Tuberculosis and Local Health Department Expenditures on Tuberculosis Services

Background: Although tuberculosis (TB) morbidity and mortality have decreased in recent decades, challenges exist regarding disproportionate distributions of TB among specific populations and geographic areas. Inconsistent local health department (LHD) funding for TB programs poses difficulties for LHDs to sustain resources and personnel that predisposes communities to risks of future outbreaks of TB and drug-resistant TB diseases. Purpose: This study examined relationships between annual TB incidence rates and LHD expenditures on TB-related services to elucidate potential impacts of TB incidence on LHD TB spending. Methods: This dataset included county-level TB incidence data with comparable, annual (2000–2010) TB-related service expenditures for each of the 160 LHDs in Florida, New York, and Washington States. A panel study design was adopted to estimate relationships between county-specific TB incidence and LHD TB service expenditures, while accounting for demographic, geographic, and TB service provision factors. Results: Following declines in TB incidence, funding for LHD TB programs in Florida, New York, and Washington State has similarly declined. This study demonstrated significant, positive association between TB incidence rate and per capita TB expenditures. Jurisdictions with higher percentages of foreign-born and black populations had significantly higher TB service spending. Micropolitan jurisdictions had significantly lower TB service spending than metropolitan jurisdictions. Implications: Effective TB control and prevention requires sustainable resources and strategies to assure local public health capacity for timely and thorough responsiveness to TB outbreaks. This capacity may need to be in the forms of cross jurisdiction sharing, state-level support, and partnerships with alternative providers in communities

Measuring Population Care Performance: Development of the Population-Patient Satisfaction Survey for Use with Community Groups

Background: Assessing the satisfaction of the “population-patient” requires conceptualizing the dimensions of satisfaction differently from that of individual patients. Purpose: The focus of this study was to develop and pilot test a short questionnaire that can reliably assess satisfaction with the care provided by public health nurses (PHNs) carrying out population-level activities in their communities. Methods: An instrument-development approach was used. With input from five experts, items were developed to assess seven dimensions of population-patient satisfaction, and then refined before use in the community with a convenience sample of community participants recruited by PHNs in six counties across two states. The pilot yielded 134 surveys collected on 28 different dates over 5 years. Analysis included calculating the means and alpha reliability of each satisfaction dimension and the overall satisfaction. Results: All dimensions except communication (alpha 0.68) had an alpha reliability above 0.80. The enthusiasm dimension received the highest rating (mean=4.6, SD=0.60). The respect dimension had the lowest rating (mean=4.3, SD=0.80). Significant differences between the two states (n=32, n=97) were found for values (p=0.02) and communication (p=0.03). Analysis of variance showed significant differences by local health departments (LHDs) on values (p=0.001), enthusiasm (p=0.002), and communication (p=0.02). Although the enthusiasm subscale seemed to be the highest for most LHDs, no clear pattern of strengths and weaknesses per LHD emerged. Implications: Data from using the Population Patient Satisfaction Survey can be used to identify perceptions of the community regarding the quality of population-focused activities and thus areas for improvement which would then enhance community health

A Method for Identifying Positive Deviant Local Health Departments in Maternal and Child Health

Local health departments (LHDs) are under increasing pressure to improve performance with limited resources. While research has found that financial resources may be associated with better health outcomes, there are some LHDs that maintain exceptional performance, even with limited budgets. Our interest was identifying LHDs that positively deviate in MCH outcomes compared to their peers while taking into account local context including geography and finances. We found that our method for identifying positive deviants was effective, and that LHD expenditures may not be linked to MCH outcomes. The next step in our work is to conduct in-depth analysis with positive deviants to understand the practices they use to achieve exceptional health outcomes

Mandated activities and limited decision-making authority among local public health officials

Local public health department leaders face difficult decisions regarding the allocation of increasingly scarce resources, yet existing evidence for public health decision making, while still limited, is underutilized by public health officials. Participants in this study described processes regarding resource allocation in response to local budget cuts as based largely on legally mandated activities and categorical funding and perceived these factors as limiting much of their agency-level decision making to a relatively small portion of flexible funding. In the limited areas in which they perceived themselves to have flexibility, they generally considered their agencies to have very little capacity for accessing or using data-driven processes in their decision making. Given the apparent large role that mandated practices and categorical funding parameters have as factors in local public health decision making, policy making and practice-based research is urgently needed to narrow the divide between what is known regarding the effectiveness of mandated and categorical public health practices and how local public health leaders feel they can approach local decision making

Local Health Department Provision of WIC Services Relative to Local “Need”— Examining 3 States and 5 Years

Great variation exists in the nature of LHD service delivery and it varies, in part, relative to jurisdiction population size. Larger LHD jurisdictions may achieve an economy of scale in WIC service delivery that is not matched in smaller areas. Overall, we found that WIC service provision appears relatively consistent across study states and in the presence of increasing need, with greater responsiveness to need in urban areas. As demand for some preventive services increases LHDs in rural areas may need greater support than LHDs in large jurisdictions for meeting local demand. Unlike WIC, LHD-provided services that have less consistently maintained service-delivery guidelines may have a harder time responding to increasing need. The relative consistency of a federally-funded program such as WIC may serve as a good baseline for further study of less consistently delivered programs among LHDs. LHD service statistics can serve as useful data sources in measuring volume of service delivery relative to need

Using a positive deviance framework to identify Local Health Departments in Communities with exceptional maternal and child health outcomes: a cross sectional study

Abstract Background The United States spends more than most other countries per capita on maternal and child health (MCH), and yet lags behind other countries in MCH outcomes. Local health departments (LHDs) are responsible for administering various maternal and child health programs and interventions, especially to vulnerable populations. The goal of this study was to identify local health department jurisdictions (LHDs) that had exceptional maternal and child health outcomes compared to their in-state peers – positive deviants (PDs) - in Washington, Florida and New York in order to support the identification of strategies that can improve community health outcomes. Methods We used MCH expenditure data for all LHDs in FL (n = 67), and WA (n = 35), and most LHDs in NY (n = 48) for 2009–2010 from the Public Health Activities and Services Tracking (PHAST) database. We conducted our analysis in 2014–2015. Data were linked with variables depicting local context and LHD structure. We used a cross-sectional study design to identify communities with better than expected MCH outcomes and multiple regression analysis to control for factors outside of and within LHD control. Results We identified 50 positive deviant LHD jurisdictions across 3 states: WA = 10 (29 %); FL = 24 (36 %); NY = 16 (33 %). Overall, internal factor variables improved model fit for identifying PD LHD jurisdictions, but individual variables were not significant. Conclusions We empirically identified LHD jurisdictions with better MCH outcomes compared to their peers. Research is needed to assess what factors contributed to these exceptional MCH outcomes and over which LHDs have control. The positive deviance method we used to identify high performing local health jurisdictions in the area of maternal and child health outcomes can assist in better understanding what practices work to improve health outcomes. We found that funding may not be the only predictor of exceptional outcomes, but rather, there may be activities that positive deviant LHDs are conducting that lead to improved outcomes, even during difficult financial circumstances. This method can be applied to other outcomes, communities, and/or services

Are local health department expenditures related to racial disparities in mortality?

Abstract available at publisher's website

Are local health department expenditures related to racial disparities in mortality?

This study estimated whether 1990-1997 changes in expenditures per capita of local health departments (LHDs) and percentage share of local public revenue allocated to LHDs were associated inversely with 1990-1997 changes in mortality rates for Black and White racial/ethnic groups in the US. Population was 883 local jurisdictions with 1990 and 1997 mortality rates for Black and White racial populations from the Centers for Disease Control and Prevention Wonder Compressed Mortality File and LHD expenditures from the National Association of County and City Health Officials. Using a time-trend ecologic design, changes in LHD expenditures per capita and percentage share of public revenue were not related to reductions in Black/White disparities in total, all-cause mortality rates. Increased LHD expenditures or percentage share were associated with reduced Black/White disparities for adults aged 15-44 and males. LHD expenditures or percentage share were related to absolute reductions in mortality for infants, Blacks, and White females but did not close Black-White mortality differences for these groups. Therefore, disparities in Black and White mortality rates for subgroups with the greatest mortality gaps may be more likely to be reduced by public investment in local health departments than disparities in Black and White total, all-cause mortality rates.Local health departments Public health expenditures Mortality disparities Race and ethnicity Public health systems research Health inequalities USA