Core Public Health Functions Research Articles

Engaging the Community in Core Public Health Functions

National Civic ReviewVolume 89, Issue 4 p. 309-326 Engaging the Community in Core Public Health Functions Derek Okubo, Derek OkuboSearch for more papers by this authorKaren Weidman, Karen WeidmanSearch for more papers by this author Derek Okubo, Derek OkuboSearch for more papers by this authorKaren Weidman, Karen WeidmanSearch for more papers by this author First published: 01 July 2003 https://doi.org/10.1002/ncr.89403Citations: 12AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume89, Issue4Winter 2000Pages 309-326 RelatedInformation

What’s in a Name: Is this an Appropriate Response?

I n their introduction to our new journal, Randy Schwartz and Bob Goodman (2000) provide us with three reasons for the choice of the term health promotion rather than health education for the journal's title. They begin by stating that for some, a debate over these two terms is still relevant. As one of the some, I offer some thoughts about why health educators should consider a debate to be relevant using the three explanations provided by these authors. The first reason cited by Schwartz and Goodman (2000), which they call a practical one, is that the abbreviation for a health education practice (HEP) journal would be too close to that of our other journal, Health Education and Behavior (HEB), and thus would be a source of possible confusion. Regrettably, practicality is often inevitable and, in fact, was even used at the Centers for Disease Control and Prevention when the Health Education Network (HEN) decided that its abbreviation was not very complimentary (and possibly sexist as well!). As with the journal title, the Network decided to add the word promotion to the name of the organization, which then became the Public Health Education and Promotion Network or PHEP-NET. The other two explanations by the authors are of greater concern. Their characterization of health education in relation to health promotion may unwittingly undermine the contributions of health education to the field of health promotion. For those who are not familiar with health education as it has been developed in the United States over the past 40 to 50 years, such characterization may further minimize the science and practice of health education as a core discipline of public health. Such minimization may tend to encourage an erroneous interchangeability of the two terms— implied by the question, “What is in a name?”—rather than an appreciation of the complementary roles that each has in improving the public's health. Lest readers be thinking “oh no, another health educator having a professional identity crisis,” let me assure you that this is not the case. With the advent of certification for health educators, the recognition of health educator as a manpower classification by the Department of Labor, and the recent work done for the development of the profession cited by Schwartz and Goodman (2000), my concern about the explanations provided for the choice of journal title is not fueled by a paranoia that the profession of health education will be replaced by that of health promotion. Rather, it is spurred by my feeling that health educators, in their own journal, should be clearly articulating the contribution of the profession to the development of health promotion and thus giving credit where credit is due. These contributions include many decades of leadership and thinking, an ever increasing science base, and the professionalization of health education as a core function of public health. The second reason cited by Schwartz and Goodman (2000) is that, “on a broader level,” the choice of health promotion is “in accordance with the definition offered by Green and Kreuter [1999], recently revised in the third edition of their classic book on health promotion planning.” However, when they contrast the definitions of health promotion and health education found on page 27 of the third edition, the authors do not mention the first edition of the book, Health Education Planning: A Diagnostic Approach (Green, Kreuter, Deeds, & Partridge), published in l980. Indeed, as a health education practitioner trained in that era, I found that the PRECEDE planning model published in this edition was robust enough to include the environmental and ecological dimensions that later appear in the second and third editions of Green et al.’s (1980) book. In commenting in the 1999 edition on the shift from health education to health promotion that occurred around the creation of the Federal Office of Health Information and Health Promotion, Green and Kreuter observe that the operational definition of health

Coalition, partnership, and constituency building by a state public health agency: a retrospective.

This article is a retrospective that traces the development of an evolutionary process for a state health agency in addressing the challenge of implementing core public health functions and the provision of essential services. Coalition, partnership, and constituency building were critical elements in the process. Various initiatives are described and their importance as building blocks to a larger process of organizational change is explained. Key lessons from the process are outlined.

Population-based clinical projects: bridging community-based and public health concepts.

Changes in the healthcare delivery system have shifted nursing curricula to a community-based focus. For public health nursing faculty, this shift requires that population-based clinical projects bridge community-based nursing concepts with those of public health. The authors describe four innovative examples of population-based clinical projects that incorporate core public health functions and public health interventions into the learning process.

Surveillance of suicidal behavior in Kitsap County, Washington: a retrospective study.

Suicide is a major source of preventable morbidity and mortality in Kitsap County, Washington State. This article describes a study of suicidal behavior to identify risk groups in order to design intervention strategies. A retrospective study was conducted by reviewing the charts of individuals exhibiting suicidal behavior who had presented to the county's only civilian hospital emergency department over a 7 month period. Frequencies were calculated to identify at-risk populations and determine risk factors. One hundred forty-five charts were reviewed. Subjects were mostly female (69%), and ages ranged from 10 to 80 years with 73% between 15 and 44 years. Two-thirds of the subjects were not working. More than half had previously exhibited suicidal behavior and more than 75% had previous mental health encounter(s). Most admissions (67.6%) occurred between 4:00 p.m. and 4:00 a.m. The core public health functions of assessment, policy development, and assurance provided the framework for this community to explore the finding that suicide was a major source of preventable morbidity and mortality. Community-based intervention strategies have been developed in an effort to reach the Healthy People 2000 objective of reducing suicide deaths to no more than 10.5 per 100,000 residents.

Mandatory reporting of diseases and conditions by health care professionals and laboratories.

Surveillance is a key component of the core public health function of health assessment. Systematic reporting by health care professionals and laboratories, which may vary by state law, statute, or regulation, continues to provide essential data for assessing public health. To describe the state and territorial reporting requirements for diseases and conditions recommended for national public health surveillance. Between May and August 1997, the state and territorial epidemiologists from all 50 states, in addition to New York City, Puerto Rico, and Guam, completed questionnaires indicating which diseases and conditions were reportable by health care professionals and laboratories in their jurisdictions. The surveys were subsequently updated to reflect reporting requirements current as of January 1, 1999. The overall response rate for the survey was 100% for US states and 90% overall, including the territories. State and territorial reporting requirements for diseases and conditions of public health concern. Of the 58 diseases and conditions recommended for national reporting, 35 (60%) were reportable in greater than 90% of the states and territories, 15 (26%) were reportable in 75% to 90%, and 8 (14%) were reportable in less than 75%. Nineteen of the infectious diseases were reportable in all of the states and territories that responded. Required reporting varies substantially by state or territory. Health care professionals are integral to public health efforts at the local, state, and national levels.

The Law and the Public's Health: A Study of Infectious Disease Law in the United States

Law plays crucial roles in the field of public health, from defining the power and jurisdiction of health agencies, to influencing the social norms that shape individual behavior. Despite its importance, public health law has been neglected. Over a decade ago, the Institute of Medicine issued a report lamenting the state of public health administration, generally, and calling, in particular, for a revision of public health statutes. The Article examines the current state of public health law. To help create the conditions in which people can be healthy, public health law must reflect an understanding of how public health agencies work to promote health, as well as the political and social contexts in which these agencies operate. The authors first discuss three prevailing ways in which the determinants of health are conceptualized, and the political and social problems each model tends to create for public health efforts. The analysis then turns to the core functions of public health, emphasizing how law furthers public health work. The Article reports the results of a fifty-state survey of communicable disease control law, revealing that few states have systematically reformed their laws to reflect contemporary medical and legal developments. The Article concludes with specific guidelines for law reform.

Core function-related local public health practice effectiveness.

This article assesses the extent to which the U.S. population in 1995 was being effectively served by public health's three core functions (assessment, policy development, and assurance). A random sample of local health departments (LHDs) stratified by population size and type of jurisdiction was asked to provide their opinion of, as well as indicate performance on 20 core function-related measures of local public health practice. The article concludes that, in 1995, the nation fell far short of its year 2000 national objective, which called for 90 percent of the population to be served by an LHD effectively carrying out public health's core functions. Considerable capacity building and performance improvement is needed within the public health system.

Profile of Public Health Nutrition Personnel: Challenges for Population/System-Focused Roles and State-Level Monitoring

Objective Our 3 objectives were to document the current public health nutrition workforce in the United States, identify top public health nutrition priorities for the next 5 years, and assess the capacity of public health nutrition personnel to address these priorities and the nutrition-related objectives of Healthy People 2000. Design A census survey was distributed to public health nutrition personnel in all state and local health agencies and nonprofit and for-profit agencies funded by official health agencies throughout the United States and US territories. Also, state and territorial nutrition directors were sent a different questionnaire. Subjects Data were collected from 49 states, the District of Columbia, and 2 territories; 7,550 public health nutrition personnel were represented. Statistical analysis Data were analyzed using EpiInfo software. Descriptive statistics are presented. Results Almost half of the respondents worked in local or county health agencies and about two thirds were involved in direct care services. Only about 40% were registered dietitians and about one fourth had a master's degree. Almost 90% of all full-time equivalent positions were funded through federal dollars; 78% of all funding was from the Special Supplemental Nutrition Program for Women, Infants, and Children. Top health concerns identified were diet/nutrition to prevent chronic disease, low breast-feeding rates, low birth weight, iron deficiency anemia, and obesity/overweight. Public health nutrition personnel will be challenged to assume population/system-focused roles and state-level monitoring of Healthy People 2000 objectives. Only 2 of the 17 nutrition objectives of Healthy People 2000 were monitored by more than 50% of the states. Applications If official health agencies are to shift to public health core functions, as recommended by an Institute of Medicine report, then a substantial proportion of the public health nutrition workforce must not only change how they practice but also obtain the knowledge and skills to do so. Strategies to improve workforce capacity are discussed, including continuing education interventions through professional organizations, distance and on-campus educational opportunities through approved public health nutrition programs, and advocacy for new funding streams focused on public health core functions. J Am Diet Assoc. 1998;98:664–670.

Building Public Health Goals into the Purchasing Process:: The Missouri Medicaid Agency As Purchaser

Introduction: As managed care radically changes the medical care environment, public health leaders are under increasing pressure to focus more on core public health functions and less on personal health services. As public health re-evaluates its key strategies, it can take advantage of its strategic role in purchasing medical care to forge new partnerships that benefit its constituents. Methods: Specific roles for public health in medical care purchasing are discussed. The state of Missouri is used as an example of successful strategies for positioning public health as a leader in the managed care environment. Key strategies include increasing influence in contracting; selecting and reporting of key health status indicators; promoting use of population-based data files; taking leadership roles in government-sponsored insurance programs; and assuring stability of critical health conditions during managed care transitions. Conclusion: Public health has unprecedented opportunities to develop new methods for improving health status. Public health’s well-developed scientific principles and methods, combined with strategic leadership, will position the discipline in the forefront of the dialogue about our nation’s health system into the next century.

Managed care and public health.

Both public health and managed care organizations share an interest in ensuring the health status of a defined population. We explore the existing and potential relationships between managed care organizations and public health in several major public health areas, specifically clinical preventive services, prevention-oriented social and political policies, and core public health functions. The latter include health information, health education, personal health services provision, work force and research, community partnerships, and evaluation of health care. We believe there is much potential to improve the population's health through the collaboration of these two sectors of the health care system.

Typology of local health departments based on maternal and child health core functions.

A survey of Missouri local health departments (LHDs) was conducted to measure core public health functions within maternal and child health (MCH). Measurement was based on a prior key informant study that defined each core function as a set of specific MCH activities, programs, and services. The 59 items in the survey operationalized these activities and enabled the creation of summary scores for assessment, policy development, and assurance. Participation included 93 of the 112 Missouri LHDs (83%) in 1995. Reliability coefficients for the summary scores ranged from .83 to .92. Cluster analysis produced six types of LHDs with differing core function patterns. By matching efforts to improve core function practice to LHD type, more efficient use of capacity building resources may result.

From measuring to improving public health practice.

Efforts to measure public health practice have taken on various forms and focused on different aspects of the system of public health practice over the past century. Before 1990, measurement was primarily based on a series of self-assessment instruments initiated under the auspices of the Committee on Administrative Practice of the American Public Health Association. These instruments emphasized measurement of immediate results of local public health services although they also provided information on local resources and capacity to perform. Following the Institute of Medicine's report in 1988, efforts began to focus on performance related to public health's core functions. These more recent assessments suggest that the system of public health practice must be improved to achieve the targets of effectiveness established for the year 2000. Ultimately, a comprehensive national surveillance system for public health practice will need to both measure and examine the relationships among inputs (resources, capacity, etc), core function-related processes, outputs (services) as well as outcomes.

A Survey of State Health Department Compliance with the Recommendations of the Institute of Medicine Report, "The Future of Public Health"

We repeated a survey of state health agencies (SHAs) designed to ascertain the extent that the recommendations of the Institute of Medicine's report, The Future of Public Health, have been implemented. This survey was originally done in 1989 and we repeated the same survey in 1996. While there has been progress in some of the recommendations, such as a separate department of health, agreed-upon public health duties, outreach, infrastructure, and scope of responsibilities, there continue to be problems with the implementation of some of the recommendations. For example, the proportion of agencies reporting that the core public health function of policy development is extant has actually declined since 1989. There continue to be problems, with developing linkages of public health with environmental health and mental health, with strengthening the public health infrastructure, and with expansion of the scope of public health responsibilities. We encourage the continued monitoring of the implementation of the IOM recommendations.

Health planning and health care for the poor: the internal ethic of public health.

Health planning involves assessing health care needs of a defined population, setting priorities, then developing, implementing,m and evaluating programs that address priority needs. The concepts of health planning are central to the 1988 report of the Institute of Medicine on the Future of Public Health, which defined the three core functions of public health as assessment, policy development, and assurance. Generally, when health planning is instituted, poor people are identified as having the poorest health status and the greatest need. An internal ethic is therefore created for public health to focus on the health care needs of those in poverty. This internal ethic of public health health can become the driving force for reforming the present U.S. health care system. A reformed health care system would be guided by the principle of care according to need, which not only has a basis in health planning, but in social justice as well.

Training and Education for Public Health: The Role of the U.S. Public Health Service

In 1993 Assistant Secretary for Health Philip R. Lee commissioned an evaluation of U.S. Public Health Service (USPHS) activities in training and education for public health (TEPH). Findings revealed significant shortages of professionals and academic faculty in the public health fields of epidemiology, biostatistics, environmental and occupational health, public health nutrition, public health nursing, and preventive medicine. An inventory of PHS activities showed that about $217 million was spent on 151 public health and prevention training programs serving over 141,000 persons in fiscal year 1993. The $217 million amounted to about 18% of the total reported PHS training expenditures of $1.2 billion and about 1% of the total spending of $19.4 billion in fiscal year 1993. The National Institutes of Health (NIH) and Health Resources and Services Administration (HRSA) had the largest training expenditures of $655 and $445 million respectively, but spent only about 7% and 17% on public health and prevention training. Other PHS agencies had larger proportional investments in prevention, but the amounts were smaller. Priority recommendations were provided to Dr. Lee in seven key areas: advanced technology, core public health functions, policy and financing, academic-practice links, educational research, research training, and coordination. Together, these could dramatically increase the PHS proportional investment in TEPH. The PHS has a rich variety of resources for TEPH, but a lack of prioritization, coordination, and planning is causing opportunities to be missed. Medical Subject Headings (MeSH): public health, training, education.

Future Training Needs in Public Health Nutrition: Results of a National Delphi Survey

The environment for health care and public health is changing rapidly in the United States. In addition, changing demographic and social patterns will have a profound effect on public health needs and priorities (1). In the Institute of Medicine's report, The Future of Public Health, the mission of public health was defined as “fulfilling society's interest in assuring conditions in which people can be healthy” (2, p1). That report also challenged official health agencies to assume leadership responsibilities for the public's health by focusing on the three core public health functions: assessment, policy development, and assurance of the availability of adequate public health services (2). Carrying out the mission and functions of public health requires social commitment, appropriate expertise, and leadership (3). Leadership requires well-trained personnel who can meet changing societal and health care demands.

Local Health Department Effectiveness in Addressing the Core Functions of Public Health: Essential Ingredients

Objective 8.14 of the U.S. Healthy People 2000 objectives calls for 90% of the population to be served by a local health department (LHD) which is effectively carrying out the core functions of public health (assessment, policy development, assurance). This study seeks to describe the structural and service characteristics of an effective LHD. Data from a 1993 national random sample survey of LHD practice were merged with data from the 1992-1993 National Association of Country and City Health Officials (NACCHO) profile of local health agencies. Using a definition of effectiveness related to the core functions of public health, the correlates of effectiveness were examined for 264 health departments in the matched sample. Effectiveness of local health agencies was not related to jurisdiction size of type. Inputs (structural factors) associated with effectiveness included having a full-time agency head, a larger budget derived from a greater number of funding sources, and a larger number of staff. With respect to outputs (services), effective health departments were also more likely to provide a greater number of services directly, particularly personal preventive and treatment services. Only a few inputs are correlated with core-function related effectiveness. However, a profile of an effective health department emerges. Effective LHDs appear more likely to have full-time leadership which is able to tap diverse funding sources to provide the mix and match of community and personal prevention and treatment services needed to address community needs and improve the public's health.

Is public health ready for reform? The case for accrediting local health departments.

Reform of the governmental public health system in the United States has been stymied by changes in political, economic, and medical care landscapes since public health was called to action by the Institute of Medicine report in 1988. Despite a new national health objective calling for 90 percent of the population to be served by a local health department effectively addressing public health's three core functions by the year 2000, capacity building initiatives have not been deployed extensively, and there is little likelihood of reaching the year 2000 objective. A national program of accrediting local and state health departments could energize public health capacity building. Accreditation would build on recent initiatives in states like Washington and Illinois, promote wider use of the Assessment Protocol for Excellence in Public Health, and facilitate reform of the public health system around public health's core functions. Key questions addressing the why, how, and who of such an initiative set the stage for consideration of a national accreditation program.

Assessing Public Health Practice: Application of Ten Core Function Measures of Community Health in Six States

Factor analysis, combined with an evaluation of item difficulty and discrimination, can provide useful insights in questionnaire development. In 1993, as part of a study to develop a questionnaire to assess performance of the core functions of public health at a community level, 370 local health departments (LHDs) in six states completed a 26-item questionnaire (94% response). This study describes factor analysis results after controlling for item difficulty and discrimination. Fifteen items had intermediate difficulty and fair-to-good discrimination. Factor analysis of these 15 items identified four factors. Three of these factors included items from more than one of the core functions. These findings pose an interesting question for future research: are the core functions of public health better conceived as three discrete, distinguishable factors or as three interlocking factors that form a single, seamless unit?