Paul C. Erwin

Estimated energy expenditures for school-based policies and active living

BACKGROUND Despite overwhelming evidence of the health benefits of physical activity, most American youth are not meeting the 60 minutes per day recommendation for moderate- to vigorous-intensity physical activity (MVPA). Policy changes have the potential to bring about substantial increases in physical activity in youth, within school and community settings. PURPOSE The purpose of this study was to quantify the increase in energy expenditure for school-based policies and built environment changes. METHODS Scientific literature reviews were consulted, and more than 300 published studies (1995-2011) in English were identified based on titles and abstracts. After an initial screening, 85 articles were included. Study quality was assessed, and the impact of various strategies for increasing physical activity in youth was estimated from objective measurements/direct observation. RESULTS Within school settings, the average minutes of MVPA gained per school day for studies in each intervention category were as follows: mandatory physical education (23 minutes); classroom activity breaks (19 minutes); afterschool activity programs (10 minutes); standardized physical education curricula (6 minutes more than traditional physical education); modified playgrounds (6 minutes); and modified recess (5 minutes more than traditional recess). Within community settings, significant MVPA was associated with active commuting (16 minutes) and park renovations (12 minutes), but proximity to parks had a small effect (1 minute). No conclusions could be drawn regarding joint-use agreements, because of a lack of studies quantifying their impact on energy expenditure. CONCLUSIONS Of the various policies and built environment changes examined, the largest effects were seen with mandatory physical education, classroom activity breaks, and active commuting to school. Policymakers can use this information along with estimates of the cost, feasibility, and population reach, to identify the best options for increasing physical activity in youth.

The performance of local health departments: a review of the literature.

Local health department (LHD) performance measurement provides an opportunity to link inputs, outputs, and outcomes in a manner that should facilitate quality improvement. Since inputs flow from LHDs that vary substantially in size, organization, funding, and other characteristics, it is Reasonable to assume that these variable inputs may affect LHD performance or outcomes. Documenting this is becoming increasingly important as LHD accreditation is being seen as one approach to standardization of inputs. This article provides a literature Review of LHD performance measurement and attempts to identify LHD inputs (or characteristics) that impact performance or outcomes. The literature Review identified 23 articles on LHD performance, published in peer-reviewed journals since the 1988 Report on the Future of Public Health. The most common findings Related to LHD size, jurisdictional size, and funding: LHDs with larger staffs, serving populations of more than 50 000 persons, and with higher funding per capita were more often higher performing. Other notable characteristics of higher-performing LHDs included greater community interaction, having a director with higher academic degrees, and leadership functioning within a management team. Prospective studies that examine the linkages among LHD performance measurement, accreditation, and outcomes will be important in achieving performance improvement over time.

The Association of Changes in Local Health Department Resources With Changes in State-Level Health Outcomes

We explored the association between changes in local health department (LHD) resource levels with changes in health outcomes via a retrospective cohort study. We measured changes in expenditures and staffing reported by LHDs on the 1997 and 2005 National Association of County and City Health Officials surveys and assessed changes in state-level health outcomes with the Americas Health Rankings reports for those years. We used pairwise correlation and multivariate regression to analyze the association of changes in LHD resources with changes in health outcomes. Increases in LHD expenditures were significantly associated with decreases in infectious disease morbidity at the state level (P = .037), and increases in staffing were significantly associated with decreases in cardiovascular disease mortality (P = .014), controlling for other factors.

Molecular Epidemiology of Foodborne Hepatitis A Outbreaks in the United States, 2003

BACKGROUND Molecular epidemiologic investigations can link geographically separate foodborne hepatitis A outbreaks but have not been used while field investigations are in progress. In 2003, outbreaks of foodborne hepatitis A were reported in multiple states. METHODS Case-control studies were conducted in 3 states. Hepatitis A virus was sequenced from serologic specimens from individuals associated with outbreaks and from individuals concurrently ill with hepatitis A in non-outbreak settings in the United States and Mexico. RESULTS Case-control studies in Tennessee (TN), North Carolina (NC), and Georgia (GA) found green onions to be associated with illness among restaurant patrons (TN: odds ratio [OR], 65.5 [95% confidence interval {CI}, 8.9-482.5; NC: OR, 2.4 [95% CI, 0.3-21.9]; GA: OR, 20.9 [95% CI, 3.9-110.3]). Viral sequences from TN case patients differed by 2 nt, compared with those from case patients in NC and GA. A third sequence, differing from the TN and GA/NC sequences by 1 nt, was identified among case patients in a subsequent outbreak in Pennsylvania. Each outbreak sequence was identical to > or =1 sequence isolated from northern Mexican resident(s) with hepatitis A. The sources of green onions served in restaurants in TN and GA were 3 farms in northern Mexico. CONCLUSIONS Ongoing viral strain surveillance facilitated the rapid implementation of control measures. Incorporation of molecular epidemiologic methods into routine hepatitis A surveillance would improve the detection of hepatitis A outbreaks and increase our understanding of hepatitis A epidemiology in the United States.

Mycobacterium tuberculosis transmission from human to canine.

A 71-year-old woman from Tennessee, USA with a 3-week history of a productive, nonbloody cough was evaluated. Chest radiograph showed infiltrates and atelectasis in the upper lobe of the right lung. A tuberculosis (TB) skin test resulted in a 14-mm area of induration. Sputum stained positive for acid-fast bacilli (AFB) and was positive for Mycobacterium tuberculosis by DNA probe and culture. Treatment was initiated with isoniazid, rifampicin, and pyrazinamide. After 14 days of daily, directly …

Capacity building for evidence-based decision making in local health departments: Scaling up an effective training approach

BackgroundThere are few studies describing how to scale up effective capacity-building approaches for public health practitioners. This study tested local-level evidence-based decision making (EBDM) capacity-building efforts in four U.S. states (Michigan, North Carolina, Ohio, and Washington) with a quasi-experimental design.MethodsPartners within the four states delivered a previously established Evidence-Based Public Health (EBPH) training curriculum to local health department (LHD) staff. They worked with the research team to modify the curriculum with local data and examples while remaining attentive to course fidelity. Pre- and post-assessments of course participants (n = 82) and an external control group (n = 214) measured importance, availability (i.e., how available a skill is when needed, either within the skillset of the respondent or among others in the agency), and gaps in ten EBDM competencies. Simple and multiple linear regression models assessed the differences between pre- and post-assessment scores. Course participants also assessed the impact of the course on their work.ResultsCourse participants reported greater increases in the availability, and decreases in the gaps, in EBDM competencies at post-test, relative to the control group. In adjusted models, significant differences (p < 0.05) were found in `action planning,’ `evaluation design,’ `communicating research to policymakers,’ `quantifying issues (using descriptive epidemiology),’ and `economic evaluation.’ Nearly 45% of participants indicated that EBDM increased within their agency since the training. Course benefits included becoming better leaders and making scientifically informed decisions.ConclusionsThis study demonstrates the potential for improving EBDM capacity among LHD practitioners using a train-the-trainer approach involving diverse partners. This approach allowed for local tailoring of strategies and extended the reach of the EBPH course.

Understanding administrative evidence-based practices: findings from a survey of local health department leaders.

BACKGROUND There are sparse data showing the extent to which evidence-based public health is occurring among local health departments. PURPOSE The purpose of the study was to describe the patterns and predictors of administrative evidence-based practices (structures and activities that are associated with performance measures) in a representative sample of local health departments in the U.S. METHODS A cross-sectional study of 517 local health department directors was conducted from October through December 2012 (analysis in January-March 2013). The questions on administrative evidence-based practices included 19 items based on a recent literature review (five broad domains: workforce development, leadership, organizational climate and culture, relationships and partnerships, financial processes). RESULTS There was a wide range in performance among the 19 individual administrative evidence-based practices, ranging from 35% for providing access to current information on evidence-based practices to 96% for funding via a variety of sources Among the five domains, values were generally lowest for organizational climate and culture (mean for the domain=49.9%) and highest for relationships and partnerships (mean for the domain=77.1%). Variables associated with attaining the highest tertile of administrative evidence-based practices included having a population jurisdiction of 25,000 or larger (adjusted ORs [aORs] ranging from 4.4 to 7.5) and state governance structure (aOR=3.1). CONCLUSIONS This research on the patterns and predictors of administrative evidence-based practices in health departments provides information on gaps and areas for improvement that can be linked with ongoing quality improvement processes.

Health Disparities in Rural Areas: The Interaction of Race, Socioeconomic Status, and Geography

The purpose of this study was to explore factors that may help explain the mortality differences between African Americans and Whites. This study was a retrospective analysis of data from Tennessee’s 95 counties. Standardized mortality ratios (SMRs) for African Americans were determined based on White, all-cause, age-specific mortality rates, and served as the dependent variable. Potential explanatory variables included measures of demography, socioeconomic status, and social environment. Bivariate and multivariate analyses showed a significant association between SMR and population density (t=2.18, p=.037) among 36 counties, with more than 20 African American deaths per year, and between SMR and the proportion of the population that is African American (t=2.23, p=.033) in an analysis that included all 95 counties. Mortality differences based on demographic characteristics, rather than on the usual social determinants of health, raise further questions about the root causes of health inequities.

Local Health Departments and the 2008 Recession: Characteristics of Resiliency

BACKGROUND The 2008 recession had a significant impact on local health departments (LHDs), with more than half of such agencies experiencing job losses and program cuts. PURPOSE To identify potential modifiable factors that can protect LHDs from job losses and budget cuts during future economic crises. METHODS This retrospective cohort study used data from 2005 and 2010 surveys of LHDs. The outcome of interest was financial resiliency for maintaining budgets during the recession and was based on the ratio of observed to predicted expenditures (O/E) per capita for 2010. Logistic regression was used to model the resiliency of the LHD with independent variables grouped around domains of organization, revenues, and services, with stratification by size of the LHD jurisdiction. Data were analyzed in 2013. RESULTS Of the 987 LHDs in the final data set, 328 (33.2%) were categorized as resilient and 659 (66.8%) as non-resilient. Overall, resilient LHDs received a higher percentage of revenues from non-local sources compared to non-resilient LHDs (p<0.05) and had a more diversified service mix, with significantly (p<0.05) more treatment, population, and regulatory services. In the final regression models, findings differed substantially across the stratifications of LHD jurisdictional population size, with no single independent or control variable significantly associated with resiliency across all population categories. CONCLUSIONS Funding streams and service mix may be modifiable characteristics, suggesting possible means for LHDs to weather future economic stress; however, these characteristics may be unique to the size of the population served.

Local health department and academic institution linkages for community health assessment and improvement processes: a national overview and local case study.

Community health improvement processes that yield community health assessments (CHAs) and community health improvement plans (CHIPs) provide data and a process to determine key community priorities and take action and are ideally collaborative endeavors. Nationally, increased focus on CHAs and CHIPs highlights the role that Academic Health Departments or other local health department (LHD)-academic linkages can play in completing CHAs and CHIPs. Drawn from the experiences of 5 LHD-academic partnerships that participated in a national demonstration and a detailed account of the experience of one, this article presents how such linkages can support CHA and CHIP work, ways to anticipate and overcome challenges, and the tangible benefits that may be realized for both the LHD and the academic partner. Community health improvement processes are ripe opportunities for LHD-academic linkages and can be fruitful and mutually beneficial partnerships to be used in completing CHAs and CHIPs to measurably improve the publics health.