Small Local Health Departments Research Articles

Using National Public Health Accreditation to Explore Quality Improvement and Performance Management in Small Local Health Departments

Context: This article focuses on 4 small local health departments (LHDs) that were in the process of seeking Public Health Accreditation Board (PHAB) reaccreditation or Pathways Recognition using PHAB Standards & Measures Version 2022. Objective: The objective of this study was to explore the experiences of 4 small LHDs related to Quality Improvement (QI) and Performance Management (PM) in their pursuit of PHAB reaccreditation or Pathways Recognition. Design: A team of researchers conducted 22 qualitative interviews with health department leaders and staff. Findings relative to QI/PM represent an embedded case study since they were part of a larger investigation. Setting: The research team conducted interviews remotely with health departments located in the West and Midwest. Participants: Participants included adults at least 18 years old and employed in 1 of 4 health departments. Main Outcome Measures: Emergent themes from this qualitative investigation included using QI/PM tracking systems, building staff buy-in for QI/PM, integrating QI/PM into daily work, and advice for other health departments regarding QI/PM. Results: Participants suggested that tracking systems helped them manage QI/PM processes. Staff buy-in for QI/PM was strengthened by building a sense of ownership of the process and connecting improvement processes to outcomes. Health departments integrated QI/PM into daily work by leadership modeling and communicating expectations. Advice for other health departments included finding a QI system that was easy to follow and recognizing the role of QI/PM in improving performance to better support the wellbeing of the community. Conclusions: QI/PM are important tools for health department effectiveness. Participants affirmed that the primary purposes of QI/PM are to enhance internal processes and improve community health outcomes. Study findings demonstrate how 4 small health departments integrated QI/PM into their public health practice.

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.

Benefits and Impacts of Public Health Accreditation for Small Local Health Departments.

This study sought to identify accreditation benefits and impacts among local health departments (LHDs) stratifying by size of population served to determine differences between small, medium, and large LHDs. The Public Health Accreditation Board operates the national accreditation program for public health departments, through which 306 LHDs have been accredited as of August 2022. Benefits of accreditation for LHDs are well documented, despite potential challenges and barriers to seeking accreditation. Research on the benefits of accreditation for small LHDs, specifically, is more limited. All health departments that completed the accreditation process between December 2013 and May 2022 were surveyed following receipt of the accreditation decision. The analytic sample included 266 LHDs (response rate of 93.7%). Data for LHDs were analyzed for specific variables related to experiences, challenges, and benefits, and stratified by size to compare small LHDs with medium and large LHDs. Bivariate analyses were conducted to identify statistical significance. Generally, small LHDs reported similar outcomes of accreditation to medium and large LHDs. These included improvements in staff competencies, capacity to provide high-quality services, and relationships with partners. Small LHDs were significantly more likely than medium and large LHDs to report that accreditation increased their use of evidence-based practices. LHDs of all sizes reported an increase in quality improvement activities due to accreditation. Challenges for small LHDs included limited staff time or staff turnover and limited funding. The public health accreditation program has offered numerous benefits to LHDs of all sizes, including small LHDs. These accreditation benefits may be particularly important for small LHDs because of their critical role in the public health system and the ongoing need to support performance improvement, strengthen infrastructure, and increase resilience.

PH WINS for All: The Critical Role of Partnerships for Engaging All Local Health Departments in the Public Health Workforce Interests and Needs Survey.

The 2021 "PH WINS for All" pilot sought to address a rural research gap by including small local health departments in the Public Health Workforce Interests and Needs Survey (PH WINS) for the first time. To do so, the de Beaumont Foundation partnered with the Public Health Training Centers in Health and Human Services Regions V and X. This article describes the collaborative efforts that made the PH WINS for All pilot successful, presents respondent demographics by agency size, and discusses the importance of gathering such data to address the unique needs of the workforce in small local health departments.

Heterogeneity and Interoperability in Local Public Health Information Systems.

Heterogeneity and Interoperability in Local Public Health Information Systems.

Application for Public Health Accreditation Among US Local Health Departments in 2013 to 2019: Impact of Service and Activity Mix.

Objectives. To examine correlates of applying for accreditation among small local health departments (LHDs) in the United States through 2019.Methods. We used administrative data from the Public Health Accreditation Board (PHAB) and 2013, 2016, and 2019 Profile data from the National Association of County and City Health Officials to examine correlates of applying for PHAB accreditation. We fit a latent class analysis (LCA) to characterize LHDs by service mix and size. We made bivariate comparisons using the t test and Pearson χ2.Results. By the end of 2019, 126 small LHDs had applied for accreditation (8%). When we compared reasons for not pursuing accreditation, we observed a difference by size for perceptions that standards exceeded LHD capacity (47% for small vs 22% for midsized [P < .001] and 0% for large [P < .001]).Conclusions. Greater funding support, considering differing standards by LHD size, and recognition that service mix might affect practicality of accreditation are all relevant considerations in attempting to increase uptake of accreditation for small LHDs.Public Health Implications. Overall, small LHDs represented about 60% of all LHDs that had not yet applied to PHAB.

Supporting Increased Local Health Department Accreditation: Qualitative Insights From Accredited Small Local Health Departments.

Accredited health departments now cover 80% of the US population. A relatively modest proportion of these are small local health departments (LHDs), serving fewer than 50 000 people. Despite comprising more than half of all health departments, only 2% of small LHDs are accredited. This brief report is a qualitative inquiry into the enablers of accreditation for small LHDs. We interviewed health department and accreditation leaders from 9 accredited small local LHDs. Interviews were transcribed, verified, and coded by 2 coders. We found that dedicated funding, prework, clear expectations, and peer examples were strong enablers of accreditation for these groups. Additional resources specific to small LHDs may be necessary to expedite application processes and encourage greater uptake from this group.

NACCHO's Follow-up Assessment of Disability Inclusion Within Local Health Departments.

NACCHO's Follow-up Assessment of Disability Inclusion Within Local Health Departments.

Pursuing Public Health Accreditation: A Focus on HOW.

Balancing competing imperatives of conserving scarce resources while improving organizational performance and community health, many local health departments (LHDs) have decided to pursue national, voluntary public health accreditation as a guide to improvement, but how to do so in the most efficient way possible remains a question for many. This study employed a participatory action research approach in which LHD directors and accreditation coordinators from 7 accredited and 3 late-stage accreditation ready Kentucky LHD jurisdictions participated. Participants organized a set of accreditation deliverables into a chronological sequencing of each site's accreditation readiness process, which was then coded by researchers to identify similarities and differences. All participating jurisdictions had all-hazards emergency operations plans and public health emergency operations plans while none had workforce development plans, quality improvement plans, or performance management plans before launching accreditation readiness activities. Also identified were the number of accreditation deliverables attempted, simultaneously, by each site and the importance of specific deliverables having a singular focus. Sequences of work on specific deliverables by the majority of participants included completing work on the quality improvement plan immediately, followed by the performance management plan, the Community Health Assessment before the Community Health Improvement Plan, and a strategic plan, followed by a workforce development plan. Factors influencing accreditation readiness processes, elements for sustaining processes, and lessons learned throughout the pursuit of accreditation were also provided by participants. Recognizing the impact of staff availability, staff skill sets, training, and available financial resources on the pursuit of accreditation, participants determined that aggregating lessons learned into a flowchart highlighting the interconnectedness of accreditation deliverables could produce a road map for LHDs. Accreditation deliverables could be attempted in a logical, efficient order particularly valuable to small LHDs with limited resources and yet adaptable for those jurisdictions able to devote more resources to the process.

Availability of Long-Acting Reversible Contraception in Kansas Health Departments.

Unintended pregnancy persists as a public health problem in the United States. Local health departments (LHDs) could play an important role in preventing unintended pregnancy by promoting and providing long-acting reversible contraception (LARC, intrauterine devices [IUDs] and implants), particularly in rural states that may lack robust family planning service infrastructure. The objective of this study was to determine availability of LARC in LHDs in Kansas. From October 2015 to January 2016, LHD administrators in Kansas were contacted to participate in a structured, cross-sectional phone survey assessing LARC availability, staff trained to place LARC, the process for obtaining LARC, and barriers to offering LARC. The main outcome measure was the proportion of Kansas LHDs offering LARC. Of 101 eligible LHDs, staff from 98 agreed to be interviewed (97.0%). Of 69.4% providing family planning services, 20.6% provided LARC (20.6% provided IUDs, 11.8% provided implants and IUDs, and none provided implants only). Overall, only 29.4% of LHDs reported discussing contraception routinely regardless of reason for visit. Rural health departments were less likely to offer testing for sexually transmitted infections and LARCs and less likely to have trained staff on site to insert LARCs when compared to nonrural LHDs. LARC methods are not commonly available in Kansas LHDs. Small LHDs in a rural state like Kansas could benefit from increased capacity to provide LARC to populations with limited access to health care. An increase in funding to prevent unintended pregnancy through expanded LARC access could result in substantial state savings and lead to fewer unintended pregnancies.

Local Health Departments' Partners and Challenges in Electronic Exchange of Health Information.

Unprecedented amounts of data are produced by the health care and other sectors, presenting opportunities for local health departments (LHDs) to access these data. LHDs will need to participate in health information exchange (HIE) with a number of partners in order to benefit from these data resources. LHDs' participation in HIEs with specific partners has not been studied. To describe the level of and challenges in LHD participation in HIE with other partners, and variation by LHD population size and governance type. This research uses data from the 2015 Informatics Capacity and Needs Assessment Survey, with a target population of all LHDs in the United States. A representative sample of 650 LHDs was drawn using a stratified random sampling design. A total of 324 completed responses were received with a 50% response rate. Survey data were cleaned, and bivariate comparisons were conducted using χ and Somer's D. Substantial variation existed in LHDs' participation in HIE by type of exchange partner. Although 71% participated in HIE with the state departments of health, only 12% with jail/correctional health, 14% with health or county-based purchasing plans, and 15% with home health agencies. Compared with large LHDs (jurisdiction populations of ≥500 000), smaller LHDs were more likely to participate in HIE with state departments of health, but less likely with other exchange partners. The challenges to HIE participation were technological, and organizational/interorganizational in nature and variation existed by LHDs' population size and governance structure with respect to state authority. Local public health agencies more commonly participate in HIE with some partners, but may need to improve HIE with many others. National strategies targeting an increase in HIE of LHDs may use our findings to focus those initiatives.

Investigating Informatics Activity, Control, and Training Needs in Large, Medium, and Small Health Departments.

A recent National Association of City & County Health Officials survey shed light on informatics workforce development needs. Local health departments (LHDs) of various jurisdictional sizes and control over informatics may differ on training needs and activity. Understanding the precise nature of this variation will allow stakeholders to appropriately develop workforce development tools to advance the field. To understand the informatics training needs for LHDs of different jurisdictional sizes. Survey responses were analyzed by comparing training needs and LHD population size. Larger health departments consistently reported having greater informatics-related capacity and informatics-related training needs. Quantitative data analysis was identified as a primary need for large LHDs. In addition, LHDs that report higher control of informatics/information technology were able to engage in more informatics activities. Smaller LHDs need additional resources to improve informatics-related capacity and engagement with the field.

Local Health Departments' Involvement in Hospitals' Implementation Plans

Background: More than half of all local health departments (LHDs) in the U.S. are involved in collaborations with nonprofit hospitals on a community health needs assessment (CHNA), yet little is known about the role that LHDs play in hospitals’ implementation plans. Purpose: This study aims to explore the current state of hospital–LHD collaborations around the implementation plan using data from a survey of LHDs across the country. Methods: The study sample included 457 LHDs that completed both the 2015 Forces of Change survey and the 2013 Profile survey conducted by the National Association of County and City Health Officials. Univariate and bivariate analyses were used to compare LHDs involved in hospitals’ implementation plans to LHDs not involved in such activities. All analyses were conducted in 2016. Results: Of the 457 sample LHDs, 62% were involved in at least one activity associated with hospitals’ implementation plans. These LHDs were larger, had greater budgets, and were more likely to be locally governed. In addition, almost all of these LHDs reported that they also collaborated with hospitals around the CHNA. Implications: There is evidence of substantial involvement of LHDs in hospitals’ implementation plans. Importantly, joint CHNAs appear to pave the path for hospital–LHD collaboration in this area. Since LHDs that collaborate with hospitals on their implementation plans tended to be better resourced, policymakers may want to find ways to ensure that smaller LHDs have the necessary human and fiscal resources to be engaged in joint community health needs assessment and improvement planning activities.

Cross-Jurisdictional Resource Sharing in Changing Public Health Landscape

Local health departments (LHDs) are striving to meet public health needs within their jurisdictions, amidst fiscal restraints and complex dynamic environment. Resource sharing across jurisdictions is a critical opportunity for LHDs to continue to enhance effectiveness and increase efficiency. This research examines the extent of cross-jurisdictional resource sharing among LHDs, the programmatic areas and organizational functions for which LHDs share resources, and LHD characteristics associated with resource sharing. Data from the National Association of County & City Health Officials' 2013 National Profile of LHDs were used. Descriptive statistics and multinomial logistic regression were performed for the 5 implementation-oriented outcome variables of interest, with 3 levels of implementation. More than 54% of LHDs shared resources such as funding, staff, or equipment with 1 or more other LHDs on a continuous, recurring basis. Results from the multinomial regression analysis indicate that economies of scale (population size and metropolitan status) had significant positive influences (at P ≤ .05) on resource sharing. Engagement in accreditation, community health assessment, community health improvement planning, quality improvement, and use of the Community Guide were associated with lower levels of engagement in resource sharing. Doctoral degree of the top executive and having 1 or more local boards of health carried a positive influence on resource sharing. Cross-jurisdictional resource sharing is a viable and commonly used process to overcome the challenges of new and emerging public health problems within the constraints of restricted budgets. LHDs, particularly smaller LHDs with limited resources, should consider increased resource sharing to address emerging challenges.

The Double Disparity Facing Rural Local Health Departments.

Residents of rural jurisdictions face significant health challenges, including some of the highest rates of risky health behaviors and worst health outcomes of any group in the country. Rural communities are served by smaller local health departments (LHDs) that are more understaffed and underfunded than their suburban and urban peers. As a result of history and current need, rural LHDs are more likely than their urban peers to be providers of direct health services, leading to relatively lower levels of population-focused activities. This review examines the double disparity faced by rural LHDs and their constituents: pervasively poorer health behaviors and outcomes and a historical lack of investment by local, state, and federal public health entities.

Use of Syndromic Surveillance at Local Health Departments

Syndromic surveillance systems enhance public health practice in both large and small population settings. However, data from these systems are typically monitored by state and federal agencies and less frequently used by small public health agencies, such as local health departments (LHDs). Syndromic surveillance system modifications may facilitate use by LHDs. To describe syndromic surveillance system modifications and survey LHD staff to assess subsequent changes in system use. Pre- and postintervention cross-sectional analysis. North Carolina (NC) LHDs, 2009 and 2012. LHD nursing and preparedness staff. Use of syndromic surveillance data by LHDs for outbreak response, seasonal event response, program management, and stakeholder reports. In NC, syndromic surveillance system modifications made between 2009 and 2012 included implementation of LHD-specific data "dashboards" and increased distribution of LHD-specific surveillance information by the state public health agency. Users of LHD syndromic surveillance system increased from 99 in 2009 to 175 in 2012. Twenty-seven of 28 (96%) and 62 of 72 (86%) respondents completed the 2009 and 2012 surveys, respectively. Among respondents, 23% used syndromic surveillance data for outbreak response in 2009, compared with 25% in 2012. In 2009, 46% of respondents used these data for seasonal event response, compared with 57% in 2012. Syndromic surveillance data were used for program management by 25% of respondents in 2009 (compared with 30% in 2012) and for stakeholder reports by 23% of respondents in 2009 (compared with 33% in 2012). Syndromic surveillance system changes supported modest increases in LHD use of syndromic surveillance information. Because use of syndromic surveillance information at smaller LHD is rare, these modest increases indicate effective modification of the NC syndromic surveillance system.

Use of twitter among local health departments: an analysis of information sharing, engagement, and action.

BackgroundSocial media offers unprecedented opportunities for public health to engage audiences in conversations and collaboration that could potentially lead to improved health conditions. While there is some evidence that local health departments (LHDs) are using social media and Twitter in particular, little is known about how Twitter is used by LHDs and how they use it to engage followers versus disseminating one-way information.ObjectiveTo examine how LHDs use Twitter to share information, engage with followers, and promote action, as well as to discover differences in Twitter use among LHDs by size of population served.MethodsThe Twitter accounts for 210 LHDs were stratified into three groups based on size of population served (n=69 for less than 100,000; n=89 for 100,000-499,999; n=52 for 500,000 or greater). A sample of 1000 tweets was obtained for each stratum and coded as being either about the organization or about personal-health topics. Subcategories for organization included information, engagement, and action. Subcategories for personal health included information and action.ResultsOf all LHD tweets (n=3000), 56.1% (1682/3000) related to personal health compared with 39.5% (1186/3000) that were about the organization. Of the personal-health tweets, 58.5% (984/1682) involved factual information and 41.4% (697/1682) encouraged action. Of the organization-related tweets, 51.9% (615/1186) represented one-way communication about the organization and its events and services, 35.0% (416/1186) tried to engage followers in conversation, and 13.3% (158/1186) encouraged action to benefit the organization (eg, attend events). Compared with large LHDs, small LHDs were more likely to post tweets about their organization (Cramer’s V=0.06) but were less likely to acknowledge events and accomplishments of other organizations (χ2=12.83, P=.02, Cramer’s V=0.18). Small LHDs were also less likely to post personal health-related tweets (Cramer’s V=0.08) and were less likely to post tweets containing suggestions to take action to modify their lifestyle. While large LHDs were more likely to post engagement-related tweets about the organization (Cramer’s V=0.12), they were less likely to ask followers to take action that would benefit the organization (χ2=7.59, P=.02. Cramer’s V=0.08). While certain associations were statistically significant, the Cramer’s V statistic revealed weak associations.ConclusionsTwitter is being adopted by LHDs, but its primary use involves one-way communication on personal-health topics as well as organization-related information. There is also evidence that LHDs are starting to use Twitter to engage their audiences in conversations. As public health transitions to more dialogic conversation and engagement, Twitter’s potential to help form partnerships with audiences and involve them as program participants may lead to action for improved health.

Diabetes-Related Services and Programs in Small Local Public Health Departments, 2009-2010

Local health departments (LHDs) vary in their capacity to perform public health services by the size of population they serve. Little is known about the extent of emerging primary prevention activities at small LHDs. The objectives of this study were to describe various diabetes-related patient care and primary prevention services offered by small LHDs (those serving a population of less than 150,000) and explore factors associated with the diversity of these services. During 2009 through 2010, we interviewed directors of a nationally representative sample of small LHDs by telephone to obtain information about staff structure, diabetes services, and partnerships. We obtained data for demographic characteristics and health status of the population from secondary sources. We analyzed the number of patient care services and primary prevention programs through multivariate regression analyses. Fifty-eight small LHDs completed the survey, a response rate of 81%. Most (n = 47) had at least 1 diabetes-related patient care service; referral to diabetes specialists was the most frequently identified service (n = 44). Nearly half of small LHDs also engaged in obesity prevention for adults (n = 26) or children (n = 26), but only 7 had a diabetes prevention program. Diversity of patient care services was positively associated with the proportion of the population that was rural, time commitment of a certified diabetes educator, and total staff size. Diversity of primary prevention programs was positively associated with intensity of collaboration with the state diabetes program and total staff size and inversely associated with the proportion of racial/ethnic minorities in the jurisdiction. Most small LHDs function as a link to local diabetes care services. Staff capacity, collaboration with the state health department, and local population factors appear to influence the diversity of diabetes-related services at small LHDs.