Core Public Health Functions Research Articles

Local Public Health Responses to the Threat of Pandemic Flu: Equitable Protection and Communities at Disproportionate Risk

L politics, public health is always local. The Department of Health and Human Services (DHHS)/Centers for Disease Control and Prevention (CDC) echoes this view when discussiong preparation for pandemic influenza: “The local level is where the effects will be felt and where the response needs to occur.”1 Public health agencies and professionals are in a prominent position when it comes to planning and response to pandemic influenza; they must ensure that core functions and essential services remain functional and that living conditions remain healthy. The purpose of this commentary is to reflect on the role of local health departments in preparing for pandemic influenza. Local public health departments—of which there are over 2,500 of various sizes and shapes—can have responsibility for populations of towns, cities, and/or counties. Many are managed by physicians while others are not. Governance varies, with Boards of Health often having little or no direct authority to hire and fire directors and make local policy. However there is one significant constant: local health departments are the most likely source of the population-based services needed during an influenza pandemic. The local nature of agencies such as metropolitan or county departments of health makes it likely that the people employed there will understand the communities they serve and hold a position of trust in those communities. Such health departments are also likely to have established collaborative relationships with multiple different types of local organizations and agencies (e.g., community-based organizations [CBOs], faith communities, block associations, parent groups, advocacy groups). Local health departments are also likely to have built strong relationships with public safety, social service agencies and the media. As far back as the planning efforts for West Nile Virus in the mid-1990s, local health departments have engaged in community planning for health crises in terms of the core functions of public health at the local level: assessment, assurance, and policy development.

Public health in an era of personal health records: opportunities for innovation and new partnerships.

In the near future, citizens will be able to control and manage their own health information through electronic personal health record systems and tools. The clinical benefits of this innovation, such as cost savings, error reduction, and improved communication, have been discussed in the literature and public forums, as have issues related to privacy and confidentiality. Receiving little attention are the benefits these will have for public health. The benefits and potential for innovation are broad and speak directly to core public health functions such as health monitoring, outbreak management, empowerment, linking to services, and research. Coupled with this is a new relationship with citizens as key partners in protecting and promoting the public’s health.

Reforming sanitary-epidemiological service in Central and Eastern Europe and the former Soviet Union: an exploratory study.

BackgroundPublic health services in the Soviet Union and its satellite states in Central and Eastern Europe were delivered through centrally planned and managed networks of sanitary-epidemiological (san-epid) facilities. Many countries sought to reform this service following the political transition in the 1990s. In this paper we describe the major themes within these reforms.MethodsA review of literature was conducted. A conceptual framework was developed to guide the review, which focused on the two traditional core public health functions of the san-epid system: communicable disease surveillance, prevention and control and environmental health. The review included twenty-two former communist countries in the former Soviet Union (fSU) and in Central and Eastern Europe (CEE).ResultsThe countries studied fall into two broad groups. Reforms were more extensive in the CEE countries than in the fSU. The CEE countries have moved away from the former centrally managed san-epid system, adopting a variety of models of decentralization. The reformed systems remain mainly funded centrally level, but in some countries there are contributions by local government. In almost all countries, epidemiological surveillance and environmental monitoring remained together under a single organizational umbrella but in a few responsibilities for environmental health have been divided among different ministries.ConclusionsProgress in reform of public health services has varied considerably. There is considerable scope to learn from the differing experiences but also a need for rigorous evaluation of how public health functions are provided.

Personalism for public health ethics.

In public health ethics, as in bioethics, utilitarian approaches usually prevail, followed by Kantian and communitarian foundations. If one considers the nature and core functions of public health, which are focused on a population perspective, utilitarianism seems still more applicable to public health ethics. Nevertheless, faulting additional protections towards the human person, utilitarianism doesn't offer appropriate solutions when conflicts among values do arise. Further criteria must be applied to protect the fundamental principles of respect for human life. Personalism offers similar advantages to utilitarianism but warrants more protection to the human person. We suggest a possible adaptation of personalism in the specific field of public health by means of four principles: absolute respect for life or principle of inviolability; subsidiarity and the "minimum" mandatory principle; solidarity; justice and non discrimination.

Health Systems Exist for Real People

Action always leads to reaction, a fundamental law of nature. The recent unprecedented investment in combating the HIV/AIDS pandemic has led to marvel at the effects of antiretroviral therapy, to constructive questioning about impact on health systems and, at one extreme, to frank hostility. Central to the debate has been the question of whether the disease-specific efforts of initiatives such as the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have strengthened or undermined national health systems in lowand middle-income countries. Regrettably, discussions have sometimes become polarized and antagonistic, drawing attention from the specifics of the enormous tasks at hand in global health. This supplement of the Journal examines the impact of HIV scale-up on health systems in a diverse array of countries and contexts, building on discussions that took place at a meeting at the Rockefeller Foundation Bellagio Center in September 2008 that focused on these issues. These discussions are rooted in documents now decades old: the 1978 Declaration of Alma-Ata and the 1993 World Development Report entitled ‘‘Investing in Health.’’ These important documents illustrate that discussions about health systems have been ongoing at the highest levels for some time but that bringing the necessary financing to bear lagged far behind. In 2001, the Commission on Macroeconomics and Health published its conclusion that better health for the world’s poor is not only a right but an important priority for development and poverty reduction. Influential academics had been speaking out since the 1990s on sub-Saharan Africa’s disproportionate burden of infectious and poverty-related diseases, and more specifically on the dominant impact of malaria, tuberculosis, and HIV. The stage was set for major donor initiatives, their nature and political origins unpredictable and themselves worthy of historical analysis. These global health initiatives reflected the interplay of multilateral and national politics, and involved the faith-based sector, perhaps for the first time. Investment in countries of the south by the Global Fund and PEPFAR began to be felt in 2003, the year that WHO launched its 3 3 5 initiative, which provided normative and policy guidance for scale-up of HIV/AIDS prevention, treatment, and care in lowand middle-income countries. Ironically, it was the evaluation of the 3 3 5 initiative that first warned that health system constraints, especially the shortage of human resources, was a rate-limiting step to scale-up toward universal access to essential HIV/AIDS services. Two other themes fueled the emerging debate about prioritization of disease-specific initiatives versus the strengthening of health systems: the growing recognition that other major health challenges, including enhancing maternal and child health, access to safe water and sanitation, and addressing non-communicable diseases, were under-resourced (and, by inference, that HIV/AIDS received ‘‘too much’’ funding); and skepticism around epidemiologic estimates of the severity of the HIV/AIDS pandemic. Against this background, a variety of studies and programs have recently examined the question of whether health systems have been strengthened or weakened by diseasespecific initiatives, and significant review articles have been published this year. That these discussions are not just academic is illustrated by their implications for programmatic funding. The Obama administration is committed to spending US$63 billion over 6 years

Public health requirements for rapid progress in global health

Effective public health interventions can save hundreds of millions of lives in developing countries, as well as create broad social and economic benefits. Unfortunately, public health approaches and solutions applied in developed countries are often assumed to be inappropriate or unattainable in developing countries. This has sometimes forestalled effective interventions in parts of the world where they are most needed, despite conditions that now facilitate lasting solutions to both long-standing and emerging global public health problems. Core public health functions are similar regardless of a country's income level. Although some resource-intensive approaches from industrialised nations are inappropriate in less developed countries, many basic public health measures achieved decades ago in developed countries are urgently needed, highly appropriate, extremely cost-effective and eminently attainable in developing countries today. About half of the disease burden in low and middle-income countries is now from non-communicable diseases, but non-communicable disease epidemics that will otherwise increase rapidly in the developing world can be avoided or reversed. Progress of public health in developing countries is possible, but will require sufficient funding and human resources; improved physical plant and information systems; effective programme implementation and regulatory capacity; and, most importantly, political will at the highest levels of government.

Use of Published Self-rated Health–Impact Studies in Community Health Needs Assessment

Assessment is a core public health function, but advances in technology, including the ready availability of health profile data on-line, have changed the skill requirements for local health agencies. Instead of creating profiles, local planners might concentrate their energies on conducting community surveys. However, neither the expertise nor the resources are reliably present at the local-agency level. On the other hand, planners in local health agencies can take better advantage of published reports about the impact of emerging risk factors for poor self-rated health. The advantages and disadvantages of making review of self-rated health-impact studies an important element in community health needs assessment are discussed.

Focus on Transformation: A Public Health Model of Mental Health for the 21st Century

Focus on Transformation: A Public Health Model of Mental Health for the 21st Century

Nursing and the health care crisis in Ukraine

ABSTRACT Ukraine, one of the largest post-Soviet countries in Eastern Europe, has endured social and economic hardships leading to unhealthy lifestyles and stress related conditions. These conditions have translated into an increase in HIV, TB, and infant mortality, along with a decrease in life expectancy for both women and men. Nurses, the cornerstone of a health care system, are ill prepared to address the health crisis. Their current education follows a medical model preparing them to function under a doctor’s direct supervision with no preparation in public health principles. Primary care functions such as physical assessment and health education are not part of nurses’ curriculum and therefore are performed by physicians. Nursing curriculum is beginning to change, but the changes are not unilateral. The current educational system for nurses and the very low salary they receive have led to a decline in the prestige of nursing as a profession. Collaboration with Western practicing public health nurses, nurse educators, and nurse researchers can help allay the crisis. Improving Ukrainian nurses’ educational preparation to include core functions of public health can positively impact the health of the population. Keywords: Ukraine health care, Ukraine nurses, International health care

Using the Wisconsin County Health Rankings to Catalyze Community Health Improvement

Assessment is a core function of public health; however, standard community health assessments often remain within the boundaries of the traditional public health system and rarely elicit public discussion and community-wide action. The University of Wisconsin Population Health Institute developed the annual Wisconsin County Health Rankings (Rankings) report in 2003 with three primary goals: (1) to increase media attention to local health outcomes and determinants; (2) to highlight the broad range of factors that influence health; and (3) to catalyze community health improvement efforts. We assessed how well the Rankings met these goals through an examination of media coverage and a survey of the local public health community following the 2006 report. Newspaper, television, and radio media across the state covered the Rankings, highlighting local results for outcomes and a broad range of determinants. Local public health officials used the Rankings for educating policy makers and community partners, performing needs assessments, and identifying program targets. The Rankings report is an approach to community health assessment that has received media attention and been found to be useful by local public health officials in their community health improvement efforts.

Ethics in Public Health Research

Public health agencies increasingly use electronic means to acquire, use, maintain, and store personal health information. Electronic data formats can improve performance of core public health functions, but potentially threaten privacy because they can be easily duplicated and transmitted to unauthorized people. Although such security breaches do occur, electronic data can be better secured than paper records, because authentication, authorization, auditing, and accountability can be facilitated. Public health professionals should collaborate with law and information technology colleagues to assess possible threats, implement updated policies, train staff, and develop preventive engineering measures to protect information. Tightened physical and electronic controls can prevent misuse of data, minimize the risk of security breaches, and help maintain the reputation and integrity of public health agencies.

Community-Level Data

ealth-related data are used at many geographic and political levels by individuals and groups for a multitude of purposes. The focus of this paper is on what and how data are used at the local level, for what purposes and by whom, as well as some of the unique challenges and methodological manipulations involved. Examples of common and unique uses of data and the analytic challenges involved are included. Health-related data are typically used at the local level to describe populations in terms of demographics, economics, social and environmental conditions, disease prevalence, births, causes of deaths, health behaviors, and available health care resources. They may also be used to characterize access to health services and the use and cost of such services. The data are generally secondary, ie, obtained from another agency that specified form and content without local user input. The data may come from the US Census (eg, income, housing, education), the state and federal vital statistics system (eg, births, deaths, communicable disease incidence), disease registries (eg, cancer incidence, prevalence), or national or state surveys (eg, Behavioral Risk Factor Surveillance System). Other sourcesmaybeagenciesresponsibleforMedicaid,Medicare, licensing and regulation, environmental protection, education, commerce, agriculture, transportation, highway safety, or law enforcement. With increasing technology and governmental investments in data collection, there is a wealth of data available, but they may not be readily useful to or easily analyzed by the local user. Local Users and Uses The users of health-related data at the community level in North Carolina might be local chapters of voluntary health organizations (eg, American Heart Association, American Lung Association), Healthy Carolinians groups, hospitals, health departments, health care providers, professional associations, academic institutions, news media, governmental agencies, elected officials, and individual citizens interested in their own health or the health of their family and community. Typical purposes for data use include community diagnosis, program planning, policymaking, advocacy, justification of requests for resources, and program evaluation. The purposes may be categorized within the 3 core functions of public health (ie, assessment, policy development, and assurance) 1

A Community-Centered Model of the Academic Health Department and Implications for Assessment

The academic health department, also referred to as the teaching health department, is receiving increased attention as an organizational structure to enhance public health workforce development. Traditionally, academic institutions have been viewed by major funders, and reported in the literature, to be the innovators of these partnerships, in part to extend the academic institution's education role in the workplace. However, the role of the local health department as innovator is emerging with implications beyond workforce development. This report illustrates how a local agency-initiated community-centered approach to an academic health department enhances the core public health function of assessment, a frequently underdeveloped function at the local level. This agency-initiated, community-centered academic health department model builds assessment capacity through a partnership that integrates academic research and public health surveillance capacity to provide comprehensive assessment, including community assessment, community-based participatory research, data analysis, and program evaluation. This organizational structure, focused on systems approaches to building community capacity rather than focusing on disease categories or high-risk populations, illustrates how a local health department can substantially enhance its assessment capacity using available resources.

Concerns in Workforce Development: Linking Certification and Credentialing to Outcomes

Investments in public health workforce development are based on the assumption that capacity and competencies are linked with the effectiveness and efficiency of providing essential public health services. However, evidence of the effects of workforce quantity or quality on the performance of core public health functions is limited. A review of public health, health care, and teacher education literature was conducted to determine the state of research in the field and to identify promising approaches and study designs for application to public health workforce training. A total of 861 articles and abstracts were reviewed from the health literature and 470 from teacher education literature. Sixty-five reports in the public health or health care literature and 68 in the education literature met the inclusion criteria. Eleven studies in public health or health literature reported positive correlations and 3 determined no substantial correlation to credentials. In the education literature, 10 studies reported a positive link, whereas 9 studies reported mixed or nonsignificant results. We conclude that a paucity of quality research or compelling evidence exists linking certification or credentialing to any related outcome. Until further research is conducted, discussions on the need for public health workforce certification and credentialing will be based on good-faith expectations for improving individual and organizational performance.

Redesigning electronic health record systems to support public health

Current electronic health record systems are primarily clinical in focus, designed to provide patient-level data and provider-level decision support. Adapting EHR systems to serve public health needs provides the possibility of enormous advances for public health practice and policy. In this review, we evaluate EHR functionality and map it to the three core functions of public health: assessment, policy development, and assurance. In doing so, we identify and discuss important design, implementation, and methodological issues with current systems. For example, in order to support public health’s traditional focus on preventive health and socio-behavioral factors, EHR data models would need to be expanded to incorporate environmental, psychosocial, and other non-medical data elements, and workflow would have to be examined to determine the optimal way of collecting these data. We also argue that redesigning EHR systems to support public health offers benefits not only to the public health system but also to consumers, health-care institutions, and individual providers.

Financing Public Health

This article documents the instability and variation in public financing of public health functions at the federal and state levels. Trust for America's Health has charted federal funding for the Centers of Disease Control and Prevention, which in turn provides a major portion of financing for state and local public health departments, and has compiled information about state-generated revenue commitments to public health activities nationwide. The federal-level analysis shows that funding has been marked by diminished support for "core" public health functions. The state-level analysis shows tremendous variation in use of state revenues to support public health functions. The combination of these factors results in very different public health capacities across the country, potentially leaving some states more vulnerable, while simultaneously posing a general threat to the nation since public health problems do not honor state borders. On the basis of this analysis, the authors suggest changes in the financing arrangements for public health, designed to assure a more stable funding stream for core public health functions and a more consistent approach to financing public health activities across the country.

Evaluating a Program to Build Data Capacity for Core Public Health Functions in Local Maternal Child and Adolescent Health Programs in California

To improve local Maternal and Child Health programs' capacity to collect and analyze data to support core public health functions, the California Maternal and Child Health Branch (CAMCHB) and the University of California San Francisco Family Health Outcomes project (FHOP) entered into a cooperative agreement. FHOP utilizes a 6-pronged strategy: face-to-face training, telephone technical assistance, on-site consultation, development of automated analytic tools, development of written guidelines, and web dissemination of data and materials. We evaluated the acceptability and effectiveness of these approaches. Local Health Jurisdiction (LHJ) staff completed a self-administered questionnaire on use of and satisfaction with FHOP's services. A 34-item assessment tool was used to independently evaluate each 5-year community assessment plan submitted by LHJs to the CAMCHB. Administrative data on the use of FHOP's service was also considered. Correlational analyses were done to determine if use of FHOP services and materials was related to more adequate plans. LHJs with higher overall adequacy scores on their plans had an overall higher level of use of FHOP's products and services. LHJs with higher adequacy scores reported calling FHOP for technical assistance more frequently, using FHOP's book - "Developing an Effective Planning Process: A Guide for Local MCH Programs," and using FHOP's automated tools including EpiBC, an EpiINFO based program for birth certificate analysis, and Microsoft Excel data analysis templates. This 6-pronged strategy is well utilized and accepted by local MCH staff and appears to have some degree of association with better quality of local MCH plan documents.

The promise of public health: ethical reflections.

Public health is in the spotlight of public and political concern, providing a unique window of opportunity for its revitalization and restoration as a pillar of the Canadian health care system. The establishment of a Federal Public Health Agency is a critical first step. The public health community has identified key challenges toward this renewal. However, public health ethics have received little attention and, when addressed, have focussed almost exclusively on communicable diseases. The ethical issues inherent in public health transcend infectious diseases and are distinct from clinical and research ethics. Identifying and addressing ethical issues at the heart of public health, including the public interest and the common good, as well as fundamental issues related to the core functions of public health will be essential if this revitalization of public health is to be achieved. While legal and regulatory reforms are necessary, they will not be sufficient to adequately address fundamental questions of the valuing of public health or the ethical issues in public health. Elements of a research agenda on the ethical foundations of public health reform are identified here.

The Promise of Public Health: Ethical Reflections

Public health is in the spotlight of public and political concern, providing a unique window of opportunity for its revitalization and restoration as a pillar of the Canadian health care system. The establishment of a Federal Public Health Agency is a critical first step. The public health community has identified key challenges toward this renewal. However, public health ethics have received little attention and, when addressed, have focussed almost exclusively on communicable diseases. The ethical issues inherent in public health transcend infectious diseases and are distinct from clinical and research ethics. Identifying and addressing ethical issues at the heart of public health, including the public interest and the common good, as well as fundamental issues related to the core functions of public health will be essential if this revitalization of public health is to be achieved. While legal and regulatory reforms are necessary, they will not be sufficient to adequately address fundamental questions of the valuing of public health or the ethical issues in public health. Elements of a research agenda on the ethical foundations of public health reform are identified here.

The Key Role of Pulsed-Field Gel Electrophoresis in Investigation of a Large Multiserotype and Multistate Food-Borne Outbreak of Salmonella Infections Centered in Pennsylvania

Five different serotypes of Salmonella enterica were implicated in a large outbreak linked to fresh Roma tomatoes served at gas station deli counters in Pennsylvania and nearby states during July 2004: S. enterica serotypes Javiana, Anatum, Thompson, Typhimurium, and Muenchen. One of these serotypes, Anatum, was isolated from both tomatoes and patients. Pulsed-field gel electrophoresis (PFGE) played a key role in identifying the outbreak-associated isolates and distinguishing them from unrelated sporadic isolates. It also demonstrated that the genetic fingerprints of serotype Anatum isolates derived from patients were indistinguishable from those derived from tomatoes. Rapid communication of PFGE fingerprints with other public health laboratories through the Centers for Disease Control and Prevention's PulseNet USA national molecular surveillance network for bacterial food-borne pathogens facilitated the tracking of this outbreak in other states. The work described in this report emphasizes the laboratory's role in core public health functions and services, thereby providing a highly visible example of public health in action.