Local Health Department Staff Research Articles

Public Health Nurses' Proficiencies and Training Needs in an Emergency Response: A Cross-Sectional Observational Study.

To address gaps in understanding the public health nursing workforce regarding competencies recognized as critical during an emergency response. A cross-sectional observational study using data with information on local health department staff- and organizational-level characteristics collected from across the United States in 2021. We used logistic regression to estimate the association between 2 binary nurse-specific predictors-(1) whether the staff person was a nurse and (2) whether the staff worked in a local health department that was "nurse-led" (directed by a nurse)-and reported proficiencies important to the COVID-19 response. Models controlled for relevant local health department and community characteristics. In the sample, 19% were nurses and 37% were at nurse-led health departments. Nurse versus nonnurse staff had higher odds of reporting proficiencies in skills related to Justice, Equity, Diversity, and Inclusion and in the skill "identifying/applying evidence-based approaches to address public health issues." However, nurses, compared with their nonnurse peers, had higher odds of reporting training needs in domains related to community engagement, policy engagement, and cross-sectoral collaboration. Conversely, staff at nurse-led health departments, compared with non-nurse-led staff, had higher odds of reporting proficiencies in many of these same areas, including "collaborating across the public health system" and "influencing policies external to the organization that affect community health." There were no areas in which nurse-led staff had lower odds of reporting proficiencies or higher odds of identifying training needs. Findings from this study highlight areas of strength for public health nurses, particularly strengths related to diversity, equity, and inclusion, as well as areas where more training is needed. Such findings can help guide future public health nurse workforce development as well as underscore the value of public health nursing leadership and staff at local health departments for supporting community health.

Psychological experience and coping strategies of pregnant women with acute pancreatitis: a qualitative descriptive study

Background To clarify the psychological experience and coping strategies in patients with acute pancreatitis in pregnancy (APIP) and propose interventional measures to improve pregnancy outcomes in these women. With an increasing trend of pregnant women in advanced ages and multiparous women, the incidence of APIP has significantly increased. Pregnancy accompanied by concurrent pancreatitis may subject these women to notable psychological stress, which is a factor that has been infrequently reported in previous studies. Methods APIP patients were interviewed from December 2020 to June 2021. Data were collected through semi-structured interviews based on an outline, including six questions. The interviews were recorded and analyzed using qualitative content analysis until data saturation was reached. Results Ten APIP patients were interviewed and four themes were identified, including excessive psychological burden, uncomfortable experience, urgent requirement for adequate medical resources, and importance of social support. Conclusion Patients with APIP suffer from significant psychological stress due to their medical conditions and management. They desired adequate medical resources and social support. The local health department, hospital administrators, and medical staff should understand the psychological requirements and provide adequate healthcare and education that are easily accessible to these APIP patients. In addition, family support should also be encouraged to promote APIP patients’ recovery.

The Implementation and Utilization of Wastewater-Based Epidemiology: Experiences From a Local Health Department.

Wastewater-based epidemiology has increasingly demonstrated its importance in addressing public health threats. The COVID-19 pandemic brought forth funding for public health agencies to conduct wastewater-based epidemiology. Using a team with diverse skills, a local health department utilized this funding to regularly monitor SARS-CoV-2 in wastewater on university campuses, a K-12 campus, an inpatient psychiatric facility, and a long-term care facility. Between September 2021 and May 2022, more than 760 wastewater samples were collected of which 102 (13.4%) were above a predetermined threshold. When sites exceeded that threshold, local health department staff provided testing resources. Wastewater-based epidemiology is a useful surveillance program that can be effectively conducted by local health departments when provided with funding and a skilled workforce.

THE ROAD MAP STRATEGIST INITIATIVE: A NATIONWIDE EFFORT TO BUILD LOCAL PUBLIC HEALTH CAPACITY ON DEMENTIA

Abstract The Road Map Strategist Initiative is a nationwide effort to build local health department (LHD) capacity to address cognitive health and dementia. Through a collaboration between the Alzheimer’s Association and the National Association of County and City Health Officials (NACCHO), the initiative aims to make policy, systems, and environmental change, with a focus on health equity. Participating health departments receive funding, training, and technical assistance to establish a part-time Healthy Brain Initiative (HBI) Road Map Strategist, a public health professional serving as a system change agent. With support and education from the program sponsors, Road Map Strategists conduct a community health needs assessment, train LHD staff and leadership, and collaborate with community partners to implement and accelerate public health actions on dementia. Actions taken by the Road Map Strategists are informed by the Healthy Brain Initiative’s State and Local Public Health Partnerships to Address Dementia, The 2018-2023 Road Map. Presenters will share lessons learned from the first cohort of eight (8) LHDs during each stage of the initiative, with a focus on approaches used for Road Map implementation efforts in their communities. This session will share evaluation findings on successes and barriers for changing health department capacity to support local dementia efforts. Data from key indicators related to knowledge gain and capacity change will be shared, including the way LHD characteristics influenced success. The session will also cover effective approaches toward advancing health equity in dementia in local communities and plans for future iterations of the initiative.

PH WINS 2021 Methodology Report.

The Public Health Workforce Interests and Needs Survey (PH WINS) was fielded in 2014 and 2017 and is the largest survey of the governmental public health workforce. It captures individual employees' perspectives on key issues such as workplace engagement and satisfaction, intention to leave, training needs, ability to address public health issues, as well as collects demographic information. This article describes the methods used for the 2021 PH WINS fielding. PH WINS 2021 was fielded to a nationally representative sample of staff in State Health Agency-Central Offices (SHA-COs) and local health departments (LHDs) from September 13, 2021, to January 14, 2022. The instrument was revised to assess the pandemic's potential toll on the workforce, including deployment to COVID-19 response roles and well-being, and the country's renewed focus on health equity and "Racism as a Public Health Crisis." PH WINS 2021 had 3 sampling frames: SHAs, Big Cities Health Coalition (BCHC) members, and LHDs. All participating agencies were surveyed using a census approach. Overall, staff lists for 47 SHAs, 29 BCHC members, and 259 LHDs were collected, and the survey was sent to 137 446 individuals. PH WINS received a total of 44 732 responses, 35% of eligible respondents. The nationally representative SHA-CO frame includes a total of 14 957 individuals, and the nationally representative LHD frame includes 26 933 individuals from 439 LHDs (decentralized and nondecentralized). PH WINS now offers a multiyear, nationally representative sample of both SHA-CO and LHD staff. Both practice and academia can use PH WINS to better understand the strengths, needs, and opportunities of the workforce. When using PH WINS for additional data analysis, there are a number of considerations both within the 2021 data set and when conducting multiyear and multiple cross-sectional analyses.

Assessing the Impact of a PrEP Aware Week Campaign on PrEP Prescription Fills in NYS.

The New York State (NYS) Department of Health AIDS Institute engaged stakeholders across NYS to participate in the state's first "PrEP Aware Week" (PAW). PAW sought to increase the knowledge, interest, and number of PrEP (pre-exposure prophylaxis) prescriptions filled across NYS. PAW activities were designed to be easy to implement, with minimal cost. Stakeholders were provided activities to implement, along with a social media tool kit featuring videos, graphic ads, and sample social media posts in English and Spanish to use as is or modify. PAW included more than 750 distinct events and activities undertaken by more than 250 participating providers. To assess the impact of PAW on PrEP prescription filling patterns in NYS. An interrupted time-series analysis was conducted to estimate the impact of PAW on overall and new PrEP prescription filling patterns. Separate models were developed by sex (male, female), race and ethnicity (White non-Hispanic, Black non-Hispanic, Hispanic, other, unknown), and region (New York City, rest of NYS). PAW took place across NYS during the week beginning October 20, 2019. PAW was undertaken by more than 250 health care providers, nonmedical health & human services providers, local and state health department staff, and colleges and universities. The number of overall and new PrEP prescriptions. PAW was associated with modest increases (6%-9%) in the number of PrEP prescription fills in NYS. The PAW impact lasted for about 2 months, generated an estimated 2727 additional PrEP prescription fills statewide, and was realized across sex, region, and racial and ethnic subgroups. Increased prescription fills were driven by those previously prescribed PrEP. Increases in new prescriptions were noted among Latinx individuals (21% increase, 55 additional prescriptions) but not overall or across other groups. NYS's PAW was effective at increasing PrEP prescription refills in NYS.

Centralized COVID-19 Contact Tracing in a Home-Rule State.

Contact tracing is an evidence-based intervention to control many communicable diseases, including COVID-19. Before the COVID-19 pandemic, contact tracing in Michigan focused on HIV, sexually transmitted infections, and tuberculosis, and it was conducted by state and local health department staff. Within 2 weeks of the first reported COVID-19 cases in Michigan in March 2020, the existing public health workforce was overwhelmed by the need for contact tracing and daily symptom monitoring. This case study narrates the development of a staffing plan that included volunteers and contractual staff to conduct centralized contact tracing in a home-rule state (ie, a state in which local health departments have full authority and autonomy under public health code to conduct the functions necessary to prevent disease, including contact tracing). This case study details various training, workforce management, and technology tools that were used. During the study period (May 2020–June 2021), contact tracers called 432 218 contacts and 269 439 were successfully reached, 48 134 of whom reported developing symptoms. The most important lesson learned was the need for more automated processes to improve efficiency in processing volunteer applicants, training, and scheduling. Nonetheless, the centralized workforce was successful, was flexible, and met the changing demands in Michigan.

Virtual Trainings Effectively Prepared the Public Health Workforce to Support Schools During the COVID-19 Pandemic in California in 2021.

Context:School closures in California due to COVID-19 have had a negative impact on the learning advancement and social development of K-12 students. Since March 2020, the achievement gap has grown between high-income and low-income students and between White students and students of color.Program:In November 2020, a team from the California Department of Public Health, University of California, San Francisco, and University of California, Los Angeles, developed the School Specialist training for local health department and state employee redirected staff to the COVID-19 response to equip them to support schools as they reopen.Implementation:A pilot of the virtual School Specialist training was carried out in December 2020, which informed subsequent biweekly half-day virtual trainings. The training consisted of lectures from experts and skill development activities led by trained facilitators.Evaluation:The objectives of the evaluation of the training were to understand whether (1) knowledge of key concepts improved from pre- to posttraining; (2) confidence in skills central to the role of a School Specialist improved from pre- to posttraining; and (3) course learners who were activated to work as School Specialists felt the training adequately prepared them for the role. The School Specialist training team sent pre- and posttraining surveys to learners between February 8 and May 18, 2021. Of the 262 learners who responded, a significant improvement was seen in knowledge, with a mean score increase of 15.6%. Significant improvement was also observed for confidence, with a 20.1% score improvement seen posttraining.Discussion:Overall, the School Specialist training was shown to be effective in increasing knowledge and confidence in preparation for School Specialist deployment. Adequate training and partnerships for local health department and school staff are critical to keep K-12 students safe and to reduce the learning achievement gap during the ongoing COVID-19 pandemic.

Community SARS-CoV-2 Surge and Within-School Transmission.

When the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic began, experts raised concerns about in-person instruction in the setting of high levels of community transmission. We describe secondary transmission of SARS-CoV-2 within North Carolina kindergarten through 12th-grade school districts during a winter surge to determine if mitigation strategies can hinder within-school transmission. From October 26, 2020, to February 28, 2021, 13 North Carolina school districts participating in The ABC Science Collaborative were open for in-person instruction, adhered to basic mitigation strategies, and tracked community- and school-acquired SARS-CoV-2 cases. Public health officials adjudicated each case. We combined these data with that from August 2020 to evaluate the effect of the SARS-CoV-2 winter surge on infection rates as well as weekly community- and school-acquired cases. We evaluated the number of secondary cases generated by each primary case as well as the role of athletic activities in school-acquired cases. More than 100 000 students and staff from 13 school districts attended school in person; of these, 4969 community-acquired SARS-CoV-2 infections were documented by molecular testing. Through contact tracing, North Carolina local health department staff identified an additional 209 infections among >26 000 school close contacts (secondary attack rate <1%). Most within-school transmissions in high schools (75%) were linked to school-sponsored sports. School-acquired cases slightly increased during the surge; however, within-school transmission rates remained constant, from presurge to surge, with ∼1 school-acquired case for every 20 primary cases. With adherence to basic mitigation strategies, within-school transmission of SARS-CoV-2 can be interrupted, even during a surge of community infections.

Determinants of workplace perceptions among federal, state, and local public health staff in the US, 2014 to 2017

BackgroundThe governmental public health workforce in the United States comprises almost 300,000 staff at federal, state, and local levels. The workforce is poised for generational change, experiencing significant levels of retirement. However, intent to leave for other reasons is also substantial, and diversity is lacking in the workforce.MethodsWorkforce perception data from 76,000 staff from Health and Human Services (HHS) including 14,000 from the Centers for Disease Control and Prevention were analyzed across 2014 and 2017. Additionally, data from 32,000 state and local health department staff in 46 agencies reporting in both years. Estimates were constructed accounting for survey design and non-response.ResultsIn 2017, women made up 43% of the total US government workforce and 33% of supervisors or higher, compared to 73 and 68% generally in State Health Agencies (p < .0001); and 62% vs 52% in HHS (p < .0001). Among state staff, intent to leave increased from 22 to 31% (p < .0001), but fell in 2017 from 33 to 28% for HHS (p < .0001). Correlates of intent to leave included low job satisfaction, pay satisfaction, and agency type. Federal entities saw the highest proportion respondents that indicated they would recommend their organization as a good place to work.ConclusionsWhile intent to leave fell at federal agencies from 2014 to 2017, it increased among staff in state and local health departments. Additionally, while public health is more diverse than the US government overall, significant underrepresentation is observed in supervisory positions for staff of color, especially women.

The Most Important Skills Required by Local Public Health Departments for Responding to Community Needs and Improving Health Outcomes.

In 2017, Public Health 3.0 was introduced, providing recommendations that expand traditional public department functions and programs. Operationalizing the framework requires that local health departments invest in the requisite professional skills to respond to their community’s needs. The purpose of this paper is to determine the professional skills that are most important for local health departments to respond to large public health issues and challenges that are having a major impact on their communities. The study used a cross-sectional assessment of the education and training needs of local public health departments in Nebraska following the principles of practice-based systems research. The assessment was designed to assess the training and education needs of local health department staff members. The questions measured the perceived importance of and respondent’s capacity across 57 core competencies for public health professionals modified from the Council on Linkages Between Academia and Public Health Practice. A total of 104 staff members from seven local health departments were requested to complete the assessment and 100% of the individuals responded to and completed the assessment. Twenty-eight skills were identified as the most important skills needed for local health departments. The skills were themed and categorized into four domains. (1) Data, Evaluation, and Quality Improvement, (2) Community Engagement and Facilitation, (3) Systems Thinking and Leadership, and (4) Policy and Advocacy. The results from this analysis provide direction to strengthen and transform the public health system into one that is connected, responsive, and nimble. Additionally, it also highlighted a glaring omission that Equity, Diversity, and Inclusion should be included as the fifth domain.

SARS-CoV-2 B.1.617.2 (Delta) Variant COVID-19 Outbreak Associated with a Gymnastics Facility - Oklahoma, April-May 2021.

The B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, was identified in India in late 2020 and has subsequently been detected in approximately 60 countries (1). The B.1.617.2 variant has a potentially higher rate of transmission than other variants (2). During May 12-18, 2021, the Oklahoma State Department of Health (OSDH) Acute Disease Service (ADS) was notified by the OSDH Public Health Laboratory (PHL) of 21 SARS-CoV-2 B.1.617.2 specimens temporally and geographically clustered in central Oklahoma. Public health surveillance data indicated that these cases were associated with a local gymnastics facility (facility A). OSDH ADS and local health department staff members reinterviewed persons with B.1.617.2 variant-positive laboratory results and conducted contact tracing. Forty-seven COVID-19 cases (age range = 5-58 years), including 21 laboratory-confirmed B.1.617.2 variant and 26 epidemiologically linked cases, were associated with this outbreak during April 15-May 3, 2021. Cases occurred among 10 of 16 gymnast cohorts* and three staff members; secondary cases occurred in seven (33%) of 26 interviewed households with outbreak-associated cases. The overall facility and household attack rates were 20% and 53%, respectively. Forty (85%) persons with outbreak-associated COVID-19 had never received any COVID-19 vaccine doses (unvaccinated); three (6%) had received 1 dose of Moderna or Pfizer-BioNTech ≥14 days before a positive test result but had not received the second dose (partially vaccinated); four persons (9%) had received 2 doses of Moderna or Pfizer-BioNTech or a single dose of Janssen (Johnson & Johnson) vaccine ≥14 days before a positive test result (fully vaccinated). These findings suggest that the B.1.617.2 variant is highly transmissible in indoor sports settings and within households. Multicomponent prevention strategies including vaccination remain important to reduce the spread of SARS-CoV-2, including among persons participating in indoor sports† and their contacts.

Incidence and Secondary Transmission of SARS-CoV-2 Infections in Schools.

In an effort to mitigate the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), North Carolina closed prekindergarten through grade 12 public schools to in-person instruction on March 14, 2020. On July 15, 2020, North Carolina's governor announced schools could open via remote learning or a hybrid model that combined in-person and remote instruction. In August 2020, 56 of 115 North Carolina school districts joined The ABC Science Collaborative (ABCs) to implement public health measures to prevent SARS-CoV-2 transmission and share lessons learned. We describe secondary transmission of SARS-CoV-2 within participating school districts during the first 9 weeks of in-person instruction in the 2020-2021 academic year. From August 15, 2020 to October 23, 2020, 11 of 56 school districts participating in ABCs were open for in-person instruction for all 9 weeks of the first quarter and agreed to track incidence and secondary transmission of SARS-CoV-2. Local health department staff adjudicated secondary transmission. Superintendents met weekly with ABCs faculty to share lessons learned and develop prevention methods. Over 9 weeks, 11 participating school districts had >90 000 students and staff attend school in person. Among these students and staff, 773 community-acquired SARS-CoV-2 infections were documented by molecular testing. Through contact tracing, health department staff determined an additional 32 infections were acquired within schools. No instances of child-to-adult transmission of SARS-CoV-2 were reported within schools. In the first 9 weeks of in-person instruction in North Carolina schools, we found extremely limited within-school secondary transmission of SARS-CoV-2, as determined by contact tracing.

Involvement of Local Health Departments in Obesity Prevention: A Scoping Review.

Local health department (LHD) obesity prevention (OP) efforts, particularly by rural LHDs, are seemingly uncommon, in part, due to limited infrastructure, workforce capacity, accessible data, and available population-level interventions aimed at social determinants of health (SDOH). We conducted a scoping review to determine LHD roles in OP efforts and interventions. Inclusion criteria were articles including evidence-based OP and LHD leaders or staff. Articles were coded by type of LHD involvement, data use, intervention characteristics, use of an SDOH lens, and urban or rural setting. We found 154 articles on LHD OP-52 articles met inclusion criteria. Typically, LHDs engaged in only surveillance, initial intervention development, or evaluation and were not LHD led. Data and SDOH lens use were infrequent, and interventions typically took place in urban settings. LHDs could likely play a greater role in OP and population-level interventions and use data in intervention decision making. However, literature is limited. Future research should focus on LHD capacity building, including academic-public health partnerships. Studies should include rural populations, data, and SDOH frameworks addressing "upstream" factors.

Public Health Officials and COVID-19: Leadership, Politics, and the Pandemic.

Public Health Officials and COVID-19: Leadership, Politics, and the Pandemic.

An Opportunity for Cross-jurisdictional Learning: COVID Response Virtual Learning Cafes

As the COVID-19 pandemic unfolded, over 3,000 local health departments (LHDs) in cities and counties across the US were tasked with developing and implementing COVID-19 prevention and response initiatives. While formal trainings and webinars were available, the opportunity for local health departments to informally learn, promote promising practices and strategize around effective COVID-19 response across jurisdictions was limited. Often, cities and counties facing similar challenges in the COVID-19 response were creating solutions independently and in a vacuum, without the benefit of learning from shared experiences. To address this gap, Resolve to Save Lives, as part of its United States COVID-19 Response program, began hosting monthly “COVID-19 Response Virtual Cafés” in October 2020. The cafés were designed for LHD staff to share promising COVID-19 response practices and jointly strategize around common challenges in a non-threatening, collaborative environment. A regularly occurring informal venue for LHDs to candidly discuss and share promising practices has been a valuable addition to health departments’ learning opportunities and ultimately their COVID-19 response. As the pandemic rapidly evolves, opportunities for continued learning and real-time dissemination across jurisdictions play an important role in COVID-19 control.

Building a Sustainable Governmental Public Health Workforce: A Look at the Millennial Generation.

Millennials have had a profound impact on society, the economy, and the US workforce. This study used generational definitions published by the Pew Research Center. Millennials includes respondents who reported an age between 21 and 36 years (born in 1981-1996) at the time the 2017 Public Health Workforce Interests and Needs Survey (PH WINS) was administered. Generation X includes respondents who reported an age between 37 and 52 years (born in 1965-1980), and the baby boom generation (baby boomers) includes respondents between 53 and 71 years of age (born in 1946-1964). Public sector agencies, including governmental public health, are increasingly interested in figuring out how to attract and retain millennials. As the governmental public health workforce anticipates upcoming retirements, knowledge about the motivations and organizational characteristics that appeal to millennials is crucial to understanding the millennial workforce and workplace dynamics for decades to come. In 2017, millennials made up 22% of the governmental public health workforce, Generation X 40%, and baby boomers 37%. This study examined opinions, expectations, and important workplace environment factors of millennials working in governmental public health compared with other generations. We performed bivariate analyses and fit a logistic regression model to evaluate the association of generation with responses to a set of satisfaction and engagement PH WINS survey questions. Data were drawn from the 2017 PH WINS of governmental health department employees, including state health agency and local health department staff. PH WINS excludes local health departments with fewer than 25 staff members or serving fewer than 25 000 people. PH WINS included responses from 47 604 staff members, which reflected a 48% overall response rate. The generations that were examined (millennials, Generation X, and baby boomers) were similarly satisfied with their jobs, organizations, and pay security, and millennials intended to leave their jobs for similar reasons as other generations. Millennials reported more strongly than other generations that their supervisors treated them with respect, that they had sufficient training to utilize technology, that their training needs are assessed, and that creativity and innovation were rewarded. They, however, reported less strongly that they were completely involved in their work and determined to give their best every day. Millennials in governmental public health agencies (excluding local health departments with <25 staff members or serving <25 000 people) may not be as different from other generations as previously thought. Governmental public health agencies should focus on highlighting workplace environment factors rated highly by millennials and on showcasing how careers in governmental public health could be attractive career options for millennials.

A quality improvement collaborative to increase human papillomavirus vaccination rates in local health department clinics

Human papillomavirus (HPV) vaccination rates are well below the Healthy People 2020 goal of 80%. Vaccinating in settings other than primary care, such as local health departments (LHDs), may help achieve higher HPV immunization rates. We tested the effect of a quality improvement (QI) collaborative to reduce missed opportunities (MOs) for HPV vaccine in LHDs. Between 2016 and 2019, we conducted four consecutive cohorts of a virtual QI collaborative at 24 LHDs across multiple states. Participants were trained on topics including how to provide an effective recommendation for HPV vaccine, strategies to reduce MOs, and motivational interviewing. Throughout the 6-month project implementation, LHDs tested strategies to reduce MOs through Plan-Do-Study-Act cycles, performed chart reviews to identify and characterize MOs, and received feedback reports to assess progress on MOs. HPV vaccination rates were assessed pre- and post-intervention. LHDs reduced MOs for HPV vaccine in all four cohorts with aggregated data showing a 25.3 percentage point reduction in MOs. Modified Poisson regression analysis found a 44% reduction in the relative risk of missing the opportunity for an HPV vaccine at a visit (RR = 0.56, 0.46–0.68, p < .001). This project shows that strategies effective in reducing MO for HPV vaccine in primary care settings are also effective in LHD settings. Training LHD staff on these strategies may help the U.S. approach national goals for HPV vaccine coverage.

Disparities in well water outreach and assistance offered by local health departments: A North Carolina case study

Drinking water supplied by private wells is a national concern that would benefit from improved outreach and support to ensure safe drinking water quality. In North Carolina (NC), local health departments (LHDs) have private well programs that enforce statewide well construction standards, offer water testing services, and provide well water outreach and assistance. Programs were evaluated to determine their capacity and capability for well water outreach and assistance and identify differences among programs. All LHDs reported overseeing the construction of new wells as required by law. However, services provided to existing well users were offered infrequently and/or inconsistently offered. Lack of uniformity was observed in the number of LHD staff and their assigned responsibilities; the costs and availability of well water testing; and the comfort of LHD staff communicating with well owners. While the total number of staff was lower in LHDs in rural counties, the number of outreach activities and services offered was typically not related to the number of well users served. Variations in structure and capacity of well programs at LHDs have created unequal access to services and information for well users in NC. This research underscores the need to examine infrastructure that supports the well water community on a national scale.

Appalachian Environmental Health Literacy: Building Knowledge and Skills to Protect Health.

Environmental health literacy (EHL) is an emerging, multidisciplinary field that promotes understanding of how environmental exposures can affect human health. After discussing the regional relevance of environmental health knowledge and skills, this article describes three ongoing Appalachian projects that are focused on measuring and building EHL.