Local Health Departments Research Articles

Fostering Trust in Public Health Messaging: Tailoring Communication for Rural Parents.

As pandemic-related mistrust of public health recommendations in rural communities may compound gaps in pediatric immunizations, our team explored parents' perceptions of trustworthiness in messaging. Qualitative study using 4 virtual focus groups. Rural Wisconsin. Participants (n = 25) were parents or guardians of children recruited through our contacts with community-based organizations serving rural communities. Researchers used task-oriented elicitation techniques to initiate discussion on the trustworthiness of messengers and messages providing health recommendations. Participants were asked to (1) review existing public health messaging on a range of topics and from a range of sponsors; and (2) rank a list of potential messengers in terms of trustworthiness (eg, local health department, Centers for Disease Control). Discussions were recorded, and audio files transcribed, to facilitate a team-based, thematic analysis. Competency in medical knowledge and parenting experience contributed to estimations of trustworthiness. Participants also responded well to messages and messengers that were able to project recognition of their children's uniqueness and their experience as parents. Participants distrusted messengers who were seen as biased or "one-sided" in their perspectives. For successful health promotion for rural-living parents, messengers must be recognized as "competent" to provide pediatric health advice and to avoid blanket recommendations that may undermine parents' experience and feelings of being "understood" and affect perceptions of trustworthiness.

Advancing Equity in Local Health Departments: An Inside-Out Approach.

The North Carolina Division of Public Health, Chronic Disease and Injury Section recommends local health departments (LHDs) adopt an "inside-out" approach to advance health and racial equity. Internally, LHDs must increase their capacity to address equity by establishing LHD policies and practices that prioritize equity and nurture a culture of trust. Externally, LHDs must seek guidance from historically marginalized populations to inform LHD policy changes and community-based public health approaches affecting these populations for greater engagement in LHD programs. (Am J Public Health. 2024;114(S7):S554-S557. https://doi.org/10.2105/AJPH.2024.307719).

Community pharmacy chlamydia and gonorrhea test-to-treat program: Development of an implementation toolkit

BackgroundSexually transmitted infection (STI) surveillance showed more than 2.5 million cases of chlamydia, gonorrhea, and syphilis nationally in the United States in 2022. Individuals often seek out nonemergency medical care at pharmacies. This makes community pharmacies well-positioned to address rising STI rates by offering services to screen and treat common STIs. A local health department, an independent pharmacy, and a school of pharmacy in Pennsylvania partnered to implement a test-to-treat service for chlamydia and gonorrhea within a pharmacy. This pilot program utilized the following: (1) patient self-collected test kits for chlamydia and gonorrhea screening and; (2) standing orders for treatment at the pharmacy. One goal of this pilot was to develop resources others can use to implement similar pharmacy-based chlamydia and gonorrhea testing and treatment services. ObjectiveDevelop an expert-informed implementation toolkit for a chlamydia and gonorrhea test-to-treat program at a community pharmacy. MethodsThe “How to Build an Implementation Toolkit from Start to Finish” framework from the University of California at Berkeley was used to design the initial toolkit outline. Toolkit content was triangulated from 3 sources: (1) comprehensive literature review; (2) pilot program implementation team meetings; and (3) feedback from public health and other experts. Pilot program partners met regularly to review and edit the toolkit. The draft toolkit was then reviewed by outside experts and potential end-users. ResultsAn 11-item toolkit was developed. Toolkit contents were reviewed by 11 outside experts and potential end-users. Toolkit resources included STI training resources for pharmacy teams, testing and treatment standing orders, pharmacy treatment screening form, marketing strategies, patient education materials, sample workflow, essential supply list, and other key resources. ConclusionPharmacies may need additional resources for STI testing and treatment program implementation. Toolkit resources developed from this pilot program may help pharmacies overcome implementation barriers for similar programs.

Developing Infectious Disease Outbreak Emergency Communications for Populations With Limited English Proficiency: Insights to Sustain Collaborations Between Local Health Departments and Community-Based Organizations.

State and local public health departments (LHDs) are encouraged to collaborate with community-based organizations (CBOs) to enhance communication and promote protective practices with communities made vulnerable during emergencies, but there is little evidence-based understanding of practical approaches to fostering collaboration in this context. This research focuses on how collaboration enhances LHD capacity for effective communication for people with limited English proficiency (LEP) during infectious disease outbreaks specifically and strategies to facilitate productive LHD-CBO collaboration. Qualitative, telephone interviews, conducted March-October 2021. Rural and urban jurisdictions with Chinese-speaking or Spanish-speaking populations across the United States. 36 LHD and 31 CBO staff working on outreach to Chinese and Spanish speakers during COVID-19. Interviews were audio-recorded, transcribed verbatim, and analyzed using a team-based, codebook approach to thematic analysis. During COVID-19, CBOs extended LHD capacity to develop and disseminate effective communication, meaning communication that is rapidly in-language, culturally resonant, locally relevant, and trusted. Practical strategies to enable and sustain effective collaboration were needed to address operational dimensions (eg, material and administrative) and relational dimensions (eg, promoting trust and respect). Policies and financing to support LHD-CBO collaborations are critical to improving communication with people with LEP and addressing long-standing inequities in outcomes during outbreaks.

Equipping the Public Health Workforce of the Future: Evaluation of an Evidence-Based Public Health Training Delivered Through Academic-Health Department Partnerships.

Maintaining a skilled public health workforce is essential but challenging given high turnover and that few staff hold a public health degree. Situating workforce development within existing structures leverages the strengths of different organizations and can build relationships to address public health challenges and health equity. We implemented and evaluated an innovative, sustainable model to deliver an established evidence-based public health (EBPH) training collaboratively among Prevention Research Centers (PRC), local and state health departments, and Public Health Training Centers (PHTC). Quantitative data: quasi-experimental, 1-group pre-post. Qualitative data: cross-sectional. Data were collected between December 2021 and August 2022. Four US sites, each a partnership between a PRC, local or state health department, and a PHTC. Governmental public health staff and representatives from other organizations that implement public health programs in practice settings. Course participants completed a pre- and postcourse survey self-rating 14 skills on a 5-point Likert scale. Differences were analyzed using mixed effects linear models. In-depth interviews (n=15) were conducted with course faculty and partners to understand: (1) resources contributed, (2) barriers and facilitators, (3) benefits and challenges, and (4) resources needed to sustain this model. Interviews were transcribed verbatim, and a thematic analysis identified themes. Statistically significant increases in all skills were observed from pre- to postcourse (n=241 at post, 90% response). The skills with the largest increases were understanding economic evaluation enough to inform decision-making (mean change=1.22, standard error [SE]=0.05) and developing an action plan (mean change=1.07, SE=0.07). Facilitators to delivering the course included having a shared goal of workforce development, existing course curricula, and dedicated funding for delivering the course. Collaborative delivery of the EBPH training can ameliorate the effects of high staff turnover, strengthen academic-practice relationships, and promote population-wide health and health equity.

Assessing Local Public Health Governance in North Carolina Across Organizational and Governance Configurations

Background Every county in North Carolina must include a board of health (BOH) with specific prescribed duties and powers. It is unclear how BOHs in North Carolina are currently exercising their governance ability. In 2012, the North Carolina General Assembly provided coun­ties with additional flexibility to select among different configurations for their local health department (LHD). The impact of this flexibility on the governance and service delivery of LHDs is yet to be explored. Methods We conducted semi-structured interviews with LHD directors and BOH members to assess the strengths and weaknesses of BOHs within different local public health configurations across North Carolina. We employed conventional content analysis to derive themes from the interview transcripts. Results BOHs were largely described as an underutilized institution, with few BOHs noted to be active beyond satisfying their required legal duties. Strong BOHs were noted to fulfill three identities on behalf of the LHD: an advocate, a bridge, and an advisor. The majority of interviewees desired to work in a standalone county health department (as opposed to a consolidated human services agency) with an appointed (versus elected) board of health. This configuration was preferred because, according to participants, it is more likely to enable a structural focus on public health initiatives. Limitations Our sample frame did not control for the length of time an interviewee had been in the office nor the professional background of each BOH member. Conclusions Wide variations exist in the exercise of BOHs across the state, partially due to how different LHD configurations structurally focus resources and attention on public health.

Kaua'i Rural and Public Health Selective: A Family Medicine Residency First.

Governmental public health professionals and community physicians often have limited understanding of each other's roles and responsibilities. To increase the connection between public health and primary care as well as to incorporate rural health care in graduate medical education training, a new "Kaua'i Rural and Public Health Selective" brings Family Medicine resident physicians (Residents) into the local health department on Kaua'i. This first-time collaboration between the Kaua'i District Health Office (KDHO) and University of Hawai'i John A. Burns School of Medicine (JABSOM) Family Medicine Residency Program advances Residents' understanding of public health and has been well-received by Residents and by department of health staff. Future plans include evaluation and continued incorporation of public health experiences into the core curriculum of a rural Family Medicine residency training program based on Kaua'i.

Best Practices and Lessons Learned From the Public Health Disability Specialists Program: Addressing the Needs of People With Disabilities During COVID-19.

The Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO) applied funding issued by the US Centers for Disease Control and Prevention (CDC) to implement the Public Health Disability Specialists Program, part of a project to address the needs of people with disabilities during the COVID-19 pandemic. Disability specialists (subject matter experts) were embedded within state, territorial, and city/county health departments to help ensure disability inclusion in emergency planning, mitigation, and recovery efforts. To evaluate the success of the Disability Specialists Program in improving emergency response planning, mitigation, and recovery efforts for people with disabilities within participating jurisdictions. Disability specialists worked with their assigned jurisdictions to conduct standardized baseline health department needs assessments to identify existing gaps and inform development and implementation of improvement plans. CDC, ASTHO, and NACCHO implemented a mixed methods framework to evaluate specialists' success. State, territorial, and local health departments across 28 jurisdictions between January 2021 and July 2022. Average number of categories of gaps addressed and qualitative documentation of strategies, barriers, and promising practices. Specialists identified 1010 gaps (approximately 36 per jurisdiction) across eight needs assessment categories, most related to mitigation, recovery, resilience, and sustainability efforts (n=213) and communication (n=193). Specialists addressed an average of three categories of gaps identified; common focus areas included equitable COVID-19 vaccine distribution and accessible communications. Specialists commonly mentioned barriers related to limited health agency capacity (eg, resources) and community mistrust. Promising practices to address barriers included sharing best practices through peer-to-peer networks and building and strengthening partnerships between health departments and the disability community. Embedding disability specialists within state, territorial, and local health departments improved jurisdictional ability to meet evolving public health needs for the entire community, including people with disabilities.

Public health use and lessons learned from a statewide SARS-CoV-2 wastewater monitoring program (MiNET)

The global SARS-CoV-2 monitoring effort has been extensive, resulting in many states and countries establishing wastewater-based epidemiology programs to address the spread of the virus during the pandemic. Challenges for programs include concurrently optimizing methods, training new laboratories, and implementing successful surveillance programs that can rapidly translate results for public health, and policy making. Surveillance in Michigan early in the pandemic in 2020 highlights the importance of quality-controlled data and explores correlations with wastewater and clinical case data aggregated at the state level. The lessons learned and potential measures to improve public utilization of results are discussed.The Michigan Network for Environmental Health and Technology (MiNET) established a network of laboratories that partnered with local health departments, universities, wastewater treatment plants (WWTPs) and other stakeholders to monitor SARS-CoV-2 in wastewater at 214 sites in Michigan. MiNET consisted of nineteen laboratories, twenty-nine local health departments, 6 Native American tribes, and 60 WWTPs monitoring sites representing 45 % of Michigan's population from April 6 and December 29, 2020. Three result datasets were created based on quality control criteria. Wastewater results that met all quality assurance criteria (Dataset Mp) produced strongest correlations with reported clinical cases at 16 days lag (rho = 0.866, p < 0.05).The project demonstrated the ability to successfully track SARS-CoV-2 on a large, state-wide scale, particularly data that met the outlined quality criteria and provided an early warning of increasing COVID-19 cases. MiNET is currently poised to leverage its competency to complement public health surveillance networks through environmental monitoring for new and emerging pathogens of concern and provides a valuable resource to state and federal agencies to support future responses.

The Impact of the COVID-19 Pandemic on Staffing Levels in Philadelphia Nursing Homes: Disparities Based on the Racial Composition of Geographical Areas.

Research to assess and inform health policy is an essential component of the policymaking process to advance equity in public health practice. This study investigated health disparities during the COVID-19 pandemic (2020-2022) in older adult institutional settings in Philadelphia, PA, to inform policy initiatives, interventions, and infrastructure development. We first explored the changing patterns of nursing staffing levels (total direct care staff and registered nurses [RNs]) measured by hours per resident per day (HPRD) before and after COVID-19. Our findings revealed that HPRD levels consistently fell below the Centers for Medicare and Medicaid Services recommended standards from 2018 to 2022, with notable declines observed starting from 2021. Results from multilevel modeling showed significant declines in HPRD for total direct care nursing staff in nursing homes located in zip codes with a high proportion of Black residents (≥40%). In contrast, HPRD for RNs significantly declined in nursing homes located in zip codes with a lower proportion of Black residents (<40%). Moreover, higher reported direct care HPRD and RN HPRD were associated with any reported COVID-19 cases only within zip codes with a low proportion of Black residents. These findings indicate the need for additional policies to address these observed patterns in staffing levels. Our study provides a foundation for future policy reviews utilizing a conceptual framework that is health equity-centric for local and state health departments program and units intended for institutional care settings for older adults.

Pipeline emergency preparedness in Nebraska: Identifying interagency preparedness gaps and proposing solutions.

In Nebraska, there are over 28,000 miles of pipelines that carry various materials, which could impact human health and the natural environment in the event of a leak or spill. Nebraska is heavily reliant on its expansive groundwater supply from the large High Plains aquifer system as well as smaller secondary aquifers. Eighty-eight percent of Nebraska's population utilizes groundwater for personal use, and the state's agricultural sector depends on it for irrigation and livestock care. The ongoing challenges facing the implementation of the proposed Keystone XL pipeline system inspired re-searchers to examine the current state of pipeline emergency preparedness in Nebraska. To do this, a pipeline emergency preparedness workshop was held in November 2021 in Norfolk, Nebraska. Conference participants in-cluded county- and regional-level leadership, local public health departments, tribal representatives, and other organizations. Pipeline emergency responders and other stakeholders were invited to listen to plenary presenta-tions about inland oil spill responses and the current state of Nebraska pipelines and to participate in a facilitated discussion identifying pipeline response challenges and potential solutions. Through a facilitated discussion process, participants identified six general response challenge categories and 24 potential solutions. From those 24 solutions, three were selected as easily implementable solutions-increased joint/coordinated planning, increased pipeline emergency exercising, and increased pipeline emergency train-ing/education. Implementing this work will assist in reducing health risks associated with potential spills.

Addressing COVID-19 and Health Literacy Disparities Among Correctional Facility Residents Through Dialogue-Based Education.

Carceral communities face heightened COVID-19-related risks while simultaneously experiencing medical mistrust and limited access to health information and services. Health education programs that incorporate dialogue-based, participatory learning models have been shown to motivate health behavior and increase health knowledge in carceral settings. To increase health literacy and change COVID-19-related health behavior among jail residents in the United States, a local health department developed a dialogue-based education program centered around COVID-19 prevention, misinformation, and navigating health care systems. Dialogue-based health information sessions took place in person in a county jail. Pre- and postsurveys gauged the sessions' influence on self-reported health literacy and behavior intention. Overall, 595 residents collectively attended 43 facilitated discussions. Key findings indicate that dialogue-based education can temper medical mistrust, influencing COVID-19 preventive behaviors and increasing health literacy in a carceral setting.

Building capacity for local public health: lessons from a mixed-methods evaluation of an academic-public health partnership used in response to COVID-19.

The Massachusetts Academic Health Department Consortium (AHD) established the Academic Public Health Volunteer Corps (APHVC) to support Local Health Departments (LHDs, n = 351) to meet rapidly emerging needs during the COVID-19 pandemic through engaging student volunteers. A program evaluation captured lessons learned and informed recommendations for sustainability and future replication. The mixed-methods evaluation leveraged the Consolidated Framework for Implementation Research (CFIR). Data were stratified by LHD engagement with APHVC. Quantitative surveys informed probes for qualitative focus groups and interviews; findings were categorized into CFIR constructs using a deductive approach. One-fifth of LHDs (n = 76, 27 used APHVC services, 45 did not) completed the survey. Eleven employees participated in follow-up focus groups or interviews. APHVC filled resource gaps, built capacity, and provided high-quality deliverables. LHDs experienced issues with reliability and communication of volunteers and lacked time to train volunteers. CFIR aided in evaluating APHVC in real time, producing actionable recommendations for best practices, dissemination, and future iterations of the program. Results are being used to enhance program effectiveness and sustainability, community health, and health equity across Massachusetts, and may help inform academic practice-based programs across the United States.

Challenges and Opportunities for Participatory Evaluation of Local Public Health Efforts to Address Structural Racism and Advance Health Equity

This report describes the process of conducting a participatory evaluation of a local public health department and community partners’ joint efforts to address structural racism and advance health equity in Chicago, Illinois. The participatory evaluation is guided by a multi-partner advisory group composed of academic researchers and research assistants at a local public university; leadership and frontline staff at the local public health department; and individuals employed through local community-based organizations. This report details three key action points in the participatory evaluation process, highlighting the challenges and opportunities that arise while evaluating health equity interventions aimed at institutional and structural change. Insights gleaned from this process can inform ongoing and future participatory evaluation efforts and contribute to the establishment of best practices for partnering across institutions to reshape systems and power relationships to advance health equity.

Applied Informatics Innovation Within a Childhood Blood Lead Poisoning Prevention Program Resulted in Improved Data Management and Demonstrated Client Outcomes.

This poster presentation describes innovative use of the Omaha System, a standardized terminology, into public health nurses' (PHNs) workflow and electronic records within a local health department's Childhood Lead Poisoning Prevention Program. The Omaha System facilitated the tracking of evidence-based interventions and client outcomes, showing a significant improvement in record completeness (from 33% pre-implementation to 84% post-implementation) and client outcomes in health care supervision, growth and development, and nutrition. Outcome data analysis revealed improvement across all post-implementation records from initial assessments to interim assessments for Health care supervision (p<.001), Growth and development (p<.001), and Nutrition (p = .025). This achievement has given program leaders and employees the ability to clearly present their services and results to policymakers, facilitating better assessment of the program's effectiveness. The successful implementation illustrates its potential applicability to other public health projects and areas.

Rapid Online Data Collection and Reporting to Local Health Departments during the Pandemic: The COVID-19 Outbreak Public Evaluation (COPE) Initiative SARS-CoV-2 Case Surveys.

To develop and implement a pilot online data collection tool to help local health departments with their COVID-19 pandemic response efforts and inform health department actions. The COVID-19 Outbreak Public Evaluation (COPE) was an online survey and was distributed by participating sites to individuals who recently tested positive for SARS-CoV-2. Surveys recorded participant demographics and assessed recent infection risk behaviors (eg, mask use, air travel), vaccination status, sleep and exercise habits, social behaviors and beliefs, and physical and mental health. Seven health departments participated in the initiative, which took place during May 1 to September 30, 2022. Identical items were administered to demographically representative samples of adults nationally in the United States within a similar timeframe. A total of 38555 participants completed surveys. Responses from participants with recent SARS-CoV-2 infections were compared with respondents from the national surveys who did not have evidence or awareness of prior SARS-CoV-2 infections. To implement of a process that allows health departments to receive data from local cases and compare this information to national controls during the COVID-19 pandemic. Fifty-four biweekly reports were provided to public health departments between May and September 2022. Information and comparisons within the reports were updated in response to evolving public health priorities for the pandemic response. The initiative helped to guide public health response efforts during the COVID-19 pandemic. Moreover, the receptiveness by local health departments and participants provides evidence to support this data collection and reporting model as a component of the public health response to future emergencies. This project demonstrates the feasibility of a centralized, rapid, and adaptive data collection system for local health departments and provides evidence to advocate for data collection methods to help guide local health departments to respond in a timely and effective manner to future public health emergencies.

Investigating the Role of Local Board of Health Governance on Local Health Department Policymaking Behavior.

This study sought to identify groupings of policymaking behavior among local governmental health departments (LHDs) across the country and assess whether such groupings were associated with the governance activity of their board of health (BOH). We conducted latent class analysis (LCA) to identify possible classes of policymaking behavior among LHDs. Once classes were identified, we used multinomial logistic regression (MLN) to estimate the association between an LHD's policymaking behavior and the governance activity of their BOH. 2019 wave of the National Association of City and County Health Officials (NACCHO) Profile Survey. All LHDs with BOHs in the 2019 NACCHO Profile Survey (n=1003). Within our MLN, our primary outcome of interest was the association between an LHD's policymaking class (the main dependent variable) and the governance activity of its BOH (the main independent variable). Based on our LCA, we determined our sample to be composed of what we characterized as "Limited Policy-Involvement," "Average Policy Involvement," and "Expanded Policy Involvement" LHDs. Those in the Expanded Class were more likely to be involved across all policy areas compared to the Limited and Average class, especially among social determinants of health (SDOH)-related areas. Our MLN estimated that having a BOH active in legal authority was associated with an 86% increased chance that an LHD would be in the "Average Class" compared to the "Limited Class" and having a BOH active in partnership engagement was associated with an 86% more likely chance that an LHD is in the "Expanded Class" compared to the "Average Class." Using nationally representative data on LHD activity, we found distinct groups of policymaking behavior, including a quarter of LHDs that are highly active in traditional and SDOH-related policy areas. We also found that groupings of policymaking behavior, as indicated by class designation, are strongly associated with the BOH's governance activity.

Increasing Access to Cardiac Rehabilitation Services Among Disadvantaged Populations.

The Prince George's County Health Department encountered several challenges to increasing access to cardiac rehabilitation (CR) services among disadvantaged populations. They include excessive patient out-of-pocket costs; requirements that CR orders must be signed by a physician; provider reluctance to refer patients to CR, with most primary care providers preferring to refer clients to cardiologists for the latter to determine whether the patient needs CR referral; limited availability of CR programs; and difficulty identifying patients eligible for CR services. Discussions with other local health departments and public health practitioners indicate that these challenges are not unique to Maryland but are indicative of policy and system barriers that prevent the optimal delivery of cardiovascular health services. This practice report documents the challenges and the Prince George's County Health Department's efforts to resolve them and provides recommendations for decision-makers seeking to make CR programs more accessible to disadvantaged populations.

Strategic Workforce Analysis: Identifying Skills and Gaps Among Frontline Public Health Workers Amidst Transformation.

Recent shifts in public health (PH) include consistent budget cuts, workforce attrition, and loss of vital skills and institutional knowledge followed by heightened pandemic-driven attention, new responsibilities, and renewed funding. This study investigates whether frontline employees working in different types of public health departments have different educational characteristics and whether these characteristics are associated with differentials in skill gaps toward informing targeted interventions to nurture a competitive workforce. Utilizing 2021 Public Health Workforce Interests and Needs Survey (PH WINS) data, we document variations in educational qualifications, skill gaps, and workforce characteristics among frontline workers in different sizes of health departments and examine attributes associated with skill gaps: level and field of education, years of experience, program areas, and job classifications using a negative binomial model. Skill gaps in resource management, systems and strategic thinking, and change management persist across all local health departments (LHDs), but the extent of these gaps is greater in small LHDs. Small LHDs also have few employees with graduate and public health degrees. Additionally, whereas public health degrees were not associated with fewer skill gaps, tenure in public health was, suggesting people learn on the job. The results highlight the role regional training centers can play in emphasizing the need for strategic skills and foundational public health concepts, as well as customizing training content by agency size and educational levels to improve accessibility, particularly for small LHDs with resource constraints.

Reducing Cardiovascular Disparities in Kentucky: The Design, Implementation, and Evaluation of the Cardiovascular Assessment Risk Reduction and Education Self-Measured Blood Pressure (CARE SMBP) Monitoring Program.

Hypertension is a leading risk factor in cardiovascular disease (CVD) with the highest national rates in southeastern and Appalachian counties. To reduce hypertension health disparities and CVD risk, the Kentucky Department for Public Health Heart Disease and Stroke Program (KHDSP) designed, implemented, and continuously evaluated the Cardiovascular Assessment Risk Reduction and Education Self-Measured Blood Pressure (CARE SMBP) program in rural and Appalachian Kentucky. Ten health care systems and two local health departments implemented CARE SMBP. CARE SMBP patients improved their blood pressure and engaged in lifestyle behavior changes that lead to improved long-term health. Health care researchers and potential SMBP implementors can reference the CARE SMBP framework and evaluation results to design their own clinically supported SMBP programs with educational support to reduce CVD risk.