels could be constructed. Most of the CHDs responding to the survey have formal agreements for field experience or adjunct teaching. This model appears to be the most common and perhaps the most basic form of the academic health department. A minority, but nevertheless substantial number, of CHDs have more extensive agreements that involve joint research and resource sharing for community capacity building and problem solving. These forms of collaboration could conceptualize the next level or tier of an academic health department. The more extensive joint sharing of faculty and staff reflected in the Duval and Palm Beach CHDs and the Arkansas and New York state health departments could be a third-level academic health department.
Recommendations
The following recommendations for advancing collaboration between academic institutions and local health departments, and for the further evolution of academic health departments, emerged from this study.
- Develop a recognition process (i.e., a review and approval process much like the accreditation process) for academic health departments as a mechanism for creating awareness and support for collaboration and partnerships with academic institutions.
- Explore and better define the academic–agency link and what both types of institutions can gain from the effort.
- Develop recommendations and guidelines for memoranda of agreements and contracts between agencies and academic institutions.
- Design model legislation for local and state governments to sustain and expand partnerships.
- Encourage state health departments to leverage their influence with the legislature, university and community college systems, and sister departments to facilitate and support development of local academic health departments.
Conclusions
Our results have other important national implications. Most of the national resources committed to enhancing the public health system through expanded academic–agency collaboration have been generally restricted to a narrow range of academic institutions (schools of public health) that are not reaching most local health departments.53 This study demonstrates that there are substantial opportunities for collaboration beyond existing partnerships, which are primarily between schools of public health and health departments. Of the 50 institutions identified through this study, only 1 had a school of public health, which had partnerships with 12 agencies; 2 other institutions had comparable numbers of partnerships with county health departments. The capacity of other academic institutions (particularly those with substantial commitments to public health) to enhance local public health systems through agency partnerships should be explored and encouraged by federal agencies such as the Centers for Disease Control and Prevention and the Health Resources and Services Administration.
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Acknowledgments |
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This study was supported by the Florida Association of County Health Officials (FACHO) and the Duval County Health Department.
Doug Holt, president of FACHO, contributed to the analysis of the data, findings, and recommendations.
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Footnotes |
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Peer Reviewed
Contributors
W.C. Livingood coordinated the study, developed the study design, analyzed results, and developed the first full draft. J. Goldhagen and W.L. Little originated the study, assisted with the synthesis of quantitative and qualitative data, and edited the article. J. Gornto coordinated key informant interviews, analyzed interview data, and developed interview results. T. Hou coordinated the Internet survey, analyzed survey results, and developed survey results. All authors helped to conceptualize ideas, interpret findings, and review article drafts.
Human Participant Protection
This study was approved by the Florida Department of Health and the University of Florida human subject institutional review boards.
Accepted for publication May 14, 2006.
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