Carolyn J. Leep

Impact of the 2008-2010 economic recession on local health departments.

We measured the impact of the 2008-2010 economic recession on local health departments (LHDs) across the United States. Between 2008 and 2010, we conducted 3 Web-based, cross-sectional surveys of a nationally representative sample of LHDs to assess cuts to budgets, workforce, and programs. By early 2010, more than half of the LHDs (53%) were experiencing cuts to their core funding. In excess of 23 000 LHDs jobs were lost in 2008-2009. All programmatic areas were affected by cuts, and more than half of the LHDs had to reduce or eliminate at least 1 programmatic area. The capacity of LHDs to provide core public health services was undermined by the economic recession.

2005 National profile of local health departments.

The National Association of County and City Health Officials (NACCHO) is the national organization representing local health departments. NACCHO supports efforts that protect and improve the health of all people and all communities by promoting national policy, developing resources and programs, seeking health equity, and supporting effective local public health practice and systems.

Quality improvement in local health departments: results of the NACCHO 2008 survey.

OBJECTIVES To assess the current status of quality improvement (QI) within local health departments (LHDs) and examine the characteristics associated with such QI efforts. METHODS A QI module was administered to a representative sample of 545 LHDs along with the core instrument in the 2008 NACCHO Profile survey of all LHDs nationally. Using the Profile survey data set, a quantitative approach was employed to determine the current status of QI within LHDs. Statistical analysis was performed to identify characteristics of LHDs associated with QI. The response rate to the QI module was 82 percent. RESULTS Of the 448 LHDs that responded to the QI Module, 55 percent reported conducting formal QI efforts during the previous 2 years. Forty-four percent of these LHDs used a specific framework for QI, 56 percent used at least one of four commonly employed QI tools or techniques, and customer focus and satisfaction was the most frequently reported area (76%) of QI efforts. LHDs with large size of jurisdiction population and those with centralized governance were more likely to have engaged in quality or performance improvement, have managers who received formal QI training, and have provided QI training to staff. CONCLUSION The 2008 NACCHO Profile QI module furnishes an excellent baseline for measuring progress of health department QI activities as accreditation and other related activities intensify. A clear definition of QI in public health that is understood by practitioners will greatly increase our ability to measure the adoption of QI by LHDs. Further research is necessary to identify and explore some of the predictors and possible barriers to increasing the application of QI by LHDs.

Quality improvement in local health departments: progress, pitfalls, and potential.

OBJECTIVES To assess the current deployment of quality improvement (QI) approaches within local health departments (LHDs) and gain a better understanding of the depth and intensity of QI activities. METHODS A mixed quantitative and qualitative approach was employed to determine the current status of QI utilization within LHDs. All respondents from the 2005 NACCHO Profile QI module questionnaire who indicated that their LHD was involved in some kind of QI activity received a follow-up Web-based survey in 2007. A smaller convenience sample of 30 LHDs representing all groups of respondents was selected for the follow-up interview to validate and expound upon survey data. RESULTS Survey response rate was 62 percent (181/292). Eighty-one percent of LHDs reported QI programmatic activities, with 39 percent occurring agency-wide. Seventy-four percent of health departments had staff trained in QI methods. External funding sources for QI were infrequent (28%). LHDs that were serving large jurisdictions and LHDs that were subunits of state health agencies (centralized states) were more likely to engage in most QI activities. However, interview responses did not consistently corroborate survey results and noted a need for shared definitions. CONCLUSION Multiple factors, including funders and accreditation, may be driving the increase of QI for public health. Additional research to confirm and validate these findings is necessary. A common QI vocabulary is also recommended.

The proof's in the partnerships: Are affordable care act and local health department accreditation practices influencing collaborative partnerships in community health assessment and improvement planning?

The strengthened requirement for nonprofit hospitals to complete a community health needs assessment and implementation plan in the Affordable Care Act, concurrent with a new voluntary accreditation process for local health departments that requires collaborative community health assessments and community health improvement plans, have led to a resurgence of interest in assessment and improvement planning. This study provides baseline data that will help determine whether the Affordable Care Act and public health accreditation will result in more collaborative community assessment and community health improvement activity by describing trends in collaborative community health assessment and community health improvement plan activities. Data sources include the National Profile of Local Health Departments studies and a database of community health assessment, community health needs assessment, community health improvement plan, and other implementation planning reports from across the country. The study finds that collaborative community assessment activity is positively associated with population size, governance type, and local health department and coalition-led efforts.

Reductions of Budgets, Staffing, and Programs Among Local Health Departments: Results From NACCHOʼs Economic Surveillance Surveys, 2009-2013

OBJECTIVES To provide an overview of budget cuts, job losses, and program reductions among local health departments (LHDs) and to examine the association between LHD infrastructure characteristics and the likelihood of budget cuts. DESIGN Data from 4 waves of the economic surveillance survey (July-August 2009, September-November 2010, January-February 2012, and January-March 2013) conducted by the National Association of County & City Health Officials were analyzed to assess cuts to budgets, jobs, and programs since 2009. Data from the 2013 National Profile of Local Health Departments survey were used to assess the infrastructural characteristics associated with budget cuts. RESULTS When asked in early 2013, more than a quarter of LHDs (26.9%) reported a reduced budget, continuing the trend of a substantial proportion of LHDs experiencing financial hardship in recent years. The percentages of LHDs that made cuts to programmatic areas fluctuated from year to year but have never been lower than 40%. Maternal and child health services were among areas most often cut during all 4 time points of the survey. Governance type, total expenditures, and percentage of revenues from local sources were significantly associated with LHD budget cuts. CONCLUSIONS Cuts in LHD budgets, staff, and activities have been widespread for a period that lasted long after the official end of the Great Recession. There is a great need for substantive and consistent funding to ensure the retention of the workforce and the delivery of essential public health services.

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.

Community Health Assessment by Local Health Departments: Presence of Epidemiologist, Governance, and Federal and State Funds are Critical

Using the data from the National Association of County and City Health Officials’ (NACCHO) 2010 Profile of Local Health Departments (LHDs) our study investigates whether or not infrastructural characteristics of LHDs were associated with completion of community health assessment (CHA). Our results show that local and shared LHD governance, greater share of revenue from federal and state sources, smaller population size in LHD jurisdiction, and having an epidemiologist significantly increased the odds of CHA completion in the past, after controlling for community characteristics and other independent variables. These findings have important implications for LHDs, PHAB and its partners.

Evidence-based public health practice among program managers in local public health departments.

OBJECTIVES We assessed the use of administrative-evidence based practices (A-EBPs) among managers of programs in chronic diseases, environmental health, and infectious diseases from a sample of local health departments (LHDs) in the United States. DESIGN Program managers completed a survey consisting of 6 sections (biographical data, use of A-EBPs, diffusion attributes, use of resources, and barriers to, and competencies in, evidence-based public health), with a total of 66 questions. PARTICIPANTS The survey was sent electronically to 168 program managers in chronic diseases, 179 in environmental health, and 175 in infectious diseases, representing 228 LHDs. The survey had previously been completed by 517 LHD directors. MEASURES The use of A-EBPs was scored for 19 individual A-EBPs, across the 5 A-EBP domains, and for all domains combined. Individual characteristics were derived from the survey responses, with additional data on LHDs drawn from linked National Association of County & City Health Officials Profile survey data. Results for program managers were compared across the 3 types of programs and to responses from the previous survey of LHD directors. The scores were ordered and categorized into tertiles. Unconditional logistic regression models were used to calculate odds ratios and 95% confidence intervals, comparing individual and agency characteristics for those with the highest third of A-EBPs scores with those with the lowest third. RESULTS The 332 total responses from program managers represented 196 individual LHDs. Program managers differed (across the 3 programs, and compared with LHD directors) in demographic characteristics, education, and experience. The use of A-EBPs varied widely across specific practices and individuals, but the pattern of responses from directors and program managers was very similar for the majority of A-EBPs. CONCLUSIONS Understanding the differences in educational background, experience, organizational culture, and performance of A-EBPs between program managers and LHD directors is a necessary step to improving competencies in evidence-based public health.

Changes in Public Health Workforce Composition: Proportion of Part-Time Workforce and Its Correlates, 2008-2013

BACKGROUND State and local public health department infrastructure in the U.S. was impacted by the 2008 economic recession. The nature and impact of these staffing changes have not been well characterized, especially for the part-time public health workforce. PURPOSE To estimate the number of part-time workers in state and local health departments (LHDs) and examine the correlates of change in the part-time LHD workforce between 2008 and 2013. METHODS We used workforce data from the 2008 and 2013 National Association of County and City Health Officials (n=1,543) and Association of State and Territorial Health Officials (n=24) profiles. We employed a Monte Carlo simulation to estimate the possible and plausible proportion of the workforce that was part-time, over various assumptions. Next, we employed a multinomial regression assessing correlates of the change in staffing composition among LHDs, including jurisdiction and organizational characteristics, as well measures of community involvement. RESULTS Nationally representative estimates suggest that the local public health workforce decreased from 191,000 to 168,000 between 2008 and 2013. During that period, the part-time workforce decreased from 25% to 20% of those totals. At the state level, part-time workers accounted for less than 10% of the total workforce among responding states in 2013. Smaller and multi-county jurisdictions employed relatively more part-time workers. CONCLUSIONS This is the first study to create national estimates regarding the size of the part-time public health workforce and estimate those changes over time. A relatively small proportion of the public health workforce is part-time and may be decreasing.