John Marx

Local Health Departments' Mission to the Uninsured

It is often maintained that local health departments (LHDs) should not directly provide personal health services. However, our nationally representative sample revealed that most LHD directors (87%) believed LHDs must directly provide these services, primarily because they perceived a high level of unmet need among the uninsured. While only a minority believed LHDs should focus exclusively on the core functions, this proportion rose dramatically when we asked directors to assume that there were no uninsured people. Directors who perceived a high level of unmet need among the uninsured in their jurisdictions were much less likely to believe that LHDs should exclusively focus on the core functions. In theory, LHDs have a unique responsibility for assuring that the uninsured and vulnerable have access to personal health services. However, a majority of directors (67%) acknowledged that they have no enforceable means of assuring access to services the health department did not directly provide.

Perceived Outcomes of Public Health Privatization: A National Survey of Local Health Department Directors

Almost three quarters of the nations local health departments (LHDs) have privatized some services. About half of LHD directors who privatized services reported cost savings and half reported that privatization had facilitated their performance of the core public health functions. Expanded access to services was the most commonly reported positive outcome. Of those privatizing, over two-fifths of LHDs reported a resulting increase in time devoted to management. Yet, one-third of directors reported difficulty monitoring and controlling services that have been contracted out. Communicable disease services was cited most often as a service that should not be privatized. There is a pervasive concern that by contracting out services, health departments can lose the capacity to respond to disease outbreaks and other crises.

Services Privatized in Local Health Departments: A National Survey of Practices and Perspectives

Privatization of public health is seemingly an oxymoron. Functions such as environmental regulation and communicable disease control would seem to be the unique purview of governmental public health departments. These services constitute public goods in that they affect entire communities, whereas personal health services are private goods, privately consumed by individuals.1 Recent pressures such as the penetration of managed care has led to shifts in personal health service provision from the public to the private sector and to various forms of public–private collaboration.2,3 However, some privatization theorists contend that public goods cannot be as effectively provided by the private sector. Others contend that even certain private goods, such as personal health services, should not be contracted out to the private sector.1 These opinions suggest that research on privatization in local health departments should examine the specific services, both public and private, that have been contracted out, a task previous studies of such health departments have not systematically addressed (L. Whitehand, M. Bechamps, and R. Bialek, unpublished data, 1997).4–15 Other articles based on the national survey of local health department directors described here have not outlined in detail the specific services privatized.16 In the present study, we examined the specific services privatized, the profit vs nonprofit status of contractors, and directors’ views about what services should not be privatized.

Financial distress and depressive symptoms among African American women: identifying financial priorities and needs and why it matters for mental health.

Prior research found that financial hardship or distress is one of the most important underlying factors for depression/depressive symptoms, yet factors that contribute to financial distress remain unexplored or unaddressed. Given this, the goals of the present study were (1) to examine the relationship between perceived financial distress and depressive symptoms, and (2) to identify financial priorities and needs that may contribute to financial distress. Surveys from 111 African American women, ages 18–44, who reside in Allegheny County, PA, were used to gather demographic information and measures of depressive symptoms and financial distress/financial well-being. Correlation and regression analyses revealed that perceived financial distress was significantly associated with levels of depressive symptoms. To assess financial priorities and needs, responses to two open-ended questions were analyzed and coded for common themes: “Imagine you won a

Untapped Resources: Exploring the Need to Invest in Doctor of Public Health–Degree Training and Leadership Development

10,000 prize in a local lottery. What would you do with this money?” and “What kinds of programs or other help would be beneficial to you during times of financial difficulties?” The highest five priorities identified by the participants were paying bills and debt, saving, purchasing a home or making home repairs, and/or helping others. The participant’s perceived needs during times of financial difficulty included tangible assistance and/or financial education. The findings from this study can be used to create new and/or enhance existing programs, services, and/or interventions that focus on the identified financial priorities and needs. Collaborative efforts among professionals in different disciplines are also needed, as ways to manage and alleviate financial distress should be considered and discussed when addressing the mental health of African American women.

Managerial and professional beliefs influencing public health privatization: Results of a national survey of local health department directors

As stated in the Institute of Medicine report Who Will Keep the Public Healthy? the doctor of public health (DrPH) degree is offered for advanced training in public health leadership.1 The Association of Schools of Public Health (ASPH) classifies the DrPH as a professional degree, as opposed to the more academic, research-oriented PhD degree.2 As a professional degree, the DrPH is oriented toward practice (i.e., the strategic, interdisciplinary application of knowledge and skills necessary to execute the public health core functions of assessment, policy development, and assurance3) in public health settings, including community, state, federal, and international agencies.2 These descriptions of the DrPH degree are consistent with those presented on the Web sites of the 23 of 38 ASPH-accredited schools of public health that offer the degree.4 Based on these widely endorsed descriptions of the DrPH degree, it is appropriate to recognize it as the highest professional degree in public health. Unfortunately, despite the degree’s significance, there is currently no national competency model for DrPH training. In addition, the fieldwide leadership role of DrPH practitioners is relatively undefined. Incomplete and inefficient treatment, combined with the collapse of public health systems in Abkhazia, have helped create strains of bacilli that are resistant to antituberculosis drugs. Used with permission of Aurora Photos. Copyright by Serge Sibert/Cosmos/Aurora.

Healthcare providers’ perspectives on expedited partner therapy for chlamydia: a qualitative study

This article describes managerial and professional beliefs underlying decisions to privatize public health services. We drew a stratified, nationally representative sample of local health departments and interviewed 347 department directors by telephone. We used logistic regression to establish the independent effects of various beliefs on the decision to privatize. Over half of directors did not believe that there was valid evidence that privatization results in more efficient performance, and those who believed there was such evidence were not more likely to privatize. However, directors held professional and managerial beliefs that influenced their decision to privatize. Directors most likely to privatize were those who believed that local health departments should exclusively focus on the core public health functions, those who asserted that public health should become involved in an increasingly diverse array of social problems, and those who believed that employees should be used on a temporary and contractual, rather than permanent, basis wherever possible.

Mechanisms of Adherence in a Harm Reduction Housing Program

Objectives Expedited partner therapy (EPT) effectively reduces rates of reinfection with chlamydia and increases the number of partners treated for the infection. Healthcare provider (HCP) provision of EPT is low. The objective of this qualitative study was to understand HCP views and opinions regarding the use of EPT in a state where EPT is permissible but underused. Methods Using a purposive sampling strategy to include diverse HCPs who treat young women at risk for chlamydia, 23 semistructured, in-depth interviews were conducted between October and December 2013. The interviews included questions about knowledge, attitudes, experiences with, and barriers and facilitators regarding the use of EPT. Results Many respondents report using EPT and believe the practice is beneficial for their patients. Most providers were unaware of their colleagues’ practices and had limited knowledge regarding institutional policies around EPT. HCPs noted a variety of barriers, such as fear of liability, confusion around the legal status of EPT and not being able to counsel patients’ partners that make routine use of this practice a challenge. Facilitators of EPT include speaking on the phone with patients’ partners and establishing legislation enabling EPT. Conclusions This is the first study to qualitatively examine HCPs’ perspectives on EPT in the USA. Barriers to EPT, including concerns about counselling patients’ partners and the legal status of EPT, can be overcome. EPT recommendations could include the use of phone calls as part of their guidelines. Changing EPT legislation at the state level in the USA is an important factor to facilitate EPT use.

Intimate partner violence, partner notification, and expedited partner therapy: a qualitative study

Advances in clinical therapies for people living with HIV have greatly increased life expectancies, but the high levels of adherence that are necessary for clinical success are infrequently achieved, especially for chronically homeless substance users. The Open Door is a harm reduction housing program that seeks to improve clinical outcomes for this population. We present findings from qualitative interviews with residents of the program, conducted to explore facilitators of residents’ success in the program, which is ultimately defined as HIV clinical adherence. Two major themes developed. Positive changes captures processes or characteristics that residents reported as having changed as a result of living in the program. Mechanisms of success reflects aspects of the program to which residents attributed their improved adherence. Given that improving adherence in vulnerable populations has both clinical and public health implications, our study suggests future avenues for research and foundations on which to build future interventions.

Ideological Primary Groups in Contemporary Cultural Movements

Summary Over one-third of women experience intimate partner violence (IPV) in their lifetime. IPV increases the risk of infection and re-infection with sexually transmitted infections (STIs). The extent to which health care providers consider IPV when recommending partner notification and expedited partner therapy is unknown. The objective of this qualitative study was to understand health care providers’ views on IPV and STIs when recommending partner treatment to patients with chlamydia. Using a purposive sampling strategy to include health care providers who treat young women at risk for chlamydia, 23 semi-structured, in-depth interviews were conducted. While some health care providers expressed concern for their patients’ safety and believed assessing for IPV was needed before provision of expedited partner therapy, nearly a third had not considered the links between IPV and STIs. Strategies used by health care providers to assess for IPV did not include inquiry about specific behaviours related to IPV, STI risk, and sexual coercion. Many health care providers understand the risk for IPV in the setting of STI treatment, yet a significant portion of those interviewed failed to recognise the link between IPV and STIs. Provider education is necessary to increase knowledge and implement more effective inquiry and counselling about IPV to more safely recommend expedited partner therapy.