Local Health Department Performance Research Articles

Addressing Health Disparities: The Health Department Nurse Lead Executive's Relationship to Improved Community Health.

The nurse-trained local health department (LHD) lead executive has been shown to be positively associated with LHD performance; however, no other research has explored whether this association translates to improved community health. To investigate the relationship between the type of LHD leadership-whether or not the lead executive is a nurse-and changes in health outcomes. This study used a multivariate panel time series design. Each model was estimated as a pooled time series and using time and unit fixed effects, with a 1-year lag used for all covariates and the main predictor. A national, county-level data set was compiled containing variables pertaining to the LHD, community demographics, and health outcomes for the years 2010-2018. The unit of analysis was the LHD. The data set was restricted to those counties with measurable mortality rates during at least 8 of the 9 time periods of the study, resulting in a total of 626 LHDs. The outcomes of interest were changes in 15- to 44-year-old all-cause mortality, infant mortality, and entry into prenatal care. In models with combined time and unit fixed effects, a significant relationship exists between a nurse-led LHD and reduced mortality in the 15- to 44-year-old Black population (-5.2%, P < .05) and a reduction in the Black-White mortality ratio (-6%, P < .05). In addition, there is a relationship between the nurse-led LHD and a reduction in the percentage of the population with late or no entry to prenatal care. The evidence presented here helps connect the known positive association between nurse lead executives and LHD performance to improvements in community health. It suggests that nurse leaders are associated with health improvements in line with addressing health inequities.

Assessing Organizational Supports for Evidence-Based Decision Making in Local Public Health Departments in the United States: Development and Psychometric Properties of a New Measure.

Fostering evidence-based decision making (EBDM) within local public health departments and among local health department (LHD) practitioners is crucial for the successful translation of research into public health practice to prevent and control chronic disease. The purpose of this study was to identify organizational supports for EBDM within LHDs and determine psychometric properties of a measure of organizational supports for EBDM in LHDs. Cross-sectional, observation study. Local public health departments in the United States. Local health department practitioners (N = 376) across the United States participated in the study. Local health department practitioners completed a survey containing 27 items about organizational supports for EBDM. Most items were adapted from previously developed surveys, and input from researchers and practitioners guided survey development. Confirmatory factor analysis was used to test and refine the psychometric properties of the measure. The final solution included 6 factors of 22 items: awareness of EBDM (3 items), capacity for EBDM (7 items), resources availability (3 items), evaluation capacity (3 items), EBDM climate cultivation (3 items), and partnerships to support EBDM (3 items). This factor solution achieved acceptable fit (eg, Comparative Fit Index = 0.965). Logistic regression models showed positive relationships between the 6 factors and the number of evidence-based interventions delivered. This study identified important organizational supports for EBDM within LHDs. Results of this study can be used to understand and enhance organizational processes and structures to support EBDM to improve LHD performance and population health. Strong measures are important for understanding how LHDs support EBDM, evaluating interventions to improve LHD capacity, and to guide programmatic and policy efforts within LHDs.

High-Performing Local Health Departments Relate Their Experiences at Community Engagement in Emergency Preparedness.

Local health departments (LHDs) are implementing a national mandate to engage community partners, including individuals, businesses, and community- and faith-based organizations in the larger public health emergency preparedness (PHEP) enterprise. Investigate how LHDs of varying size and resource levels successfully engage the community in PHEP to help uncover "best practices" that aspiring agencies can replicate, particularly in low-resource environments. In-depth, semistructured qualitative interviews with practitioners from 9 highly performing LHDs. Participating agencies comprised equal amounts of small (serving <50 000 residents), medium (serving 50 000-500 000 residents), and large (serving >500 000 residents) LHDs and were diverse in terms of geographic region, rural-urban environment, and governance structure. A cross section of LHD staff (n = 34) including agency leaders, preparedness coordinators, public information officers, and health educators/promoters. Local health department performance at community engagement as determined by top scores in 2 national LHD surveys (2012, 2015) regarding community engagement in PHEP. Based on key informant accounts, high-performing LHDs show a holistic, organization-wide commitment to, rather than discrete focus on, community engagement. Best practices clustered around 5 domains: administration (eg, top executive who models collaborative behavior), organizational culture (eg, solicitous rather than prescriptive posture regarding community needs), social capital (eg, mining preexisting community connections held by other LHD programs), workforce skills (eg, cultural competence), and methods/tactics (eg, visibility in community events unrelated to PHEP). For LHDs that wish to enhance their performance at community engagement in PHEP, change will entail adoption of evidence-based interventions (the technical "what") as well as evidence-based administrative approaches (the managerial "how"). Smaller, rural LHDs should be encouraged that, in the case of PHEP community engagement, they have unique social assets that may help offset advantages that larger, more materially resourced metropolitan health departments may have.

Relationships among providing maternal, child, and adolescent health services; implementing various financial strategy responses; and performance of local health departments.

We explored the relationships between local health department (LHD) structure, capacity, and macro-context variables and performance of essential public health services (EPHS). In 2012, we assessed a stratified, random sample of 195 LHDs that provided data via an online survey regarding performance of EPHS, the services provided or contracted out, the financial strategies used in response to budgetary pressures, and the extent of collaborations. We performed weighted analyses that included analysis of variance, pairwise correlations by jurisdiction population size, and linear regressions. On average, LHDs provided approximately 13 (36%) of 35 possible services either directly or by contract. Rather than cut services or externally consolidating, LHDs took steps to generate more revenue and maximize capacity. Higher LHD performance of EPHS was significantly associated with delivering more services, initiating more financial strategies, and engaging in collaboration, after adjusting for the effects of the Affordable Care Act and jurisdiction size. During changing economic and health care environments, we found that strong structural capacity enhanced local health department EPHS performance for maternal, child, and adolescent health.

Local health department factors associated with performance in the successful implementation of community-based strategies: a mixed-methods approach.

We examined which local health department (LHD)-level factors contributed to successful implementation of policy, systems, and environmental change strategies in Minnesota. We used a retrospective mixed-methods design to evaluate the relationship between the Statewide Health Improvement Plan (SHIP) grant initiative and key predictor variables (2009-2011). We obtained quantitative capacity data for 91 cities and counties in Minnesota; in addition, we conducted 15 key informant interviews to examine factors that facilitated and acted as barriers to LHD performance. Grantee performance was distributed as follows: exceeds expectations (29.7%), meets expectations (55.0%), and is approaching expectations (15.3%). Organizational quality improvement (QI) maturity was strongly positively associated with grantee performance on SHIP. Organizations with high QI maturity, effective leadership, efficient decision-making, and successful regional or cross-jurisdictional partnerships were more likely to be rated as exceeding expectations. This study successfully translated practice-based research findings into tangible outcomes, including new system-level performance measures for local public health and recommendations for shaping the statewide initiative examined in this study. The approach taken in this study to systematically monitor communications, dissemination, and translation may be a model for others.

Analysis of Local Health Department Factors that Accelerate Population-based Intervention Strategies: Preliminary Findings

Introduction: This practice-based research study capitalized on the statewide implementation of a comprehensive, locally-driven initiative to implement evidence-based policy, system and environmental changes related to obesity and tobacco use. The study examined local health department (LHD) performance and factors such as organizational quality improvement (QI) maturity, structure and governance. Methods: State health department staff reviewed grant reports and documentation pertaining to all LHD grantees, which collectively represented all 87 counties and 4 cities in Minnesota (MN), in order to designate grantees as either: “Exceeds Expectations,” “Meets Expectations” or “Approaching Expectations.” A study team of state, local and academic partners then used select measures from the QI Maturity Tool to calculate a QI Maturity Score, and subsequently place grantees into three levels of QI maturity: low, medium and high. Multivariate regression was performed to examine the potential relationship between grantee performance and QI maturity, as well as other covariates. Results: Of the final sample of 91 counties/cities, 87 had complete data for multivariate analysis. The distribution of grantee performance was: exceeds expectations (29.7%), meets expectations (55.0%) and approaching expectations (15.3%). Organizational QI maturity was strongly, positively associated with grantee performance comparing the “exceeds expectations” to those who “met or approached expectations” (OR=4.29, 95 % CI: 1.90-9.73, p=0.0005). Implications: Organizational QI maturity was strongly associated with LHD performance. More research is needed to determine whether a more mature approach to quality improvement is merely a marker for overall LHD capacity or has its own unique contribution to performance. Findings have been used to inform the next funding cycle of this initiative and provide support to implementing annual assessment of QI maturity in MN.

The Performance of Local Health Departments

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.

Local health department performance: compliance with state statutes and rules.

Compliance with statutes and rules is a measure of local health department (LHD) performance. This study analyzed compliance rates in one state. High overall compliance rates were found, although gaps existed between measured and expected compliance. Factors associated with lower compliance included lower LHD certification level (characteristic of smaller agencies) and human services organizational structure in lower-level LHDs. Improvements in compliance rates will require increased attention to development and documentation of policies, procedures, and local ordinances. Compliance is necessary for LHD effectiveness but may not be a sufficient measure of overall LHD performance.

Application of Core Function Concepts to Local Health Department Occupational Safety and Health Activities

To illustrate how core function concepts might be useful in evaluation of specific local health department (LHD) programs, we analyzed preliminary results from a national questionnaire survey of LHD occupational safety and health (OSH) activities during 1992-1993 in categories corresponding to the three core functions: assessment, policy development, and assurance. Overall, 2,079 (71%) LHDs returned completed questionnaires. With regard to the first core function (assessment), the state health department was the most frequent source of data used by the respondent LHDs (47%) to assess worker health and occupational hazards. Concerning the second core function category (policy development), 5% of LHDs had conducted an appraisal in the past three years to summarize the OSH needs of their communities. With regard to the third core function category (assurance), 23% of LHDs directly provided worksite health promotion activities for workers in their communities. We conclude that core function concepts can be a useful adjunct in evaluation of specific LHD programs. Additional research is needed to further refine and improve core function indicators providing insights into specific LHD programs, as well as into overall LHD performance.

Model Standards impact on local health department performance in California.

An evaluation of a state-local negotiation process to implement Model Standards in 18 California local health departments was conducted during 1985-87. Model Standards specific to California were developed by state and local public health officials for seven programs. Nine counties participated in state-local negotiations to set performance standards in these seven programs. During the two-year effort, greater use of Model Standards and more improvement in local program performance occurred in local health departments that participated in the state-local negotiation process. The use of Model Standards appeared to contribute to establishing program priorities, emphasizing the measurement of outcomes, improving data management systems, and evaluating the current performance of programs. While this state-local negotiation process is suggested as the preferred approach to encouraging the use of Model Standards in local health departments, it must be recognized that this process requires time and commitment of resources from both the state and local levels.