Editorial Comment: Changing the Rules in Vaccine Coverage for Vulnerable Populations

Increasing life expectancy through decreasing vaccine preventable deaths is a hallmark of modern public health in the United States (1). Two federal vaccine programs help insure coverage for vulnerable populations. The Vaccines for Children (VFC) Program provides vaccines to eligible children[1] at no cost, removing financial barriers to vaccinations. Close to half of US children and 30 percent of adolescents are vaccinated through the VFC program yearly (2). The federal Section 317 Immunization Grant Program (Section 317) complements VFC by supporting the national immunization infrastructure, primarily immunization workforce, delivery systems, and emergency response, as well as by providing vaccines for non-VFC eligible financially vulnerable populations

Use of the County Health Rankings by Local Health Departments in Florida, 2010 - 2011

This paper describes how local health departments (LHDs) in Florida used the County Health Rankings over the first two years of their release (2010 – 2011). We surveyed LHD leadership to describe if, how and to what extent the Rankings were used by Florida’s 67 LHDs to improve the health of their communities and describe changes in use from the 2010 to the 2011 release. Our results indicate substantial use of the Rankings by Florida’s LHDs, particularly as applied to community health assessments, staff education, as a starting point for examining other indicators and databases, and in grant applications. From 2010 to 2011, we found significant increases in LHD use of the Rankings to build broad multisectoral community involvement in the solution of community health problems. However, media engagement with the Rankings appears to have decreased with time. A primary implication for public health practice is the apparent utility of the Rankings as a tool for community organizing around public health issues and communicating the multifactorial nature of health

A Tool to Cost Environmental Health Services in North Carolina Local Health Departments

Introduction: The cost of providing a basic set of public health services necessary not been well-described. Recent work suggests public health practitioners are unlikely to have the empirically-based financing information necessary to make informed decisions regarding practice. The purpose of this paper is to describe the development of a costing tool used to collect primary data on the number of services provided, staff employed, and costs incurred for two types of mandated environmental health services: food and lodging inspections and onsite water services. Methods: The tool was iteratively reviewed, revised, and piloted with local health department (LHD) environmental health and finance managers. LHDs (n=15) received technical support to estimate costs for fiscal year 2012. Results: The tool contained the following sections: Agency/Respondent Information, Service Counts, Direct Labor Costs, Direct Non-Labor Costs, and Indirect/Overhead Costs. The time required to complete the tool ranged from 2 to 12 hours (median = 4). Implications: LHDs typically did not track costs by program area, nor did they acknowledge indirect costs or costs absorbed by the county. Nonetheless, this costing tool is one of the first to estimate costs associated with environmental health programs at the LHD level and has important implications for practitioners and researchers, particularly when these limitations are recognized

Factors Driving Local Health Department’s Collaboration with Other Organizations in the Provision of Personal Healthcare Services

Background: Recent work has highlighted the necessity of integrating primary care services and public health to improve quality and reduce the cost of healthcare. Research Objectives: To describe levels of partnership between local health departments (LHD) and other organizations in the community in the provision of personal healthcare services; and to assess LHD organizational characteristics and community factors that contribute to partnerships. Data Sets and Sources: Data were drawn from the 2013 NACCHO Profile Study (Module 1) and the Area Health Resource File. A total of 490 LHDs responded to Module 1, where LHDs were asked to describe the level of partnership for selected programs including three personal healthcare services—Maternal and Child Health (MCH), communicable/infectious disease control, and chronic disease prevention. The five levels of partnership were measured on an ordinal level from “not involved”, “networking”, “coordinating”, “cooperating”, to “collaborating”, with “collaborating” as the highest level of partnership. The level of partnership in these three personal healthcare services were the outcomes examined in this analysis. Covariates included both LHD organizational and community factors. Study Design: This is a cross-sectional study, based on secondary data from multiple sources, linked at the LHD as a unit of observation. Analysis: Three ordinal logistic regression models were run to assess factors associated with higher levels of partnership in the three personal healthcare programs. Data analyses were conducted using Stata 13 SVY procedures to account for the Profile Study’s survey design. Principal Findings:Overall, proportions of LHDs at the five levels of partnership—not involved, networking, coordinating, cooperating , and collaborating—for MCH were 11.8%, 12.4%, 28.3%, 24.9%, and 22.6%; for infectious disease control were 8.1%, 3.9%, 27.6%, 31.8%, and 28.9%; for chronic disease prevention were 10.4%, 14.2%, 37.7%, 21.2%, and 16.5%, respectively The proportion of LHDs engaged in collaboration, the highest level of partnership, increased with LHD jurisdiction population size. For MCH, 14.1% of LHDs with =500,000 people reported collaboration (p=500,000 reported collaboration with other organizations in the community (p Conclusion: Level of partnership varied across LHDs of different jurisdiction population sizes. And the level of partnership was highest for infectious disease control, and the lowest in chronic disease prevention. Implications for Public Health Practice and Policy: Factors that might promote LHD’s collaboration in the provision of personal health care services include having a public health physician on staff, higher per capita expenditure, and conducting a community health assessment

Local Health Departments’ Costs of Providing Environmental Health Services

Background: A detailed understanding of the costs that local health departments (LHDs) incur in the provision of public health services plays an important role in their efforts to provide services in an effective and efficient manner. However, surprisingly little evidence exists about the key cost components that LHDs incur in the provision of services. Purpose: The purpose of this report was to provide empirical estimates of LHDs’ cost structure. Methods: Using cost information for 2012 from 15 LHDs in North Carolina for two public health services—food and lodging and onsite water—this report first presents estimates of the total costs per service provided. In a second step, total costs are decomposed into key components, including direct and indirect costs. Both data collection and analysis were conducted in 2014. Results: For the LHDs examined in this report, median cost per service amounted to $145 for food and lodging and$82 for onsite water. Service costs, however, varied widely across agencies. Decomposition showed that direct labor costs represented more than 80% of total costs. Other direct costs accounted for 10% to 15% of total costs, while indirect costs represented 5% to 6% of total costs. Implications: The finding that labor costs represent a majority of the total costs of service provision has important implications for public health practitioners. Perhaps most importantly, for the purpose of costing public health services, estimation procedures may be simplified by focusing primarily on the cost of labor required to provide any given service

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

Health Communication as a Public Health Training and Workforce Development Issue

Effective communication is one of the core competencies for public health professionals and is required for local health department (LHD) accreditation. Public health communication specialists play a critical role as conduits of health information, particularly with regard to managing relationships with media and the message that is ultimately represented by news outlets. However, capacity for engagement with traditional media in community health improvement at the local level has not been well-described. As part of a larger study examining the use and impact of the County Health Rankings in North Carolina, LHD media staffing and interaction with traditional media were examined through a cross-sectional, online survey, administered to North Carolina LHDs. Results indicate that most LHDs in North Carolina have staff designated to work with media, but few have dedicated staff or staff with an educational background in mass communication. Most communication staff enter their position with less than one year of experience, though almost all receive some training once on the job. Press releases are issued relatively infrequently, which implies that media engagement and message management are underdeveloped at the local level. These results suggest that health communication specialists are underutilized in LHDs and these skills should be emphasized in LHD hiring practices and in public health workforce development

Designing for Dissemination: Lessons in Message Design from 1-2-3 Pap

Despite a large number of evidence-based health communication interventions tested in private, public, and community health settings, there is a dearth of research on successful secondary dissemination of these interventions to other audiences. This article presents the case study of 1-2-3 Pap, a health communication intervention to improve human papillomavirus (HPV) vaccination uptake and Pap testing outcomes in Eastern Kentucky, and explores strategies used to disseminate this intervention to other populations in Kentucky, North Carolina, and West Virginia. Through this dissemination project, we identified several health communication intervention design considerations that facilitated our successful dissemination to these other audiences; these intervention design considerations include (a) developing strategies for reaching other potential audiences, (b) identifying intervention message adaptations that might be needed, and (c) determining the most appropriate means or channels by which to reach these potential future audiences. Using 1-2-3 Pap as an illustrative case study, we describe how careful planning and partnership development early in the intervention development process can improve the potential success of enhancing the reach and effectiveness of an intervention to other audiences beyond the audience for whom the intervention messages were originally designed

Addressing Psychological, Mental Health and Other Behavioral Health Care Needs of the Underserved Populations in the U.S.: Role of Local Health Departments

Aims: (1) To assess the extent to which local health departments (LHDs) implement and evaluate strategies to target the behavioural healthcare needs for the underserved populations and (2) to identify factors that are associated with these undertakings. Methods: Data for this study were drawn from the 2013 National Profile of Local Health Departments Study conducted by National Association of County and City Health Officials. A total of 505 LHDs completed the Module 2 questionnaire of the Profile Study, in which LHDs were asked whether they implemented strategies and evaluated strategies to target the behavioural healthcare needs of the underserved populations. To assess LHDs’ level of engagement in assuring access to behavioural healthcare services, descriptive statistics were computed, whereas the factors associated with assuring access to these services were examined by using logistic regression analyses. To account for complex survey design, we used SVY routine in Stata 11. Results: Only about 24.9% of LHDs in small jurisdiction ( Conclusions: The extent to which the LHDs implemented or evaluated strategies to target the behavioural healthcare needs of the underserved population varied by geographic regions and jurisdiction types. Different community needs or different state Medicaid programmes may have accounted for these variations. LHDs could play an important role in improving equity in access to care, including behavioural healthcare services in the communities

Factors Driving Local Health Departments\u27 Partnerships With Other Organizations in Maternal and Child Health, Communicable Disease Prevention, and Chronic Disease Control

Objectives: To describe levels of partnership between local health departments (LHDs) and other community organizations in maternal and child health (MCH), communicable disease prevention, and chronic disease control and to assess LHD organizational characteristics and community factors that contribute to partnerships. Data Sources: Data were drawn from the National Association of County & City Health Officials\u27 2013 National Profile Study (Profile Study) and the Area Health Resources File. LHDs that received module 1 of the Profile Study were asked to describe the level of partnership in MCH, communicable disease prevention, and chronic disease control. Levels of partnership included “not involved,” “networking,” “coordinating,” “cooperating,” and “collaborating,” with “collaborating” as the highest level of partnership. Covariates included both LHD organizational and community factors. Data analyses were conducted using Stata 13 SVY procedures to account for the Profile Study\u27s survey design. Results: About 82%, 92%, and 80% of LHDs partnered with other organizations in MCH, communicable disease prevention, and chronic disease control programs, respectively. LHDs having a public health physician on staff were more likely to partner in chronic disease control programs (adjusted odds ratio [AOR] = 2.33; 95% confidence interval [CI], 1.03-5.25). Larger per capita expenditure was also associated with partnerships in MCH (AOR = 2.43; 95% CI, 1.22-4.86) and chronic disease prevention programs (AOR = 1.76; 95% CI, 1.09-2.86). Completion of a community health assessment was associated with partnership in MCH (AOR = 7.26; 95% CI, 2.90-18.18), and chronic disease prevention (AOR = 5.10; 95% CI, 2.28-11.39). Conclusion: About 1 in 5 LHDs did not have any partnerships in chronic disease control. LHD partnerships should be promoted to improve care coordination and utilization of limited health care resources. Factors that might promote LHDs\u27 partnerships include having a public health physician on staff, higher per capita expenditure, and completion of a community health assessment. Community context likely influences types and levels of partnerships. A better understanding of these contextual factors may lead to more complete and effective LHD partnerships