Richard C. Ingram

Public Health Delivery Systems: Evidence, Uncertainty, and Emerging Research Needs

The authors review empirical studies published between 1990 and 2007 on the topics of public health organization, financing, staffing, and service delivery. A summary is provided of what is currently known about the attributes of public health delivery systems that influence their performance and outcomes. This review also identifies unanswered questions, highlighting areas where new research is needed. Existing studies suggest that economies of scale and scope exist in the delivery of public health services, and that key organizational and governance characteristics of public health agencies may explain differences in service delivery across communities. Financial resources and staffing characteristics vary widely across public health systems and have expected associations with service delivery and outcomes. Numerous gaps and uncertainties are identified regarding the mechanisms through which organizational, financial, and workforce characteristics influence the effectiveness and efficiency of public health service delivery. This review suggests that new research is needed to evaluate the effects of ongoing changes in delivery system structure, financing, and staffing.

Public Health Performance

This review examines past, current, and future issues in developing and using public health performance data for improving the public health system. Issues are explored relating to public health performance data collection and analysis, and inferences made from those data, largely by examining public health performance data collected since the Year 2000. More research is needed to improve understanding of the context in which public health systems operate and how that context affects performance and its relationship to health outcomes. There are major areas of concern that must be addressed by the public health practice organizations, governmental public health entities, and the public health systems research communities, such as ensuring that data are collected on public health infrastructure, practice, and performance and that data from various sources are collected in a harmonious fashion. At issue also is the examination of the impact of new arrivals to the public health system, such as accreditation and credentialing of the public health workforce, on public health system performance.

Local public health system performance and community health outcomes.

BACKGROUND Public health systems are charged with protecting the health and well-being of the communities they serve. Higher-performing public health systems should be associated with improved community health status. Currently, little research examines the impact of variations in public health system performance on community health outcomes. PURPOSE The current study seeks to provide local public health system partners with evidence regarding the impact of their efforts. It does so through examining the relationship between variations in local public health system performance in providing the core functions of public health (assessment, assurance, and policy development) and community health outcomes. METHODS Measures of community health status (dependent variables) and community demographic characteristics, collected from 1994 to 2003, were merged with measures of public health system performance collected from 2002 to 2007 (independent variables). For each dependent variable, Pearson correlations were calculated with all of the independent variables. Multivariate linear regression models were developed for each health outcome. Analysis was completed in 2010. RESULTS Bivariate analysis found nine associations between local public health system performance and health outcomes. Linear regression models found associations between performance and three of the six outcomes measured. The outcomes associated with performance are those that would seem to be most sensitive to variations in practice. Poverty is significantly associated with all the health outcomes measured. CONCLUSIONS These associations between performance and health outcomes suggest that improving performance of the core functions of public health may improve health.

The Economic, Institutional, and Political Determinants of Public Health Delivery System Structures

Objectives. A typology of local public health systems was recently introduced, and a large degree of structural transformation over time was discovered in the systems analyzed. We present a qualitative exploration of the factors that determine variation and change in the seven structural configurations that comprise the local public health delivery system typology. Methods. We applied a 10-item semistructured telephone interview protocol to representatives from the local health agency in two randomly selected systems from each configuration—one that had maintained configuration over time and one that had changed configuration over time. We assessed the interviews for patterns of variation between the configurations. Results. Four key determinants of structural change emerged: availability of financial resources, interorganizational relationships, public health agency organization, and political relationships. Systems that had changed were more likely to experience strengthened partnerships between public health agencies and other community organizations and enjoy support from policy makers, while stable systems were more likely to be characterized by strong partnerships between public health agencies and other governmental bodies and less supportive relationships with policy makers. Conclusions. This research provides information regarding the determinants of system change, and may help public health leaders to better prepare for the impacts of change in the areas discussed. It may also help those who are seeking to implement change to determine the contextual factors that need to be in place before change can happen, or how best to implement change in the face of contextual factors that are beyond their control.

Factors Associated With Pharmacy Student Interest in International Study

Objectives. To examine the interest of pharmacy students in international study, the demographic factors and involvement characteristics associated with that interest, and the perceived advantages and barriers of engaging in international opportunities during pharmacy school. Methods. A self-administered electronic survey instrument was distributed to first-, second-, and third-year pharmacy students at the University of Kentucky College of Pharmacy. Results. There were 192 total respondents, for a response rate of 50.9%. Seventy-two percent reported interest in international study. Previous international study experience (p=0.001), previous international travel experience (p=0.002), year in pharmacy school (p=0.03), level of academic involvement (p<0.001), and level of diversity involvement (p<0.001) were associated with international study interest. Positive influences to international study included desire to travel and availability of scholarships. Perceived barriers included an inability to pay expenses and lack of foreign language knowledge. Conclusions. The needs and interests of pharmacy students should be considered in the development and expansion of internationalization programs in order to effectively optimize global partnerships and available international experiences. Colleges and schools of pharmacy should engage students early in the curriculum when interest in study-abroad opportunities is highest and seek to alleviate concerns about expenses as a primary influence on study-abroad decisions through provision of financial assistance.

Communication efforts among local health departments and health care professionals during the 2009 H1N1 outbreak.

OBJECTIVES The purpose of this study was to examine the public health response to the emergence of influenza H1N1 by evaluating the effectiveness of communication between health departments, community physicians, and pharmacists in Kentucky during the initial H1N1 outbreak. METHODS This study used a cross-sectional survey design to gather information from health departments, physicians, and pharmacists regarding information dissemination and receipt during the early H1N1 outbreak (April to July2009). Study participants included members of practice-based research networks in public health, primary care, pharmacy, and their partners. RESULTS Ninety-five percent of participating local health departments (LHDs) reported that health care professional notification was a risk mitigation strategy initiated in their local jurisdiction, and 81% of responding LHDs rated their capacity to disseminate information to health care providers as very good or excellent. However, only 52% of surveyed physicians and 16% of surveyed pharmacists reported receiving any information about H1N1 from an LHD. Seventy-four percent of pharmacists were not aware of their LHDs emergency plan in the event of an influenza outbreak. CONCLUSION These findings suggest that deficiencies exist in the outreach and effectiveness of information dissemination efforts from LHDs to health care professionals during an influenza outbreak. Research that identifies improved methods for members of public health and health care systems to communicate and share information with one another is needed. An intervention focused on improving communication about infectious disease outbreaks and examining the impact of such an intervention would be useful and productive.

A consensus-based approach to national public health accreditation.

The Public Health Accreditation Board (PHAB) solicited (and continues to solicit) the input of more than 400 subject matter experts in various areas of public health during the development and ongoing revision of the accreditation standards and measures. This process is designed to ensure that the standards and measures remain relevant and accommodate the various contexts under which public health departments practice in the United States. One way PHAB gathers feedback is convening a series of discussion meetings, or think tanks, with thought leaders in specific areas of public health, that focus on specific programmatic areas of public health, on the broader context of public health practice, or on emerging issues, such as public health informatics. The think tanks complement other mechanisms to assure that standards and measures are relevant, including gathering input from the practice community, receiving recommendations from public health departments that have undergone the accreditation process, and reviewing relevant literature. While this process allows PHAB to demonstrate its commitment to continuous quality improvement by modifying and improving the standards and measures, it also serves as a communication vehicle for PHAB to educate thought leaders and public health practitioners about the national accreditation program.

Public Health Systems and Services Research: Building the Evidence Base to Improve Public Health Practice

Public health services and systems research (PHSSR) is the American designation for a field that uses a number of research disciplines and perspectives to examine the organization of public health systems, how they are financed, how they deliver public health services, the quality and costs of services they deliver, and the impact of variations in all these areas on population health; it is closely related to health services research (HSR), and uses many of the same methods as HSR. This article traces the developmental path of PHSSR, identifies organizations that have been critical in its growth, provides examples of PHSSR that demonstrate the potential it has to improve public health practice, and discusses the future of PHSSR and the use of PHSSR to influence public policy. While there have been sporadic attempts to examine the public health system in the United States since the early 20th century, PHSSR has only been a formally recognized area of scientific inquiry since the early 2000s. PHSSR has experienced rapid growth, and evolved from mainly descriptive research to inferential research, and towards yielding results that suggest causation rather that correlation. While PHSSR as a field shows great promise to improve public health practice, in order for it to fulfill that promise it is vital that PHSSR produce results that are of use to the practice and policy making communities.

Diabetes Education: Quality Improvement Interventions Through Health Departments

BACKGROUND As the burden of diabetes continues to overwhelm the public health system, there is increased demand on local health departments (LHDs) to improve public health services. Quality improvement (QI) techniques have been shown to be an effective means to improve the delivery of services by LHDs. PURPOSE To evaluate the extent to which the adoption of organizational QI strategies influences the delivery and outreach of diabetes self-management education (DSME) services provided by LHDs. METHODS A change facilitation model that included QI team development and on-site QI training and facilitation was delivered to six LHDs that provide DSME, during 2010-2011. After training, each LHD developed and implemented a QI project to improve the outreach and delivery of DSME services. Pre- and post-intervention surveys were administered to evaluate the extent of change in DSME outreach and delivery. Data were analyzed in 2011. RESULTS The number of individuals who completed an entire course of DSME increased by >100%, and 14% more diabetics attended DSME on a monthly basis. Half of LHDs reported receiving increased numbers of referrals per month, and 15% more healthcare providers referred diabetic patients to the LHD for DSME. CONCLUSIONS Participation in Community Outreach and Change for Diabetes Management (COACH 4DM) led to improvements in the LHD QI infrastructure, and in the outreach and delivery of services to diabetic patients. The techniques used during COACH 4DM are applicable to a wide variety of contexts and may be an effective tool to improve the delivery of other clinical and community preventive services.

Application of Situational Leadership to the National Voluntary Public Health Accreditation Process

Successful navigation through the accreditation process developed by the Public Health Accreditation Board (PHAB) requires strong and effective leadership. Situational leadership, a contingency theory of leadership, frequently taught in the public health classroom, has utility for leading a public health agency through this process. As a public health agency pursues accreditation, staff members progress from being uncertain and unfamiliar with the process to being knowledgeable and confident in their ability to fulfill the accreditation requirements. Situational leadership provides a framework that allows leaders to match their leadership styles to the needs of agency personnel. In this paper, the application of situational leadership to accreditation is demonstrated by tracking the process at a progressive Kentucky county public health agency that served as a PHAB beta test site.