Athena Pantazis

Targeted health department expenditures benefit birth outcomes at the county level

BACKGROUND Public health leaders lack evidence for making decisions about the optimal allocation of resources across local health department (LHD) services, even as limited funding has forced cuts to public health services while local needs grow. A lack of data has also limited examination of the outcomes of targeted LHD investments in specific service areas. PURPOSE This study used unique, detailed LHD expenditure data gathered from state health departments to examine the influence of maternal and child health (MCH) service investments by LHDs on health outcomes. METHODS A multivariate panel time-series design was used in 2013 to estimate ecologic relationships between 2000-2010 LHD expenditures on MCH and county-level rates of low birth weight and infant mortality. The unit of analysis was 102 LHD jurisdictions in Washington and Florida. RESULTS Results indicate that LHD expenditures on MCH services have a beneficial relationship with county-level low birth weight rates, particularly in counties with high concentrations of poverty. This relationship is stronger for more targeted expenditure categories, with expenditures in each of the three specific examined MCH service areas demonstrating the strongest effects. CONCLUSIONS Findings indicate that specific LHD investments in MCH have an important effect on related health outcomes for populations in poverty and likely help reduce the costly burden of poor birth outcomes for families and communities. These findings underscore the importance of monitoring the impact of these evolving investments and ensuring that targeted, beneficial investments are not lost but expanded upon across care delivery systems.

Space–time smoothing of complex survey data: Small area estimation for child mortality

Many people living in low and middle-income countries are not covered by civil registration and vital statistics systems. Consequently, a wide variety of other types of data including many household sample surveys are used to estimate health and population indicators. In this paper we combine data from sample surveys and demographic surveillance systems to produce small area estimates of child mortality through time. Small area estimates are necessary to understand geographical heterogeneity in health indicators when full-coverage vital statistics are not available. For this endeavor spatio-temporal smoothing is beneficial to alleviate problems of data sparsity. The use of conventional hierarchical models requires careful thought since the survey weights may need to be considered to alleviate bias due to non-random sampling and non-response. The application that motivated this work is estimation of child mortality rates in five-year time intervals in regions of Tanzania. Data come from Demographic and Health Surveys conducted over the period 1991-2010 and two demographic surveillance system sites. We derive a variance estimator of under five years child mortality that accounts for the complex survey weighting. For our application, the hierarchical models we consider include random effects for area, time and survey and we compare models using a variety of measures including the conditional predictive ordinate (CPO). The method we propose is implemented via the fast and accurate integrated nested Laplace approximation (INLA).

Classifying Local Health Departments on the Basis of the Constellation of Services They Provide

OBJECTIVES We explored service variation among local health departments (LHDs) nationally to allow systematic characterization of LHDs by patterns in the constellation of services they deliver. METHODS We conducted latent class analysis by using categorical variables derived from LHD service data collected in 2008 for the National Profile of Local Health Departments Survey and before service changes resulting from the national financial crisis. RESULTS A 3-class solution produced the best fit for this data set of 2294 LHDs. The 3 configurations of LHD services depicted an interrelated set of narrow or limited service provision (limited), a comprehensive (core) set of key services provided, and a third class of core and expanded services (core plus), which often included rare services. The classes demonstrated high geographic variability and were weakly associated with expenditure quintile and urban or rural location. CONCLUSIONS This empirically derived view of how LHDs organize their array of services is a unique approach to categorizing LHDs, providing an important tool for research and a gauge to monitor how changes in LHD service patterns occur.

Social patterns and differentials in the fertility transition in the context of HIV/AIDS: evidence from population surveillance, rural South Africa, 1993 – 2013

Literature is limited on the effects of high prevalence HIV on fertility in the absence of treatment, and the effects of the introduction of sustained access to antiretroviral therapy (ART) on fertility. We summarize fertility patterns in rural northeast South Africa over 21 years during dynamic social and epidemiological change. We use data for females aged 15–49 from the Agincourt health and socio-demographic surveillance system (1993–2013). We use discrete time event history analysis to summarize patterns in the probability of any birth. Overall fertility declined in 2001–2003, increased in 2004–2011, and then declined in 2012–2013. South Africans showed a similar pattern. Mozambicans showed a different pattern, with strong declines prior to 2003 before stalling during 2004–2007, and then continued fertility decline afterwards. There was an inverse gradient between fertility levels and household socioeconomic status. The gradient did not vary by time or nationality. The fertility transition in rural South Africa shows a pattern of decline until the height of the HIV/AIDS pandemic, with a resulting stall until further decline in the context of ART rollout. Fertility patterns are not homogenous among groups.

A parsimonious characterization of change in global age-specific and total fertility rates

This study aims to understand trends in global fertility from 1950-2010 though the analysis of age-specific fertility rates. This approach incorporates both the overall level, as when the total fertility rate is modeled, and different patterns of age-specific fertility to examine the relationship between changes in age-specific fertility and fertility decline. Singular value decomposition is used to capture the variation in age-specific fertility curves while reducing the number of dimensions, allowing curves to be described nearly fully with three parameters. Regional patterns and trends over time are evident in parameter values, suggesting this method provides a useful tool for considering fertility decline globally. The second and third parameters were analyzed using model-based clustering to examine patterns of age-specific fertility over time and place; four clusters were obtained. A country’s demographic transition can be traced through time by membership in the different clusters, and regional patterns in the trajectories through time and with fertility decline are identified.

Developing the Evidence for Public Health Systems to Battle Vaccine Preventable Disease at the Local Level: Data Challenges and Strategies for Advancing Research

Context: Generally decreasing local health department (LHD) resources devoted to immunization programs and changes in LHD roles in immunization services represent major shifts in a core LHD service. Objective: Within a rapidly changing immunization landscape and emerging vaccine preventable disease outbreaks, our objective was to examine how LHD immunization expenditures are related to county-level immunization coverage and pertussis rates. Design: We used a practice-based approach in which we collaborated with practice partners and uniquely detailed LHD immunization expenditure data. Our analyses modeled the ecologic relationship between LHD immunization expenditures and LHD system performance and health outcomes. Setting: This study was launched through a consortium of public health Practice-Based Research Network states as part of a suite of studies examining the relationship between various LHD service-related expenditures and health outcomes. Participants: We investigated and sought to include all LHDs in the states of Florida, New York (except New York Citys LHD), and Washington. Outcome Measures: With LHD immunization expenditures as our independent variable, our outcomes were 1 year of jurisdiction-level rates of toddler immunization completeness, to measure immunization system performance, and 11 years of annual jurisdiction-level numbers of pertussis cases per 100 000 population, to measure related health outcomes. Results: Immunization completeness and pertussis rates varied greatly, but our models did not produce significant results despite numerous analytic approaches and while controlling for other factors. Conclusion: While our study was part of a suite of studies using similar methods and producing significant results, this study was instead challenged by serious data limitations and highlighted the gap in consistent, standardized data that can support critically needed evidence regarding immunization rates and disease. With LHDs at the epicenter of reducing vaccine preventable disease, it is vital to utilize emerging opportunities to understand the nature of their efforts in immunization coverage and disease prevention.