Local Health Jurisdictions Research Articles

Perceived Need Versus Current Spending: Gaps in Providing Foundational Public Health Services in Communities.

Our objective was to estimate the gap between the costs for local health jurisdictions (LHJs) to provide foundational public health services (FPHS) and actual spending on FPHS and to examine factors associated with that gap. We employed resource-based cost estimation methods for this observational study and conducted multivariate analyses with measures derived from secondary administrative data. We used primary data collected from LHJ leaders that depicted 2014 spending and perceived need. We also included secondary administrative data depicting annual 2000-2013 expenditures organized into categories containing key elements of FPHS areas. We included primary data from a representative sample of 10 LHJs in Washington State and secondary data for all 35 LHJs in Washington. Participants were public health practice leaders from each sample LHJ. Our main outcome of interest was the gap identified between current spending and the perceived spending needed to provide FPHS in a jurisdiction. Actual FPHS spending was approximately 65% of spending needed to provide overall FPHS for our sample LHJs, but the size of the gap varied substantially by program. Some gaps also varied widely by LHJ, with spending gaps widest among rural and high poverty communities. Percent poverty and the metropolitan nature of a jurisdiction were factors significantly related to FPHS spending in our multivariate analyses. Actual spending lags far behind local officials' estimates of spending needed to provide FPHS and is likely influenced by local conditions. Major apparent gaps between spending and need, particularly in areas such as costly Business Competencies, underscore the need for cross-cutting capabilities to support public health system responsiveness and for attention to be paid to local conditions.

Five Community-wide Approaches to Physical Activity Promotion: A Cluster Analysis of These Activities in Local Health Jurisdictions in 6 States.

Local health departments (LHDs) have essential roles to play in ensuring the promotion of physical activity (PA) in their communities in order to reduce obesity. Little research exists, however, regarding the existence of these PA interventions across communities and how these interventions may impact community health. In this exploratory study, we used cluster analysis to identify the structure of co-occurring PA interventions, followed by regression analysis to quantify the association between the patterns of PA interventions and prevalence of PA and obesity at a population level. Our study setting included local health jurisdictions in Colorado, Florida, Minnesota, New Jersey, Tennessee, and Washington. Participating jurisdictions were those 218 local health jurisdictions (mostly counties) from which LHD leaders had provided data in 2013 for the Multi-Network Practice and Outcome Variation Examination Study. We obtained unique public health activities data on PA interventions conducted in 2012 from 218 LHDs in 6 participating states. We categorized jurisdictions using cluster analysis, based on PA intervention approaches indicated by LHD leaders as available in their communities and then examined associations between categories and prevalence of obesity and of residents engaged in PA. We identified 5 distinct PA intervention categories representing community-wide approaches-Comprehensive Approach, Built Environment, Personal Health, School-Based Interventions, and No Apparent Activities. Prevalence rates of obesity and PA among jurisdictions in the intervention clusters were significantly different from jurisdictions with No Apparent Activities, with more population-level approaches most significantly related to beneficial outcomes. Our findings suggest the importance of standardized public health services data for generating evidence regarding health-related outcomes. The intervention categories we identified appear to reflect broad, local community-wide prevention approaches and demonstrated that population-level PA interventions can be testable and may have particularly beneficial relationships to community health. Widespread adoption of such standardized data depicting local public health prevention activity could support monitoring practice change, performance improvement, comparisons across communities that could reduce unnecessary variation, and the generation of evidence for public health practice and policy-making.

Too Big, Too Small, or Just Right? Cost-Efficiency of Environmental Inspection Services in Connecticut.

To assess optimal activity size/mix of Connecticut local public health jurisdictions, through estimating economies of scale/scope/specialization for environmental inspections/services. Connecticut's 74 local health jurisdictions (LHJs) must provide environmental health services, but their efficiency or reasons for wide cost variation are unknown. The public health system is decentralized, with variation in organizational structure/size. We develop/compile a longitudinal dataset covering all 74 LHJs, annually from 2005 to 2012. We estimate a public health services/inspections cost function, where inputs are translated into outputs. We consider separate estimates of economies of scale/scope/specialization for four mandated inspection types. We obtain data from Connecticut Department of Public Health databases, reports, and other publicly available sources. There has been no known previous utilization of this combined dataset. On average, regional districts, municipal departments, and part-time LHJs are performing fewer than the efficient number of inspections. The full-time municipal departments and regional districts are more efficient but still not at the minimum efficient scale. The regional districts' elasticities of scale are larger, implying they are more efficient than municipal health departments. Local health jurisdictions may enhance efficiency by increasing inspections and/or sharing some services.

An information supply chain system view for managing rare infectious diseases: The need to improve timeliness

Timely reporting of rare infectious disease cases to the public health system, especially after identification at laboratories, is essential to initiate quick and effective public health response. To ensure that the public health reporting system is appropriately monitoring the rare infectious diseases under surveillance, it is recommended to have a regular assessment of timeliness, especially after the rare infectious case is confirmed. This study aimed to evaluate the timeliness of data reported to the Ohio Disease Reporting System (ODRS), a public health reporting system in Ohio, for managing rare infectious diseases. In a cross-sectional analysis of rare infectious disease reporting data in four local health jurisdictions (LHJs) in the state of Ohio, wide delays were found between various reporting steps, particularly when the laboratories were not using the electronic method of reporting, and the delay observed was mainly at the hospital level and at the LHJ level. This study highlights the supply chain nature of information transfer and calculates the delay at various interacting points of the information supply chain system. The results establish that a centralized approach with an electronic disease reporting system conveys information faster than traditional reporting channels (decentralized approach). Delays of the decentralized approach are isolated at various stakeholder levels and with respect to various types of rare infectious diseases for better understanding of the information supply chain system for managing rare infectious diseases.

Regional Governance of Syndromic Surveillance for the Texas Gulf Coast

ObjectiveDescribe and explain the transition of the syndromic surveillanceprogram at the Houston Health Department (HHD) from being alocally managed and aging system to an ESSENCE system governedby a regional Consortium of public health agencies and stakeholdersin the 13-county area of the southeast Texas.IntroductionSyndromic surveillance systems are large and complex technologyprojects that increasingly require large investments of financial andpolitical capital to be sustainable. What was once a minor surveillancetool in the mid-2000s has evolved into a program that is regardedas valuable to public health yet is increasingly difficult to maintainand operate for local health departments. The Houston HealthDepartment installed a syndromic surveillance system (SyS) sixyears before Meaning Use became known to healthcare communities.The system chosen at the time was the Real-time Outbreak DiseaseSurveillance System (RODS) which, at the time and for its purpose,was a suitable platform for syndromic surveillance. During the past13 years however, maintaining, operating, and growing a SyS by alocal health department has become increasingly difficult. Inclusionin Meaningful Use elevated the importance and profile of syndromicsurveillance such that network growth, transparency of operations,ease of data sharing, and cooperation with other state systems inTexas became program imperatives.MethodsWith support from the informatics group at Tarrant County PublicHealth (TCPH) in the form of mentoring, HHD devised a two prongstrategy to re-invigorate the syndromic program. The first was toreplace RODS with ESSENCE from Johns Hopkins Applied PhysicsLaboratory (JH/APL). The second was to strengthen the regionalnetwork by creating a governance structure that included outsideagencies and stakeholders. The product of this second effort wasthe creation of the Syndromic Surveillance Consortium of SoutheastTexas (SSCSeT) on the Communities of Practice model1usingparliamentary procedure2.ResultsAcquiring ESSENCE and forming SSCSeT were necessary stepsfor the continuing operation of the SyS. The Consortium includesmembers from local health jurisdictions, health care providers, healthpolicy advocates, academicians, and data aggregators. Created asa democratic society, SSCSeT wrote its constitution and by-laws,voted in officers, formed working groups and has begun developingpolicies. The Consortium is cooperating with the Texas Departmentof State Health Services (DSHS) as well as TCPH. Having ESSENCEwill ensure the HHD-SyS will conform to standards being developedin the state and provide a robust syndromic platform for the partnersof the Consortium.ConclusionsSyndromic systems operated by local health departments canadapt to regulatory changes by growing their networks and engagingregional stakeholders using the Communities of Practice model.

Predictors of public support for nutrition-focused policy, systems and environmental change strategies in Los Angeles County, 2013

BackgroundSince 2010, federal and local agencies have invested broadly in a variety of nutrition-focused policy, systems and environmental change (PSE) initiatives in Los Angeles County (LAC). To date, little is...

Education and notification approaches for harmful algal blooms (HABs), Washington State, USA

While numerous strategies have been used to educate and notify the public about potential hazards from exposure to Harmful Algal Blooms (HABs), at present there are no national guidelines or suggested outreach approaches. To raise public awareness and determine effective HAB outreach methods, two Washington State agencies and three counties in the Puget Sound region implemented several education and notification strategies. These approaches were rated for effectiveness by state and county public health and water quality professionals. At the state level, the most effective action was a three-tiered advisory posting protocol for notifying external users that was introduced to local health jurisdictions at workshops around the state. Supplemental permanent signage is recommended for lakes with blooms to overcome the time lag between HAB onset and testing/posting. The state also implements effective notification of toxicity test results through a web-based HAB database and listserv. Lake residents were best notified through electronic alerts including email and social media while mailers to lake residents were useful during initial HAB events and to gain subscribers to electronic alerts. Press releases were most valuable when used sparingly for severe blooms or for blooms in large lakes. Initial analyses of lake recreational use indicates these strategies encourage behavior change in lake users. Based on these findings, a general framework for HAB outreach and a specific notification strategy is proposed to assist other regions or agencies that are developing HAB education and notification programs.

The Importance of Partnerships in Local Health Department Practice Among Communities With Exceptional Maternal and Child Health Outcomes.

The purpose of this study was to identify unique practices underway in communities that have been empirically identified as having achieved exceptional maternal and child health (MCH) outcomes compared with their peers. We used a qualitative, positive deviance approach to identify practices implemented by local health department (LHD) jurisdictions in Florida, Washington, and New York that achieved better MCH outcomes than expected compared with their in-state peer jurisdictions. We identified a total of 50 LHDs in jurisdictions that had better than expected MCH outcomes compared with their peers, and we conducted 39 hour-long semistructured interviews with LHD staff. We conducted inductive thematic analysis to identify key themes and subthemes across all LHD cases in the sample. Partnerships with providers, partnerships for data collection/assessment, and partnerships with community-based organizations were associated with exceptional MCH outcomes based on our interviews. This study offers specific examples of practices LHDs can implement to improve MCH outcomes, even with limited resources, based on the practices of high-performing local health jurisdictions.

Using a positive deviance framework to identify Local Health Departments in Communities with exceptional maternal and child health outcomes: a cross sectional study.

BackgroundThe United States spends more than most other countries per capita on maternal and child health (MCH), and yet lags behind other countries in MCH outcomes. Local health departments (LHDs) are responsible for administering various maternal and child health programs and interventions, especially to vulnerable populations. The goal of this study was to identify local health department jurisdictions (LHDs) that had exceptional maternal and child health outcomes compared to their in-state peers – positive deviants (PDs) - in Washington, Florida and New York in order to support the identification of strategies that can improve community health outcomes.MethodsWe used MCH expenditure data for all LHDs in FL (n = 67), and WA (n = 35), and most LHDs in NY (n = 48) for 2009–2010 from the Public Health Activities and Services Tracking (PHAST) database. We conducted our analysis in 2014–2015. Data were linked with variables depicting local context and LHD structure. We used a cross-sectional study design to identify communities with better than expected MCH outcomes and multiple regression analysis to control for factors outside of and within LHD control.ResultsWe identified 50 positive deviant LHD jurisdictions across 3 states: WA = 10 (29 %); FL = 24 (36 %); NY = 16 (33 %). Overall, internal factor variables improved model fit for identifying PD LHD jurisdictions, but individual variables were not significant.ConclusionsWe empirically identified LHD jurisdictions with better MCH outcomes compared to their peers. Research is needed to assess what factors contributed to these exceptional MCH outcomes and over which LHDs have control. The positive deviance method we used to identify high performing local health jurisdictions in the area of maternal and child health outcomes can assist in better understanding what practices work to improve health outcomes. We found that funding may not be the only predictor of exceptional outcomes, but rather, there may be activities that positive deviant LHDs are conducting that lead to improved outcomes, even during difficult financial circumstances. This method can be applied to other outcomes, communities, and/or services.

Using Syndromic Surveillance to Enhance Arboviral Surveillance in Arizona

Arizona is facing multiple threats from mosquito-borne diseases. Traditional surveillance, however, may take as long as 14 days between specimen collection and laboratory reporting to the health department. The Arizona Department of Health Services partnered with local public health jurisdictions to enhance traditional arboviral surveillance by incorporating syndromic surveillance. The objectives of this project were to develop a protocol for enhancing traditional arboviral surveillance with syndromic surveillance and to evaluate the protocol for accuracy, effectiveness, and timeliness.

Effects of Economic Conditions and Organizational Structure on Local Health Jurisdiction Revenue Streams and Personnel Levels in Connecticut, 2005-2012.

We investigated whether or not changes in economic conditions during the 2008-2010 U.S. recession were associated with changes in Connecticut local health jurisdictions' (LHJs') revenue or personnel levels. We analyzed Connecticut Department of Public Health 2005-2012 annual report data from 91 Connecticut LHJs, as well as publicly available data on economic conditions. We used fixed- and random-effect regression models to test whether or not LHJ per capita revenues and full-time equivalent (FTE) personnel differed during and post-recession compared with pre-recession, or varied with recession intensity, as measured by unemployment rates and housing permits. On average, total revenue per capita was significantly lower during and post-recession compared with pre-recession, with two-thirds of LHJs experiencing per capita revenue reductions. FTE personnel per capita were significantly lower post-recession. Changes in LHJ-level unemployment rates and housing permits did not explain the variation in revenue or FTE personnel per capita. Revenue and personnel differed significantly by LHJ organizational structure across all time periods. Economic downturns can substantially reduce resources available for local public health. LHJ organizational structure influences revenue levels and sources, with implications for the scope, quality, and efficiency of services delivered.

Effect of legal status of pharmacy syringe sales on syringe purchases by persons who inject drugs in San Francisco and San Diego, CA

BackgroundSharing blood-contaminated syringes is the main risk factor for acquiring and transmitting blood-borne infections among persons who inject drugs (PWID). To reduce this risk, in 2005, California enacted legislation allowing local health jurisdictions to legalize non-prescription syringe sales after approving a disease prevention demonstration project (DPDP). With San Francisco approving a DPDP immediately and San Diego never approving one, we compared PWID across cities for their use of pharmacies PWID to obtain syringes. MethodsPWID age 18–30 years old were recruited into separate studies in San Francisco (n=243) and San Diego (n=338) between 2008 and 2011. We used multivariable logistic regression to compare the proportions of PWID who obtained syringes from pharmacies by city while controlling for sociodemographics, injection practices and other risk behaviors. ResultsOverall, most PWID were White (71%), male (63%), and between the ages of 18–25 years (55%). Compared to San Francisco, a smaller proportion of PWID in San Diego had bought syringes from pharmacies in the prior three months (16.9% vs. 49.8%; p<0.001), which remained statistically significant after adjusting for sociodemographic and behavioral factors (adjusted odds ratio=4.45, 95% confidence interval: 2.98, 6.65). ConclusionsUse of pharmacies to obtain syringes was greater where it was legal to do so. Public health policy can influence HIV and hepatitis C associated risk among PWID; however, implementation of these policies is crucial for the benefits to be realized.

Proportions of patients with HIV retained in care and virally suppressed in New York City and the United States: higher than we thought.

The purpose of this analysis is to compare 2 newly developed methods (a "likelihood" method and a "weighting" method) with the widely used method (the "include-all" method) to estimate the proportions of HIV-infected persons retained in care and virally suppressed in New York City (NYC). The NYC HIV registry data were used for the analysis. The include-all method included all patients in the denominator who were diagnosed and/or receiving care in NYC and not known to be dead by December 31, 2012. The likelihood method included patients in the denominator who were likely to reside in NYC in 2012 based on their length of absence from HIV care. The weighting method included patients in the denominator who were residing in NYC in 2012 by weighting each in-care patient based on their probability of receiving HIV care. The include-all method estimated that 114,926 persons were diagnosed and living with HIV in NYC, 63.7% were retained in care (≥1 care visit in 2012), and 48.9% were virally suppressed (≤200 copies/mL). The likelihood method and the weighting method produced equivalent estimates with 80,074 and 80,509 persons diagnosed and living with HIV in NYC, 91.5% and 91.0% retained in care, and 70.2% and 71.7% virally suppressed, respectively. Using 2 newly developed methods, we were able to report more accurate estimates of the proportions of patients retained in care and virally suppressed. Other local health jurisdictions should consider using these new methods to measure care outcomes and monitor the National HIV/AIDS Strategy.

How Connecticut health directors deal with public health budget cuts at the local level.

We investigated the perspectives of local health jurisdiction (LHJ) directors on coping mechanisms used to respond to budget reductions and constraints on their decision-making. We conducted in-depth interviews with 17 LHJ directors. Interviews were audio recorded, transcribed, and analyzed using the constant comparative method. LHJ directors use a range of coping mechanisms, including identifying alternative revenue sources, adjusting services, amending staffing arrangements, appealing to local political leaders, and forming strategic partnerships. LHJs also face constraints on their decision-making because of state and local statutory requirements, political priorities, pressures from other LHJs, and LHJ structure. LHJs respond creatively to budget cuts to maintain important public health services. Some LHJ adjustments to administrative resources may obscure the long-term costs of public health budget cuts in such areas as staff morale and turnover. Not all coping strategies are available to each LHJ because of the contextual constraints of its locality, pointing to important policy questions on identifying optimum jurisdiction size and improving efficiency.

Uptake and population-level impact of expedited partner therapy (EPT) on Chlamydia trachomatis and Neisseria gonorrhoeae: the Washington State community-level randomized trial of EPT.

BackgroundExpedited partner therapy (EPT), the practice of treating the sex partners of persons with sexually transmitted infections without their medical evaluation, increases partner treatment and decreases gonorrhea and chlamydia reinfection rates. We conducted a stepped-wedge, community-level randomized trial to determine whether a public health intervention promoting EPT could increase its use and decrease chlamydia test positivity and gonorrhea incidence in women.Methods and FindingsThe trial randomly assigned local health jurisdictions (LHJs) in Washington State, US, into four study waves. Waves instituted the intervention in randomly assigned order at intervals of 6–8 mo. Of the state’s 25 LHJs, 24 were eligible and 23 participated. Heterosexual individuals with gonorrhea or chlamydial infection were eligible for the intervention. The study made free patient-delivered partner therapy (PDPT) available to clinicians, and provided public health partner services based on clinician referral. The main study outcomes were chlamydia test positivity among women ages 14–25 y in 219 sentinel clinics, and incidence of reported gonorrhea in women, both measured at the community level. Receipt of PDPT from clinicians was evaluated among randomly selected patients. 23 and 22 LHJs provided data on gonorrhea and chlamydia outcomes, respectively. The intervention increased the percentage of persons receiving PDPT from clinicians (from 18% to 34%, p < 0.001) and the percentage receiving partner services (from 25% to 45%, p < 0.001). Chlamydia test positivity and gonorrhea incidence in women decreased over the study period, from 8.2% to 6.5% and from 59.6 to 26.4 per 100,000, respectively. After adjusting for temporal trends, the intervention was associated with an approximately 10% reduction in both chlamydia positivity and gonorrhea incidence, though the confidence bounds on these outcomes both crossed one (chlamydia positivity prevalence ratio = 0.89, 95% CI 0.77–1.04, p = 0.15; gonorrhea incidence rate ratio = 0.91, 95% CI .71–1.16, p = 0.45). Study findings were potentially limited by inadequate statistical power, by the institution of some aspects of the study intervention outside of the research randomization sequence, and by the fact that LHJs did not constitute truly isolated sexual networks.ConclusionsA public health intervention promoting the use of free PDPT substantially increased its use and may have resulted in decreased chlamydial and gonococcal infections at the population level.Trial RegistrationClinicalTrials.gov NCT01665690

Congenital syphilis investigation processes and timing in Louisiana.

Congenital syphilis (CS) is a potentially life-threatening yet preventable infection. State and local public health jurisdictions conduct investigations of possible CS cases to determine case status and to inform public health prevention efforts. These investigations occur when jurisdictions receive positive syphilis test results from pregnant women or from infants. We extracted data from Louisiana's electronic case management system for 328 infants investigated as possible CS cases in 2010 to 2011. Using date stamps from the case management system, we described CS investigations in terms of processes and timing. Eighty-seven investigations were prompted by positive test results from women who were known to be pregnant by the health jurisdiction, and 241 investigations were prompted by positive syphilis test results from infants. Overall, investigations required a median of 101 days to complete, although 25% were complete within 36 days. Investigations prompted by positive test results from infants required a median of 135 days to complete, and those prompted by positive test results from pregnant women required a median of 41 days. Three times as many CS investigations began with reported positive syphilis test results from infants as from pregnant women, and these investigations required more time to complete. When CS investigations begin after an infant's birth, the opportunity to ensure that women are treated during pregnancy is missed, and surveillance data cannot inform prevention efforts on a timely basis. Consistently ascertaining pregnancy status among women whose positive syphilis test results are reported to public health jurisdictions could help to assure timely CS prevention efforts.

HIV Tests And New Diagnoses Declined After California Budget Cuts, But Reallocating Funds Helped Reduce Impact

Historically, California supplemented federal funding of HIV prevention and testing so that Californians with HIV could become aware of their infection and obtain lifesaving treatment. However, budget deficits in 2009 led the state to eliminate its supplemental funding for HIV prevention. We analyzed the impact of California's HIV resource allocation change between state fiscal years 2009 and 2011. We found that the number of HIV tests declined 19 percent, from 66,629 to 53,760, in local health jurisdictions with high HIV burden. In low-burden jurisdictions, the number of HIV tests declined 90 percent, from 20,302 to 2,116. New diagnoses fell from 2,434 in 2009 to 2,235 in 2011 (calendar years) in high-burden jurisdictions and from 346 to 327 in low-burden ones. California's budget crunch prompted state and local programs to redirect remaining HIV funds from risk reduction education to testing activities. Thus, the impact of the budget cuts on HIV tests and new HIV diagnoses was smaller than might have been expected given the size of the cuts. As California's fiscal outlook improves, we recommend that the state restore supplemental funding for HIV prevention and testing.

Technical Description of the Distribute Project: A Community-based Syndromic Surveillance System Implementation.

This paper describes the design of a syndromic surveillance system implemented for community-based monitoring of influenza-like illness. The system began as collaboration between colleagues from state and large metropolitan area health jurisdictions, academic institutions, and the non-profit, International Society for Disease Surveillance. Over the six influenza seasons from 2006 to 2012, the system was automated and enhanced, with new features and infrastructure, and the resulting, reliable, enterprise grade system supported peer comparisons between 44 state and local public health jurisdictions who voluntarily contributed summarized data on influenza-like illness and gastrointestinal syndromes. The system was unusual in that it addressed the needs of a widely distributed, voluntary, community engaged in real-time data integration to support operational public health.

Estimating population size, HIV prevalence and HIV incidence among men who have sex with men: a case example of synthesising multiple empirical data sources and methods in San Francisco

ObjectiveThe number of persons living with HIV/AIDS, the number of new infections and the number of persons at risk for HIV infection are the foundations of evidence-based prevention, treatment and...

Public Health Practice within a Health Information Exchange: Information Needs and Barriers to Disease Surveillance

Introduction:Public health professionals engage in frequent exchange of health information while pursuing the objectives of protecting and improving population health. Yet, there has been little study of the information work of public health workers with regard to information exchange. Our objective was to gain a better understanding of information work at a local health jurisdiction before and during the early stages of participation in a regional Health Information Exchange.Methods:We investigated the information work of public health workers engaged in disease surveillance activities at a medium-sized local health jurisdiction by conducting semi-structured interviews and thematically analyzing interview transcripts.Results:Analysis of the information work of public health workers revealed barriers in the following areas: information system usability; data timeliness, accuracy and completeness; and social interaction with clients. We illustrate these barriers by focusing on the work of epidemiologists.Conclusion:Characterizing information work and barriers to information exchange for public health workers should be part of early system design efforts. A comprehensive understanding of the information practice of public health workers will inform the design of systems that better support public health work.