Academic Health Centers and Cooperative Extension Service: A Model for a Working Partnership

Cooperative State Research, Education and Extension Service (CSREES) has a long history of bridging the gap between research and the community application of that research. CSREES ensures that new knowledge is quickly and productively applied in communities. The historic partnership in 1862, the Morrill Act, allowed the United States Department of Agriculture (USDA) to establish the Cooperative Extension Service (CES). This collaboration gave the land-grant university the charge to address the work life and family issues that rural and agricultural residents faced. In the beginning of the university Cooperative Extension Service its education mission focused on advancements in agricultural technology and home economics (CSREES, 2006).

Today approximately 20% of the U.S. population lives in rural areas, and fewer than 2% live on farms (CSREES, 2006). As farm life has evolved, newer challenges have surfaced for rural residents. Increased rates of occupational hazards, substance abuse, and chronic disease plague rural families. These new challenges require CES to shift its community role to address these changes. With this evolution, however, the mission of CES continues to be the provision of new information, guided by scientific evidence and inspired by practice (Peters, 2002).

Evolving concerns and focus require new partnerships between CES, colleges, and research centers on the university campus. The rise of health issues as prospective CES concerns predicates a logical new partner, the academic health center (AHC). The AHC is composed of a cluster of health professions school such as medicine, dentistry, allied health and public health, along with one or more teaching hospitals. (AAHC, 2006) The mission of an AHC is to advance leadership and education in health professions as well as research, and the provision of health care. Frequently, community health is also a part of the mission of AHCs.

The relationship between the College of Agriculture (COA), which typically houses CES, and the AHC is frequently difficult due to geographic or administrative separation. In many states, the land-grant institution is in a different university than the state-supported academic health center. This distance makes it difficult for the AHC to partner with CES to provide the results of health research to the community. It limits the ability of the CES to draw on the latest health research and knowledge to develop community health Extension programs. In addition, CES agents have been frequently overlooked as resources for the translation of AHC research into the community.

In some cases the relationship between the AHC and COA has developed and worked well in spite of geographic and administrative separatism (Franz, Dailey, 2002). Land-grant institutions such as the University of Minnesota and Texas A&M have been successful at combining the COA and AHC resources to formulate a relationship and translate research findings of the AHC to impact state-wide communities.

The University of Kentucky (UK) is one of few land-grant universities that has an AHC and a COA, with an embedded CES unit, geographically and administratively on the same campus. The co-terminus nature of the UK AHC and COA has allowed for the development of an ideal model partnership. The deans at UK of both the AHC and COA report to the same provost. This facilitates a streamlined chain-of-command and encourages discussion between these administrators and their staff.

Many of the principles that were used to develop the model for a working partnership between the AHC and COA at UK could be applied to other university settings, even if they are geographically and administratively separated. This article describes a model for partnership between the CES and the AHC, using illustrative examples of program planning, program development and examples.

Setting

The University of Kentucky, established in 1865 as an agriculture and mechanics institution, is the state of Kentucky's land-grant university. In the early 1950s, a college of medicine was created at the university. Over the next three decades, colleges of dentistry, nursing, pharmacy, and health sciences were created. In 2001, the college of public health was established on the UK campus. With this development, UK became one of a limited number of land-grant universities that has an AHC with six health professions schools.

Program Development

The University of Kentucky is the site of the National Institute of Occupational Safety and Health (NIOSH) funded Southeast Center for Agricultural Health and Injury Prevention. The center is administered by the Department of Preventive Medicine and Environmental Health in the College of Public Health and deals with a variety of agricultural issues, from farmer suicide prevention to tractor roll over protection. As the result of this project, an opportunity to expand the existing relationship between the AHC and COA emerged. This discussion centered on the similarities in community health education goals between CES and that of AHC colleges.

For example, both had health programs that focused on nutrition and cancer screening. However, CES programs were frequently ad hoc, developed by an Extension agent from their own knowledge base. As a result, these programs were not necessarily based on current evidence-based practices. This suggested that a collaborative and more aggressive health program between the two administrative entities should be pursued (Griner & Parker, 2005).

The Process

After identifying the need for partnership between CES and the AHC, university administrative "buy-in" was key to the formation of partnerships within the university. In addition, creating a partnership with Kentucky's 1890 land-grant institution was important to address the health needs of minorities and their families throughout the state.

Health programming, including goals and objectives, are best determined by objective quantitative data analysis, combined with qualitative input from advisory committees and the community. The Kentucky rates of cancer, heart disease, diabetes, and chronic obstructive pulmonary disease, combined with the rates of poor health habits such as tobacco, nutrition, and sedentary life style, are among the highest in the nation. After careful review of Kentucky vital statistics data and Behavioral Risk Factor Surveillance System (BRFSS) data on mortality, morbidity, risk factors, and other health risk factors, there was a demonstrated need to focus on reducing Kentucky's chronic disease preventable risk factors.

Based on Kentucky health needs data assessments, the Health Education through Extension Leadership Project (HEEL) was conceived. The purpose of HEEL is to influence chronic disease outcomes by encouraging sustainable lifestyle behavioral changes. These changes include dietary modification and mitigating risk factors associated with cancer, cardiovascular disease, diabetes, and mediating stressors that affect mental health and wellness, well-being of children, and domestic and family violence.

HEEL is a partnership, between the College of Public Health and the College of Agriculture and its Cooperative Extension Service unit. The project is led by a senior administrator in the school of public health and the associate director of Extension for family and consumer sciences in the COA. Formal partnerships were officially established with the College of Dentistry (to influence oral health in rural Kentucky), the College of Pharmacy (for prescription medication and over- the- counter medication compliance), and the College of Social Work (to focus on farm stress management). The program was funded through resources from the COA by the US Department of Agriculture (USDA) and its Cooperative State Research, Education and Extension Service (CSREES).

Program Planning

As a part of our effort, we looked for models of collaboration between AHC and CES/COA. Little information was available on existing partnerships. Therefore, the Healthy People 2010 goals for the nation were used to build health programming for HEEL.

The primary objectives of HEEL program are as follows:

• To educate and empower individuals and families to adopt health behaviors and lifestyles,


• To build community capacity to improve health, and


• To educate consumers to make informed health choices.

We then proceeded to accomplish the following steps:

• A UK advisory committee was created with representatives from other academic units within the university system, with ties to the community (i.e., dentistry, pharmacy, social work, Area Health Education Centers, Kentucky Cancer Program, Kentucky State University (KSU), and the state Department of Public Health).


• The health Extension specialist position was revamped to include Extension and public health duties. (Eligibility criteria included faculty status, with experience in health promotion and disease prevention program, and a good working knowledge of agriculture and CES).


• Health Extension specialists were used to conduct further program development and planning, using evidence-based community health needs assessments tools along with CES agents.


• Joint appointments in the COA and in public health were offered to health Extension specialists.

In order to make CES agents aware of the health Extension specialist resource, in-service programs were held. The UK health Extension specialists led the programs to assist Extension agents in development of their health programming. In addition, to facilitate their relationships with others in the community concerned with comparable public health missions, CES formed relationships with the local health department and the Area Health Education Centers (AHEC). Health Extension specialists also worked with homemaker groups to help them develop sustainable community health coalitions, based on community-based participatory research and methods.

To provide a continuing source of information and suggestions for our Extension agents, we established a Web site, www.ca.uky.edu/heel/. The Web site provides county-specific health information that the Extension agents can use. It also provides current information on HEEL activities. This has been a successful Web site, with over a half million hits since it went on line in 2003 (HEEL, Program Development Section, 2005). In addition to the Web site, HEEL provides a monthly health bulletin, primarily intended to be used by Extension agents, but increasingly used by others interested in health behavior change.

CES agents have worked in their local communities to develop coalitions, usually using existing homemaker groups, to focus on improving lifestyle and behaviors focused on chronic disease prevention. A total of 114 counties now have coalitions that focus on chronic disease prevention. Through the efforts of the program, over 1,800 local health education programs have been offered in rural Kentucky communities.

Program Examples

Two examples illustrate successful outcomes from the HEEL program. Given that Kentucky is first in the nation for percentage of individuals who are sedentary, resulting in high rates of obesity, overweight, and other related illnesses, it was important to develop a program that addressed the needs of those who were physically inactive. A successful program associated with physical inactivity--Get Moving Kentucky!--was created. (Editor's Note: See "Physical Activity Programming for Limited Resource Audiences: Get Moving Kentucky!" in this issue.)

Get Moving Kentucky! is an 8-week physical activity program for teams and individuals that focuses on increasing the physical activity of Kentuckians. The program invokes a friendly competition to see who can be the most active. Participants are able to track their physical activity progress via a Web-based tracking system. In order to facilitate the program statewide, HEEL partnered with the Kentucky state government's Cabinet for Health and Human Services and the UK Wellness Center (focused on improving the health and lifestyles of UK employees on the campus). In addition, using public health social marketing tools, a major media awareness campaign was conducted. The program was also endorsed by UK President Lee Todd, a well-known figure in Kentucky. Between 2004-2005 Get Moving Kentucky! was used by over 35,000 individuals statewide.

Another example of a successful HEEL program is the Drug Endangered Children Program (DEC). A growing methamphetamine abuse problem has plagued Kentucky, resulting in abandoned or abused children. To address this problem, a HEEL health Extension specialist created and managed the DEC program. The primary objective is to help professionals who have to respond to drug-related situations that may involve children to protect these children. The program involves representatives of the following agencies: child protection, community education, healthcare, law enforcement, criminal investigation, emergency medical response teams, prevention, public health, and state government.

Numerous programs have been developed in addition to the ones we have chosen to highlight; they range across a broad spectrum of health problems and conditions and involve a number of colleges and academic departments in the academic health center and across the UK campus. The number and breadth of those programs continues to increase as those on the campus of UK discover the capacity that Extension brings to the issues that face Kentuckians.

Lessons Learned

Role of Extension

There are several lessons that can be gained from HEEL development experiences. First, CES agents are a well kept health secret. In many cases, the Extension agents in Kentucky's counties were laboring with little or no involvement from the university, other than with the College of Agriculture. Extension agents are anxious to have available state-of-the-art health intervention materials to assist them in their tasks. They welcome the suggestions and assistance of AHC health professionals on the university campus.

Many partnerships and coalitions exist to address major health problems in Kentucky, as they do in other states. In many cases, the Extension agent is not thought of by faculty and staff of the AHC when developing those partnerships and coalitions. However, many health units at UK now are taking notice of the successful health programs that are being developed and are increasingly involving CES agents in their health programs.

Also, increasing the involvement of Extension in health-related programming in counties across Kentucky is essential for hard-to-reach-communities. The simple act of providing the name of the director of the local health department to the Extension agent, and the Extension agents name to the health department, with a letter from the director of Extension and the state health commissioner, has provided the impetus to inclusion of a much broader set of community participants in community health efforts.

Leadership

There has been a rapid proliferation of partnerships with the various colleges of the Academic Health Center for not only service, but also education and research activities. For example, the Extension agents are working with the AHEC in Kentucky and the medical school, so that medical students who are working in rural communities are oriented by CES agents to those communities, their nature, people, and problems.

The extent to which such a program is successful is dependent on leadership. The leadership of the president of the university, deans of the AHC colleges and COA is imperative. The COA dean must understand that the nature of Extension and the problems it must address has changed. Similarly, if the deans of health and human services programs do not feel any commitment to the communities in which they live, then the program will quickly come to an end. They will not see the advantage in partnering with the COA if it does not influence the factors that contribute to a college's reputation nationally or on the campus itself. The availability of assistance and caring leadership has made a significant impact on the morale of agents who want to be involved in addressing the health problems of their communities.

Conclusion

As said at the outset, this is the initial description of a new program designed to bring CES and the AHC together to facilitate health programs and, it is hoped, improve the life and health of a state's communities. The HEEL program continues to grow, with more activities that cover a broader range of health issues and attract support from a variety of sources to encourage the partnership of Extension and the traditional health community to build a healthier community.

The partnership of the COA/CES with the entities of academic health centers provides a fertile foundation for the delivery of science, research, and health education to communities. Despite geographical and administrative barriers, common goals of enhancing the lives and lifestyles of people through extensive program planning and development can overcome the challenges. At the University of Kentucky, the HEEL program presents a best-practice method for other universities to model. The program continues to exceed expectations for Extension and affords the opportunity to expand and collaborate with other organizations with similar interests of providing quality care for its communities.

References

Association of Academic Health Centers. About AAHC. (2006) Retrieved on May 25, 2006 from: http://www.ahcnet.org/about/index.php

Cooperative State Research, Education and Extension Service. CSREES background. (2006) Retrieved on May 18, 2006 from: http://www.csrees.usda.gov/qlinks/extension.html

Franz, N., Peterson, R., & Dailey, A. (2002). Leading organizational change: A comparison of county and campus views of Extension engagement. Journal of Extension [On-Line], 40(3). Available at: http://www.joe.org/joe/2002june/rbl.html.

Griner, L., & Parker, L. (2005).Extension as a delivery system for prevention programming: Capacity, barriers, and opportunities. Journal of Extension [On-line], 43(1) Article 1FEA1. Available at: http://www.joe.org/joe/2005February/comm1.shtml.

Health Education through Extension Leadership (HEEL): Program Development (2005). Retrieved: July 13, 2005 for University of Kentucky, College of Agriculture: www.ca.uky.edu/heel/

Health Education through Extension Leadership (HEEL): Executive Summary (2004). University of Kentucky, College of Agriculture, Cooperative Extension Service.

Peters, S. (2002). Rousing the people on the land: The roots of the educational organizing tradition in Extension work. Journal of Extension [On-Line], 40(3). Available at: http://www.joe.org/joe/2002june/a1.html.

The Land-Grant Tradition. National Association of State Universities and Land-Grant Colleges. Washington, DC. March 1995.