Local Health Departments’ Governance: A Visual Display Using LHD Shape Files

Analyses conducted for public health systems and services research (PHSSR) frequently include a variable that represents the relationship between state and local health departments (i.e., a governance category) in their analyses, either as an explanatory variable or a control variable. A number of organizations and researchers has categorized states according to governance, but the categorizations have been inconsistent across studies. This lack of agreement regarding governance category has been problematic for PHSSR. The Association of State and Territorial Health Officials (ASTHO) in conjunction with NORC at the University of Chicago and with input from the National Association of County and City Health Officials (NACCHO) conducted a study to systematically categorize state health agencies by their governance relationships with their local health departments (LHDs), using specific criteria. Based on a literature review, expert opinion, a survey, and follow-up telephone interviews in selected states, the relationships that exist between state and local health departments in each state were classified into four core categories: centralized, decentralized, shared and mixed. States’ systems were further classified based on a determination of what percentage of a state\u27s population is served by LHDs of each governance type, creating additional categories of largely centralized, largely decentralized and largely shared for those states where more than 75 percent of the population is served by that predominant governance structure. The classification system for LHDs developed by NACCHO defines the governance relationship of each LHD with the state health agency as local, state or shared. The presentation will include a map showing the classification of each state. A second map, developed using ARCGIS, will show the classification of each local health department based on NACCHO’s classification system. These new governance categories will be included in the data sets from ASTHO’s Profile survey and NACCHO’s Profile survey. These newly standardized state and local public health agency governance categorizations should help PHSSR by providing greater uniformity and validity across research studies

Public Health Workforce Taxonomy

Thoroughly characterizing and continuously monitoring the public health workforce is necessary for ensuring capacity to deliver public health services. A prerequisite for this is to develop a standardized methodology for classifying public health workers, permitting valid comparisons across agencies and over time, which does not exist for the public health workforce. An expert working group, all of whom are authors on this paper, was convened during 2012-2014 to develop a public health workforce taxonomy. The purpose of the taxonomy is to facilitate the systematic characterization of all public health workers while delineating a set of minimum data elements to be used in workforce surveys. The taxonomy will improve the comparability across surveys, assist with estimating duplicate counting of workers, provide a framework for describing the size and composition of the workforce, and address other challenges to workforce enumeration. The taxonomy consists of 12 axes, with each axis describing a key characteristic of public health workers. Within each axis are multiple categories, and sometimes subcategories, that further define that worker characteristic. The workforce taxonomy axes are occupation, workplace setting, employer, education, licensure, certification, job tasks, program area, public health specialization area, funding source, condition of employment, and demographics. The taxonomy is not intended to serve as a replacement for occupational classifications but rather is a tool for systematically categorizing worker characteristics. The taxonomy will continue to evolve as organizations implement it and recommend ways to improve this tool for more accurate workforce data collection

LHDs Increase Their Use of EBDM Practices From 2010 to 2013

Background: An evidence-based approach is needed to effectively address the gap between population health goals in the United States and current morbidity and mortality rates. Recently, the authors developed an index to allow researchers to assess the frequency of evidence-based decision making (EBDM) practice in LHDs. The first descriptive analysis was conducted with data from the NACCHO 2010 Profile Study of Local Health Departments (LHDs). The current research was designed to assess changes in the percentage of LHDs using EBDM practices from 2010 to 2013. Research Objective: To identify changes in the frequency with which LHDs carried out EBDM practices from 2010 to 2013. Data sets and sources: 2010 NACCHO Profile of LHDs Survey, 2013 NACCHO Profile of LHDs Survey. The NACCHO Profile Surveys are conducted every 2-3 years. All LHDs in the country are invited to respond. Study Design: Cross-sectional survey Analysis: The research reported here used an index of EBDM practices previously developed by the authors. Descriptive analysis was used to identify the frequency with which LHDs used each EBDM practice comprising the index and the frequency of the total number of practices they used in both 2010 and 2013. Principal Findings: Overall, the percentage of LHDs using EBDM practices increased from 2010 to 2013. Specifically, in 2010, forty-five percent of LHDs used three EBDM practices or fewer; 41.5% used four or five EBDM practices; and 13.5% used six or seven practices. In 2013, thirty-seven percent of LHDs used three EBDM practices or fewer; 39% used four or five practices; and 23.7% used six or seven practices. The overall increase in numbers of EBDM practices used by LHDs was largely driven by increases in percentages of LHDs that use the County Health Rankings (37.8% to 66.5%) and that use The Guide to Community Preventive Services (26% to 41.2%)(Table 1). Implications for PH Policy and Practice: The results reveal that there is an increase in the use of EBDM practices in LHDs from 2010 to 2013. More research is needed to understand details of how LHDs implement EBDM strategies and use them to innovate the practice of public health

LHDs\u27 Implementation and Evaluation of Strategies to Target Psychological, Mental Health, and Other Behavioral Healthcare Needs of the Underserved Population

Background: Underserved subgroups face barriers when accessing behavioral healthcare. Local health departments (LHDs) are charged with “linking people to needed personal health services and assure the provision of healthcare when otherwise unavailable”. Research Objectives: 1) To assess the extent to which LHDs implement and evaluate strategies to target the behavioral healthcare needs for the underserved populations; 2) To identify factors that are associated with these undertakings. Datasets and Sources: Data were drawn from the 2013 National Profile of Local Health Departments Study conducted by National Association of County and City Health Officials The Module 2 questionnaire of the Profile contained question about strategies used by LHDs to target the behavioral healthcare needs of the underserved populations (N=505). Study Design: Cross-sectional, quantitative survey. Analysis: Factors associated with assuring access to behavioral health services were examined by using logistic regression analyses. Descriptive statistics were also computed. To account for complex survey design, we used SVY routine in Stata 11. Principal Findings: About 30% of LHDs implemented or evaluated strategies to target the behavioral healthcare needs of underserved populations in their jurisdiction. Our multivariate analysis indicates that LHDs with city/multicity jurisdiction (AOR=0.16, 95% CI: 0.04-0.77), centralized governance (AOR=0.12, 95% CI: 0.02-0.85), and those located in the South Region (AOR=.0.25, 95% CI: 0.08-0.14) or the West Region (AOR=.0.36, 95% CI: 0.14-0.94) were less likely to have targeted the behavioral healthcare needs of the underserved. LHDs with higher per capita expenditures (AOR=1.85, 95% CI: 1.00-3.42), or those with greater number of activities to address health disparities (AOR=1.27, 95% CI: 1.08-1.49) had higher odds of having targeted the behavioral healthcare needs of the underserved. Conclusion: Extent to which the LHDs implemented or evaluated strategies to target the behavioral healthcare needs of the underserved populations varied by centralization of governance, the degree to which LHDs were well-funded, health disparities reduction activities, geographic region, and jurisdiction type. Implications for Public Health: Policy and practice focus on mental health issues in under-served populations is ever more critical, given the low proportion of LHDs targeting behavioral health needs, and the increased vulnerability of underserved population emanating from recent financial crises

Local Boards of Health as Linkages Between Local Health Departments and Health Care and Other Community Organizations

Introduction: Efficient provision of essential public health services may be influenced by collaborative capacity of local health departments (LHDs). Local boards of health (LBoHs) are well positioned to facilitate partnerships. Objectives: We examined the degree to which LBoHs serve as a linkage between LHDs and 2 types of community organizations, health care providers and local government agencies, and the LBoH characteristics associated with tendency of LBoHs to perform such linkage function. Methods: We analyzed data from a recent cross-sectional survey, the 2015 National Survey of Local Boards of Health. This survey used a probability sample of 685 LHDs stratified by the state of LHD location and the population size of LHD jurisdiction, resulting in 394 responses for a response rate of 58%. We used multivariate logistic regression to pursue the study objectives. Results: LHD respondents reported that LBoHs served as a linkage with hospitals or other health care providers for 20% of LHDs and with local government agencies for 19% of LHDs. Significant association of LBoHs\u27 performance of governance functions existed with their chances of linking LHDs with hospitals or other health care providers (adjusted odds ratio [AOR] = 1.25; P \u3c .001) and with local government agencies (AOR = 1.23; P \u3c .001). Among the factors associated with LBoHs serving as the linkage, the governance function oversight was the strongest, followed by governance functions policy development, continuous improvement, and resource stewardship. Legal authority had weakest association with both types of linkages. A strong positive association existed between LBoHs seeking community input from elected officials and LBoHs\u27 tendency of serving as the linkage with both health care providers and local government agencies. Conclusions: The role of LBoHs in linking with hospitals, other health care providers, and government agencies could be further maximized, particularly given the high proportion of LBoHs that include members who are health care professionals

Developing and Applying a Taxonomy of Local Boards of Health: A Standardized Tool for Efficient Public Health Governance, Policy and Practice

Background: Local boards of health (LBoHs), are a fundamental component of the public health governance structure. Current studies have reported mixed results about the impact of LBoHs as the LHDs\u27 governing bodies, because there is no standardized typology to show variation in LBoHs. Purpose: The purpose of our research is to develop and apply a taxonomy of LBoH to provide a coherent framework for describing variation in the nature of LBoH functioning, and effectiveness. Data and Methods: This study uses the 2015 Local Board of Health Survey, conducted by the NACCHO, using a stratified random sampling design. The survey received 394 responses for a response rate of 58%. The creation and application of this taxonomy consisted of the following steps: (a) theoretically guided initial theme development; (b) mapping 2015 LBoH Survey variables to the proposed themes; (c) data reduction using principal component analysis (PCA); and (d) scale development and testing internal consistency. Results: The final taxonomy included 59 items across six governance functions and four additional themes. The additional themes included: LBoH composition; use of diverse perspective in actively seeking community input on public health issues and initiatives; level of LBoH engagement in LHD affairs; and sophistication in sources of LBoH strategic directions. Application of taxonomy strongly supports the premise that the boards of health differ in significant ways regarding their performance of governance functions and with respect to other crucial characteristics. Conclusions: The LBoH taxonomy provides a standardized tool for classifying LBoHs from the viewpoint of LHD administrators and professionals. While simple use of presence or absence of the LBoH have historically added to confusion in the literature examining the influence of LBoH, we recommend that future studies use the six governance functions and proposed items measuring those functions, plus the four additional themes in the taxonomy

Local Health Departments\u27 Performance of Community Health Assessment, Community Improvement Planning, and Strategic Planning: Do These Activities Predict Plans for Seeking Accreditation?

Research Objective: To examine the nature of relationship between LHDs\u27 intentions to seek Public Health Accreditation Board (PHAB) accreditation in the future and having completed within five years the three PHAB pre-requisites: community health assessment (CHA), community health improvement plan (CHIP), and the agency-wide strategic plan. Data Sets and Sources: We used data from the NACCHO\u27s 2010 National Profile of Local Health Departments (2010 Profile Study) survey, administered to 2656 LHDs. Analysis: Our bivariate analyses included Somers-D test for the nominal variables and Kendal\u27s Tau-b for the ordinal variables. For the multivariate analysis of the ordinal dependent variable, we performed multinomial logistic regression. Principal Findings: Our multivariate analysis showed that completion of community health assessment or community health improvement plan within the past five years had negative association with LHDs\u27 intention to seek accreditation, and recent completion of a strategic plan had no association with accreditation, after controlling for the potential confounding factors. Conclusion: Contrary to our expectations, our analyses did not show a positive association between completion of the PHAB accreditation prerequisites and local health departments\u27 intentions to seek PHAB accreditation. However, a positive association existed between intent to seek accreditation and plans to complete a strategic plan in the next year. Implications for the Field of PHSSR: As agencies prepare for accreditation, it is important to understand how intentions to seek accreditation are related to the current level of readiness based on the three PHAB prerequisites. Our presentation will include important implications for LHDs, PHAB and its partners

Local Health Department Funding Cuts and Impacts

This study sought to quantify the impact of the economic recession on the budgets, workforce, and programs of Local Health Departments (LHDs) across the United States. The National Association of County and City Health Officials (NACCHO) conducted two on-line surveys in 2008–2009; the first conducted in December of 2008 using census design, and the second in August 2009 using a nationally representative stratified sample of 990 LHDs. Trends found in the first two surveys will be compared with a third survey to be conducted in January 2010. Findings of the first two surveys demonstrate that across the country, LHDs experienced substantial reduction in budgets, employees, and public health activities and services. In 2009, 45 percent of LHDs reported cuts in their budget compared to the previous fiscal year; this is up from 27 percent in 2008. Job losses increased; in calendar year 2008 an estimated 7,000 LHD jobs were lost, while 8,000 staff positions were lost over six months in the first half of 2009 (January 1–June 30). In addition to staff lost through layoffs, an additional 12,000 LHD employees were subjected to reduced hours or mandatory furloughs in January–June 2009. From July 2008–June 2009, 55 percent of LHDs made cuts to important public health programs. As of July 2009, only 14 percent of LHDs had received funding from the American Reinvestment and Recovery Act. The findings from this study show that LHDs are severely strained by increasing budget and workforce cuts, to the point that they are being forced to eliminate or reduce vital programs that protect the public’s health. These pressures come even as LHDs are being called upon to take the lead in local H1N1 vaccination campaigns and as the demand for many different services has increased due to adverse economic conditions

State of Public Health Voluntary Accreditation: Barriers, Facilitators, and Impact on Evidence-Based Practices

This presentation was given at the State of Public Health Annual Conference

Factors Associated with Recent Budget Reductions for Local Public Health Agencies

Research Objective: The general objective of this study is to examine the manner in which current economic downturn facing the country has impacted the budgets of local health departments (LHDs) around the country, and to identify factors instrumental in predicting the vulnerability of a LHD to experiencing budget cuts. Specific research objectives include: 1. To determine the proportion of LHDs that have had their budgets reduced compared to previous fiscal year; 2. To examine the extent to which LHD budgets have decreased over the past year; 3. To identify organizational characteristics that are associated with vulnerability to budget cut; and 4. To examine factors associated with level of reduction or increase in the LHD budgets. Study Design: This study involves analysis of linked data from two recent cross-sectional national surveys of LHDs conducted by NACCHO in late 2008 – the National Survey of LHD Budget Changes; and the 2008 National Profile of LHDs. Potential explanatory variables for the multivariate models include population size and degree of urbanization of jurisdiction, type of governance, funding mix (sources of LHD revenue), per capita LHD expenditures, type of services provided, and characteristics of the LHD’s top executive. We will use logistic regression to model the dichotomous variable representing whether or not LHD experienced a budget cut, as well as polytomous variable representing the extent of budget cut. Population Studied: The target population for the study is all local health departments in the country, defined as “an administrative or service unit of local or state government concerned with health, and carrying some responsibility for the health of a jurisdiction, smaller than the state.” The Profile survey was a complete census of all LHDs (2795 at the time of the survey), whereas the Budget-Cut Survey used predominantly census approach with exception of five states, where sampling was performed for only those groups of LHDs, for which the same contact person was listed for the entire group, and not separately for each LHD in the group. Principal Findings: Our preliminary analysis shows that 27% of LHDs experienced a decrease in budget in the current year compared with the prior year and this percentage shows considerable variation across states and categories of jurisdiction population. We expect to find a significant impact of several organizational characteristics on vulnerability for budget cuts. Conclusion: The proportion of LHDs experiencing budget reductions, and the level of reductions are substantial enough that it should draw attention of all stakeholders to the factors associated with vulnerability of LHDs, to be identified by our multivariate analyses. Implications For Policy, Delivery Or Practice: The findings of this study are very timely, given the current economic crisis. Identifying characteristics of local health departments that make them particularly vulnerable to budget cuts during an economic downturn will provide insights to leaders at all levels of the public health system. Local health department leaders and local government officials will be able to gauge the expected relative impact to their agency in a general economic downturn and consider whether changes to their structure, funding, or service mix might result in more stable funding levels in the future. A better understanding of the types of local health departments most severely impacted by an economic downturn may allow state and federal public health leaders to make better decisions about resource allocation, particularly at times when budgets are declining. Funding Source(s): CDC, Robert Wood Johnson Foundation Theme: Public Healt