Betty Bekemeier

Collaborative partnerships at the state level: promoting systems changes in public health infrastructure.

Reforms in the public health infrastructure such as those called for in recent Institute of Medicine reports require stakeholder engagement on different levels than traditional grass-roots community work. The Turning Point Initiative, funded by The Robert Wood Johnson Foundation, involves 21 state-wide partnerships established for systems change and focused in specific areas of public health innovation and policy development. These partnerships represent a different model of strategic alliances and relationship-building than has been previously described in the literature on community-level and health-promotion collaborations. This article utilizes qualitative data to illustrate the ways in which state-level partnerships for systems change both confirm and extend previous models. Findings indicate that state-level public health partnerships share many of the challenges and opportunities of locally-based and health-promotion-oriented partnerships. Collaboration at the state level, however, involves more attention to organizational alliances, coordination of institutional change, and strategic responses to political changes. These partnerships depend on a combination of interpersonal skills, material resources, and organizational savvy to manage complex planning and implementation processes. Influencing policy development and organizational redesign in public health systems requires nuanced understanding of the opportunities provided by various kinds of organizational partners.

Our Community in Focus The Use of Photovoice for Youth-Driven Substance Abuse Assessment and Health Promotion

The successful development and implementation of prevention curricula requires seeking strategies that combine the strengths of researchers and community members. Because young people are considered to be the experts in their own lives, it is important to determine effective ways to engage them in substance abuse assessment and prevention initiatives. The community-based participatory action research methodology of photovoice is one way to engage youth in assessment of this public health issue. “Our Community in Focus” was a project that used the photovoice methodology to engage high school youth in a community-based assessment of adolescent substance use and abuse. Through the photovoice method, youth were able to reflect their community’s strengths and concerns with regards to adolescent substance abuse, as they took photographs to answer the question “What contributes to adolescents’ decisions to use or not to use alcohol and other drugs?” The youth and the community were highly receptive to the project and its methodology, and photographs taken by photovoice participants presented a compelling argument for action.

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.

Applying Community-Based Participatory Research Partnership Principles to Public Health Practice-Based Research Networks

With real-world relevance and translatability as important goals, applied methodological approaches have arisen along the participatory continuum that value context and empower stakeholders to partner actively with academics throughout the research process. Community-based participatory research (CBPR) provides the gold standard for equitable, partnered research in traditional communities. Practice-based research networks (PBRNs) also have developed, coalescing communities of practice and of academics to identify, study, and answer practice-relevant questions. To optimize PBRN potential for expanding scientific knowledge, while bridging divides across knowledge production, dissemination, and implementation, we elucidate how PBRN partnerships can be strengthened by applying CBPR principles to build and maintain research collaboratives that empower practice partners. Examining the applicability of CBPR partnership principles to public health (PH) PBRNs, we conclude that PH-PBRNs can serve as authentic, sustainable CBPR partnerships, ensuring the co-production of new knowledge, while also improving and expanding the implementation and impact of research findings in real-world settings.

Local Public Health Delivery of Maternal Child Health Services: Are Specific Activities Associated with Reductions in Black–White Mortality Disparities?

To identify which MCH services delivered by local health departments (LHD) appear associated with reducing differences in Black–White mortality. We used a time-trend design to investigate relationships between change in MCH activities provided by LHDs in 1993 and in 2005 and changes in 1993–2005 Black–White mortality disparities. Secondary data were analyzed for 558 US counties and multi-county districts. Independent variables included the six MCH services provided by LHDs and captured in the 1993 and 2005 NACCHO Profile of Local Public Health Departments surveys. MCH service variables represented change in each service from 1993 to 2005. Control variables included selected LHD characteristics and county-level socioeconomic, demographic, and health provider resource data. Absolute change in Black and White mortality rates and changes in the mortality disparity “gap” between these rates in 1993 and 2005 were examined as dependent variables. Among the MCH services examined, prenatal care had a significant beneficial relationship with Black all-age mortality change and with reducing the mortality “gap.” Family planning services had a beneficial relationship with reducing the mortality “gap” for females in the jurisdictions in the study sample. WIC services indicated the most consistently beneficial relationship with both Black mortality and White mortality change, but these changes did not influence the mortality “gap” during the study period. LHD delivery of family planning and prenatal care by LHDs appears related to reductions in Black–White mortality disparities. Implications of this study suggest the importance of certain MCH services for reducing Black–White mortality disparities.

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.

A Public Health Nursing Research Agenda

Public health nurses (PHNs) use many interventions to prevent illness and promote the health of populations. Unfortunately, generating evidence regarding PHN practice is not explicitly identified as a research priority area of the major national funding agencies. Nor has PHN, as a profession, had a strong enough research agenda to drive practice improvement on a population-level and to drive funding to support such areas of research. To further advance the science needed to guide PHN practice, a national conference to set the research agenda was held in October 2010 with grant support from the Agency for Healthcare Research and Quality. The conference was part of a multimethod, participatory, multistage approach taken to generate the final research priority themes and corresponding priority research questions. The process yielded four high priority PHN research themes: PHN intervention models, Quality of population-focused PHN practice, Metrics of/for PHN, and comparative effectiveness and PHN outcomes. As the agenda is adopted by funding agencies, researchers, and practice-based partners, a more focused program of research will produce evidence that can guide population-focused PHN practice.

Relationships between local public health agency functions and agency leadership and staffing: a look at nurses.

UNLABELLED The United States is facing a severe shortage of well-trained public health workers, and public health nursing is the discipline with the greatest shortage. A local public health agencys (LPHAs) staffing and leadership characteristics are critical in determining its programs, performance, and capacity. A better understanding of the relationship between specific staffing and leadership characteristics and public health programs is needed to address this capacity challenge. METHOD Data from the 2005 National Profile of Local Health Departments, were examined to identify associations between an LPHAs nursing workforce and the specific activities performed by LPHAs. RESULTS LPHAs with a nurse as senior executive had a greater breadth of immunization, maternal/child health, and prevention activities than their nonnurse-led counterpart LPHAs, particularly in rural areas. Nurse-led LPHAs were less likely, however, to have a broad level of environmental health and regulation activities or to have recently conducted community assessment and planning activities. CONCLUSIONS Both LPHA nurse leaders and nursing staff play an important role in the provision of LPHA services, and a shortage of LPHA nursing leaders and staff, particularly in rural areas, will likely have a major impact on certain LPHA programs unless steps are taken to address these challenges.

Local Public Health Systems and the Incidence of Sexually Transmitted Diseases

OBJECTIVES We examined the associations of local public health system organization and local health department resources with county-level sexually transmitted disease (STD) incidence rates in large US health jurisdictions. METHODS We linked annual county STD incidence data (2005-2008) to local health department director responses (n = 211) to the 2006 wave of the National Longitudinal Study of Local Public Health Systems, the 2005 national Local Health Department Profile Survey, and the Area Resource File. We used nested mixed effects regression models to assess the relative contribution of local public health system organization, local health department financial and resource factors, and sociodemographic factors known to be associated with STD incidence to county-level (n = 307) STD incidence. RESULTS Jurisdictions with local governing boards had significantly lower county-level STD incidence. Local public health systems with comprehensive services where local health departments shoulder much of the effort had higher county-level STD rates than did conventional systems. CONCLUSIONS More integration of system partners in local public health system activities, through governance and interorganizational arrangements, may reduce the incidence and burden of STDs.

Three Population‐Patient Care Outcome Indicators for Public Health Nursing: Results of a Consensus Project

OBJECTIVES Difficulties in recruiting nurses into public health settings threaten the publics health. Gaps in existing data make determining the health impact of workforce changes numbers difficult to perform. Public health practice leaders are left to make difficult staffing and program decisions without knowing how the health of their vulnerable populations will be affected. The objective of this study was to identify indicators that could be used to document the effect of the shortage of public health nurses (PHNs) on the health of a population. DESIGN AND SAMPLE A consensus-building process was used. Nursing directors from 6 local health departments (LHDs) in 2 states participated along with 3 public health system researchers. RESULTS The findings from this collaborative process suggest that it is possible to identify outcome indicators across states and multiple LHDs that may be sensitive to PHN staffing levels and interventions. Possible connections between PHN staffing and each population-patient care indicator (rates of Chlamydia, first trimester prenatal care, early childhood immunization) are presented. CONCLUSIONS The process used here in identifying these indicators and the proposed nursing-sensitive population outcome indicators themselves provide a template for the development and analysis of additional outcome indicators sensitive to the quality of nursing and other health care.