US State Health Research Articles

Adaptive Governance: Empowering Data Sharing for Public Health Impact - Insights from North Carolina Department of Health and Human Services

Objective and ApproachAt the 2022 IPDLN Conference, we presented work led by the North Carolina Department of Health and Human Services (NCDHSS), in partnership with university-based researchers, to build legal and ethical processes for routine data sharing. This session provides significant updates on the methods, results, and implications of these efforts–namely, that NCDHHS implemented an enterprise-wide data governance process and a legal framework that has enabled timely, impactful use of cross-sector data. We relied on Participatory Action Research and Deliberative Dialogue methods to engage a diverse range of partners in a data landscape overview and the co-creation of new data sharing processes that better enables the enterprise to adapt to a changing world. ResultsFour key actions were taken as a result of the participatory research process: NCDHHS developed a data strategy, created a data sharing guidebook, staffed their Data Office, and implemented a new legal framework. In addition to describing how these actions support data use across a large US state health and human services agency, we provide three use cases demonstrating the impact of this work. ConclusionsEstablishing routine data sharing presents legal, technical, and cultural challenges, particularly in large agencies. Through a collaborative, participatory approach, the NCDHHS successfully established enterprise-wide data governance and a legal framework to support data-driven policymaking and, ultimately, improve health outcomes for residents. ImplicationsThis research presents a successful, actionable, and replicable framework for developing and implementing processes to support intradepartmental data access, linkage, and use.

U.S. state health agencies and organizational learning: An exploratory analysis of website accessibility during COVID-19

The COVID-19 pandemic has exposed the inaccessibility of government information and communication technologies (ICTs) for members of the disability community. Organizational learning around ICT accessibility can be impacted by factors influencing strategies and assumptions or values and norms. Using data collected over two time periods in 2021, we study how the accessibility of US state health agencies COVID-19 information and vaccine websites improve over time. We examine how time, state policies, and partisanship influence organizational learning around website accessibility. Our analysis determines that the longer a COVID-19 related website exists on the Internet, the less accessible the website. We also find that more extensive internal state accessibility policies are more correlated with websites that meet fundamental accessibility requirements. Additionally, we find that partisanship plays an unexpected role in meeting fundamental accessibility demands, although both state policies and politics do not influence if an ICT meets the best practices standards of accessibility. Our paper initiates a discussion around the factors that influence organizational learning about government website accessibility and points to future research questions where the primary ICT function is not influenced by a rapidly evolving pandemic.

Program adaptation by health departments.

IntroductionThe dissemination of evidence-based interventions (i.e., programs, practices, and policies) is a core function of US state health departments (SHDs). However, interventions are originally designed and tested with a specific population and context. Hence, adapting the intervention to meet the real-world circumstances and population's needs can increase the likelihood of achieving the expected health outcomes for the target population from the implemented intervention. This study identified how SHD employees decide to adapt public health programs and what influences decisions on how to adapt them.Materials and methodsSHD employees (n = 45) were interviewed using a qualitative semi-structured interview guide. Telephone interviews were audio-recorded and transcribed verbatim. The transcripts were consensus-coded and themes were identified using thematic analysis. Several themes aligned with the Model for Adaptation Design and Impact.ResultsData, outcomes, and health department evaluations influenced decisions to adapt a program (pre-adaptation), and reasons to adapt a program included organizational and sociopolitical contextual factors. SHD middle-level managers, program managers and staff, and local agencies were involved in the decisions to adapt the programs. Finally, the goals for adapting a program included enhancing effectiveness/outcomes, reach and satisfaction with the program; funding; and partner engagement. After SHD employees decided to adapt a program, data and evidence guided the changes. Program staff and evaluators were engaged in the adaptation process. Program managers consulted partners to gather ideas on how best to adapt a program based on partners' experiences implementing the program and obtaining community input. Lastly, program managers also received input on adapting content and context from coalition meetings and periodic technical assistance calls.DiscussionThe findings related to decisions to adapt public health programs provide practitioners with considerations for adapting them. Findings reaffirm the importance of promoting public health competencies in program evaluation and adaptation, as well as systematically documenting and evaluating the adaptation processes. In addition, the themes could be studied in future research as mechanisms, mediators, and moderators to implementation outcomes.

Achieving Reductions in Opioid Dispensing: A Qualitative Comparative Analysis of State-Level Efforts to Improve Prescribing.

To determine whether any combinations of state-level public health activities were necessary or sufficient to reduce prescription opioid dispensing. We examined 2016-2019 annual progress reports, 2014-2019 national opioid dispensing data (IQVIA), and interview data from states to categorize activities. We used crisp-set Qualitative Comparative Analysis to determine which program activities, individually or in combination, were necessary or sufficient for a better than average decrease in morphine milligram equivalent (MME) per capita. Twenty-nine US state health departments. State health departments implementing the Centers for Disease Control and Prevention's Prevention for States (PfS) program. Combinations of prevention activities related to changes in the rate of prescription opioid MME per capita dispensing from 2014 to 2019. Three combinations were sufficient for greater than average state-level reductions in MME per capita: (1) expanding and improving proactive reporting in combination with enhancing the uptake of evidence-based opioid prescribing guidelines and not moving toward a real-time Prescription Drug Monitoring Program; (2) implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with enhancing the uptake of evidence-based opioid prescribing guidelines; and (3) not implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with not enhancing the uptake of evidence-based opioid prescribing guidelines. Interview data suggested that the 3 combinations indicate how state contexts and history with addressing opioid overdose shaped programming and the ability to reduce MME per capita. States successful in reducing opioid dispensing selected activities that built upon existing policies and interventions, which may indicate thoughtful use of resources. To maximize impact in addressing the opioid overdose epidemic, states and agencies may benefit from building on existing policies and interventions.

Barely Tweeting and Rarely About Racism: Assessing US State Health Department Twitter Use During the COVID-19 Vaccine Rollout.

The general public was discussing racism and potential inequities in COVID-19 vaccinations among African Americans on Twitter before the first COVID-19 vaccine received emergency use authorization, but it is unclear how US state health departments (SHDs) were using Twitter to address the inequities. This study examines the frequency, content and timing of SHD tweets during the US rollout of the first SARS Co-V2 vaccine. This was a prospective study of tweets posted from the official Twitter accounts of each of the 50 US SHDs and the DC health department from October 19, 2020 to February 28, 2021. We retrieved the content and metadata of 100% of their tweets; calculated frequencies and proportions of tweets containing key terms related to COVID-19 vaccines, equity and racism; stratified the data by region; and charted longitudinal trends. Overall, SHDs tweeted infrequently, and rarely tweeted about inequities, mistrust or racism. Though 55.48% of all SHD tweets were about COVID-19, hardly any tweets contained the terms: race/ethnicity (1.20%); equity (1.09); mistrust (.59%); or racism (.06%). Similar patterns existed among vaccination-related tweets, which accounted for 24.38% of all tweets. Only 21.64% of vaccination-related tweets containing any race/ethnicity, equity, mistrust, or racism terms were posted prior to the first Emergency Use Authorization (EUA). Those about African Americans (70.45%) were posted ≥8 weeks after EUA. Concerns about racism and inequities in COVID-19 vaccination continue on Twitter, but SHDs rarely tweet about them. This strikes a worrisome chord of disconnection from the science linking health inequities to racism.

State Health Department Communication about Long COVID in the United States on Facebook: Risks, Prevention, and Support.

Greater public awareness of long COVID severity and susceptibility is needed to support those with long COVID and encourage preventive behaviors. It is not yet known to what extent health departments have informed the public about long COVID risks or offered guidance and support for those with long COVID. The objective of this research was to determine how and to what extent US state health departments have communicated with the public about long COVID via Facebook. Facebook posts with COVID-19 and long COVID terms made by 50 US state health departments plus Washington, DC, from 1 January 2020 to 31 January 2022, were collected using CrowdTangle. The first long COVID post appeared on 15 July 2020. From 15 July 2020 to 31 January 2022, state health departments made 49,310 COVID-19 posts and 137 long COVID posts. Using quantitative content analysis methods, long COVID posts were coded for health belief model constructs. Among long COVID posts, 75.18% included language about susceptibility, 64.96% severity, and 64.23% benefits of prevention. Cues to preventive action appeared in 54.01% of posts. 19.71% of posts provided guidance for those with long COVID. While health departments posted extensively about COVID-19, posts about long COVID were rare. This represents a missed opportunity to bolster arguments for preventive behaviors and support those experiencing long COVID.

Approaches for Ending Ineffective Programs: Strategies From State Public Health Practitioners.

Background: Public health agencies are increasingly concerned with ensuring they are maximizing limited resources by delivering evidence-based programs to enhance population-level chronic disease outcomes. Yet, there is little guidance on how to end ineffective programs that continue in communities. The purpose of this analysis is to identify what strategies public health practitioners perceive to be effective in de-implementing, or reducing the use of, ineffective programs.Methods: From March to July 2019, eight states were selected to participate in qualitative interviews from our previous national survey of US state health department (SHD) chronic disease practitioners on program decision making. This analysis examined responses to a question about “…advice for others who want to end an ineffective program.” Forty-five SHD employees were interviewed via phone. Interviews were audio-recorded, and the conversations were transcribed verbatim. All transcripts were consensus coded, and themes were identified and summarized.Results: Participants were program managers or section directors who had on average worked 11 years at their agency and 15 years in public health. SHD employees provided several strategies they perceived as effective for de-implementation. The major themes were: (1) collect and rely on evaluation data; (2) consider if any of the programs can be saved; (3) transparently communicate and discuss program adjustments; (4) be tactful and respectful of partner relationships; (5) communicate in a way that is meaningful to your audience.Conclusions: This analysis provides insight into how experienced SHD practitioners recommend ending ineffective programs which may be useful for others working at public health agencies. As de-implementation research is limited in public health settings, this work provides a guiding point for future researchers to systematically assess these strategies and their effects on public health programming.

Reporting and Availability of COVID-19 Demographic Data by US Health Departments (April to October 2020): Observational Study.

BackgroundThere is an urgent need for consistent collection of demographic data on COVID-19 morbidity and mortality and sharing it with the public in open and accessible ways. Due to the lack of consistency in data reporting during the initial spread of COVID-19, the Equitable Data Collection and Disclosure on COVID-19 Act was introduced into the Congress that mandates collection and reporting of demographic COVID-19 data on testing, treatments, and deaths by age, sex, race and ethnicity, primary language, socioeconomic status, disability, and county. To our knowledge, no studies have evaluated how COVID-19 demographic data have been collected before and after the introduction of this legislation.ObjectiveThis study aimed to evaluate differences in reporting and public availability of COVID-19 demographic data by US state health departments and Washington, District of Columbia (DC) before (pre-Act), immediately after (post-Act), and 6 months after (6-month follow-up) the introduction of the Equitable Data Collection and Disclosure on COVID-19 Act in the Congress on April 21, 2020.MethodsWe reviewed health department websites of all 50 US states and Washington, DC (N=51). We evaluated how each state reported age, sex, and race and ethnicity data for all confirmed COVID-19 cases and deaths and how they made this data available (ie, charts and tables only or combined with dashboards and machine-actionable downloadable formats) at the three timepoints.ResultsWe found statistically significant increases in the number of health departments reporting age-specific data for COVID-19 cases (P=.045) and resulting deaths (P=.002), sex-specific data for COVID-19 deaths (P=.003), and race- and ethnicity-specific data for confirmed cases (P=.003) and deaths (P=.005) post-Act and at the 6-month follow-up (P<.05 for all). The largest increases were race and ethnicity state data for confirmed cases (pre-Act: 18/51, 35%; post-Act: 31/51, 61%; 6-month follow-up: 46/51, 90%) and deaths due to COVID-19 (pre-Act: 13/51, 25%; post-Act: 25/51, 49%; and 6-month follow-up: 39/51, 76%). Although more health departments reported race and ethnicity data based on federal requirements (P<.001), over half (29/51, 56.9%) still did not report all racial and ethnic groups as per the Office of Management and Budget guidelines (pre-Act: 5/51, 10%; post-Act: 21/51, 41%; and 6-month follow-up: 27/51, 53%). The number of health departments that made COVID-19 data available for download significantly increased from 7 to 23 (P<.001) from our initial data collection (April 2020) to the 6-month follow-up, (October 2020).ConclusionsAlthough the increased demand for disaggregation has improved public reporting of demographics across health departments, an urgent need persists for the introduced legislation to be passed by the Congress for the US states to consistently collect and make characteristics of COVID-19 cases, deaths, and vaccinations available in order to allocate resources to mitigate disease spread.

The Relationships Between State Health Department Practitioners' Perceptions of Organizational Supports and Evidence-Based Decision-Making Skills.

Evidence-based decision making (EBDM) allows public health practitioners to implement effective programs and policies fitting the preferences of their communities. To engage in EBDM, practitioners must have skills themselves, their agencies must engage in administrative evidence-based practices (A-EBPs), and leaders must encourage the use of EBDM. We conducted this longitudinal study to quantify perceptions of individual EBDM skills and A-EBPs, as well as the longitudinal associations between the 2. An online survey completed among US state health department practitioners in 2016 and 2018 assessed perceptions of respondents' skills in EBDM and A-EBPs. We used χ2 tests, t tests, and linear regressions to quantify changes over time, differences by demographic characteristics, and longitudinal associations between individual skills and A-EBPs among respondents who completed both surveys (N = 336). Means of most individual EBDM skills and A-EBPs did not change significantly from 2016 to 2018. We found significant positive associations between changes in A-EBPs and changes in EBDM skill gaps: for example, a 1-point increase in the relationships and partnerships score was associated with a narrowing of the EBDM skill gap (β estimate = 0.38; 95% CI, 0.15-0.61). At both time points, perceived skills and A-EBPs related to financial practices were low. Findings from this study can guide the development and dissemination of initiatives designed to simultaneously improve individual and organizational capacity for EBDM in public health settings. Future studies should focus on types of strategies most effective to build capacity in particular types of agencies and practitioners, to ultimately improve public health practice.

National Trends of Cases of COVID-19 in Children Based on US State Health Department Data.

* Abbreviations: CDC — : Centers for Disease Control and Prevention COVID-19 — : coronavirus disease 2019 NYC — : New York City Although there are several accessible sources providing data on coronavirus disease 2019 (COVID-19) cases, hospitalizations, and deaths in the United States,1,2 little information has been reported on pediatric cases. However, information on COVID-19, categorized by age group, is publicly accessible on nearly all state health department Web sites. In a Centers for Disease Control and Prevention (CDC) report in April, it was reported that only 1.7% of confirmed COVID-19 cases were in children <18 years of age,3 whereas more recent CDC data indicate 8.2% of cases were in children.4 Although there are reports of serious illness in children from COVID-19 (including multisystem inflammatory syndrome in children), available data indicate children are far less … Address correspondence to William Cull, PhD, Research, American Academy of Pediatrics, 345 Park Blvd, Itasca, IL 60143. Email: wcull@aap.org

Adopting YouTube to Promote Health: Analysis of State Health Departments.

We describe videos posted to the YouTube video-sharing Web site by US state health departments (SHDs) and associated institutional factors. YouTube channels from SHDs were identified, their data retrieved, and their videos saved to a playlist on January 10, 2016. Ten randomly sampled videos from each channel were manually coded for topics. The 2012 Association of State and Territorial Health Officials profile survey was used to obtain information on staff, expenditure, and top 5 priorities for each SHD. Descriptive statistics and univariable regression were conducted. Forty-three SHDs had YouTube channels. Together, all SHDs posted 3957 videos, accumulated 12,151,720 views, and gained 6302 subscribers. In total, 415 videos were manually coded. Information about the agency (17.6%), communicable diseases (12.5%), and mother/infant health (8.9%) comprised the largest share of topics. No statistically significant association was observed between the log-transformed number of videos posted on an SHD's YouTube channel and any of the explanatory variables of SHD staffing and expenditure in 2011. The number of full-time employees (r = 0.34, p = 0.03), number of epidemiologists and biostatisticians (r = 0.41, p = 0.01), and 2011 total year expenditure (r = 0.38, p = 0.02) were positively correlated with the log-transformed number of views per YouTube video posted by SHDs. No meaningful patterns of statistical association were observed between the percentage of expenditure on a specific program area and the topics of videos. Most SHDs are using YouTube, which provides a unique opportunity for SHDs to disseminate health messages.

US state health expenditure convergence: A revisited analysis

This paper studies the evolution of US state health expenditure for a sample that covers 1966–2014. Our results provide evidence against the existence of a single pattern of behavior of personal health care expenditure across the US states. Rather, we can observe the existence of two statistically different convergence clubs. We cannot find evidence of convergence when we disaggregate health expenditure into its three main payers: Medicare, Medicaid and private health insurance expenditure, whilst we again find evidence of convergence clubs. However, the estimated clubs for Medicaid and private health insurance expenditure are statistically different that estimated for total health expenditure. Consequently, our results offer strong evidence of heterogeneity in the evolution of US health expenditure. The analysis of the forces that drive club creation shows that economic situation and some supply-side factors are important. We can also appreciate that some healthcare outcome variables are only related to private insurance health expenditure. The other health expenditures, thus, show a certain lack of efficiency which may be due to practices that have little benefit for patient health.

Self-reported Preparedness to Respond to Mass Fatality Incidents in 38 State Health Departments.

Public health departments play an important role in the preparation and response to mass fatality incidents (MFIs). To describe MFI response capabilities of US state health departments. The data are part of a multisector cross-sectional study aimed at 5 sectors that comprise the US mass fatality infrastructure. Data were collected over a 6-week period via a self-administered, anonymous Web-based survey. In 2014, a link to the survey was distributed via e-mail to health departments in 50 states and the District of Columbia. State health department representatives responsible for their state's MFI plans. Preparedness was assessed using 3 newly developed metrics: organizational capabilities (n = 19 items); operational capabilities (n = 19 items); and resource-sharing capabilities (n = 13 items). Response rate was 75% (n = 38). Among 38 responses, 37 rated their workplace moderately or well prepared; 45% reported MFI training, but only 30% reported training on MFI with hazardous contaminants; 58% estimated high levels of staff willingness to respond, but that dropped to 40% if MFIs involved hazardous contaminants; and 84% reported a need for more training. On average, 76% of operational capabilities were present. Resource sharing was most prevalent with state Office of Emergency Management but less evident with faith-based organizations and agencies within the medical examiner sector. Overall response capability was adequate, with gaps found in capabilities where public health shares responsibility with other sectors. Collaborative training with other sectors is critical to ensure optimal response to future MFIs, but recent funding cuts in public health preparedness may adversely impact this critical preparedness element. In order for the sector to effectively meet its public health MFI responsibilities as delineated in the National Response Framework, resources to support training and other elements of preparedness must be maintained.

Comparing US State Health Efficiencies Employing Data Envelope Analysis

Over the past several decades, there have been improvements in health outcomes such as life expectancy, infant mortality rates and maternal mortality rates. Yet, the improvements in national health indicators often have not resulted in significantly reducing burdens of chronic disease among US citizens. Burden of disease studies examining population health employ assessments to measure chronic disease and disability burdens. We used the disability-adjusted life year (DALY) as the measure for overall disease burden. Our paper evaluates the efficiency of health care resources on a state-by-state population basis in the US by examining the 50 states through the application of a non-parametric method known as data envelope analysis (DEA). DEA allows multi-input and multioutput analysis. We conducted analyses to compare each state vis-a-vis the other states to examine the efficiency of the use of health resources in relation to disease burdens. We used three input variables-the number of physicians per 100,000 residents per state, the number of hospital beds per 1000 inhabitants per state and the public health funding per capita per state and one output variable- disability adjusted life years to reflect burden of disease. The study was conducted over a six-year duration (2008-2014). Our study demonstrates that there are varying levels of efficiency in the utilization of health resources (i.e. number of physicians, number of hospital beds and public health expenditures) among the 50 US states in affecting the output of disease burden. It appears that the Western US states and the northern most Midwest regions are the most efficient relative to the other states. The least efficient states were clustered in the south Midwestern region. The states showing the most improvement include the previously least efficient south-eastern states. This indicates that these south-eastern states are “catching up” or improving relative to the other states, but still have a large gap in efficiency utilization. The Western states with high efficiency also had higher use of technology. In contrast, the North-Midwestern states with high efficiency values had lower use of technology. This finding appears to show that these North-Midwestern states are efficient with their use of health resources, but their efficiency is not due to technological improvements as in the Western states.

CHIP-ing Away at Health Disparities: Has State-Provided Health Insurance Reduced Race- and Nativity-Based Differences in Health Care Utilization among US Children?

Although recent legal permanent residents and undocumented immigrants are generally barred from accessing public health insurance, some US states cover immigrant children through the Children’s Health Insurance Program (CHIP). In this study, we examine the contextual effect of US state health insurance eligibility policy, particularly with respect to immigrant children, on race/ethnic and nativity-based disparities in children’s routine health care. Utilizing our original data on state CHIP eligibility policies and child-level data from the Survey of Income and Program Participation, we find that a significant portion of between-state variation in children’s routine health care results from diversity in CHIP eligibility rules for poor and foreign-born children. Immigrant-specific disparities are reduced when states do not require five years of residency for CHIP participation.

New Ways to Disseminate the US National Notifiable Disease Provisional Data

The purpose of this study was to identify ideas for an enhanced dissemination of the US National Notifiable Diseases Surveillance System (NNDSS) provisional data. The author conducted a search of all US State Health Department websites looking for on-line data display tables and tools for either reportable or notifiable diseases. In addition, the scope of the search of websites was expanded to include notifiable diseases of several countries, organizations and institutions. As a result of this study the author proposes enhancement of the current US notifiable disease data display from a static format to a more interactive dashboard design.

Environmental Scan of the US States' and Other Countries' Notifiable Disease Provisional Data Online Display: Results and Recommendations

The purpose of this project was to identify ideas and potential options for an enhanced dissemination of provisional data for the US National Notifiable Diseases Surveillance System (NNDSS). We conducted a search of all US State Health Department websites looking for on-line data display tables and tools for either reportable or diseases. As of May 1, 2013 our review showed that only 22 States (44%) presented provisional data in either static report or on-line interactive data display formats. There may be room for improvement in the style and content of the dissemination of US nationally notifiable disease provisional data using interactive tools or dashboard design.

2009 Safe states alliance state of the states survey an assessment of capacity in US state health departments

The Safe States Alliance (formerly the State and Territorial Injury Prevention Directors Association (STIPDA)) is currently implementing the 2009 State of the States Survey (SOTS), the third implementation assessing capacity...

HumanSalmonellaInfection Yielding CTX-M β-Lactamase, United States

Human<i>Salmonella</i>Infection Yielding CTX-M β-Lactamase, United States

Institutional trust, information processing and perception of environmental cancer risk

This paper examines how institutional trust affects the way in which people process information and perceive risk. Data come from a study of risk perception in the circumstance of US state health department investigations of suspected cancer clusters, with 30 cases examined (n = 1,111). Trust is assessed for three information sources: state health departments, civic groups and industries involved in each case. Higher trust for the state directly predicts lower risk perception, while high trust for civic groups predicts greater risk perception. Perceiving high trust for industry and state - and low trust for civic groups-promotes heuristic processing, which in turn predicts lower risk perception. Alternately, perceiving industry to have low trust and civic groups to have high trust promotes greater systematic processing, which consistently leads to perception of greater risk. Almost all of the effect of industry trust on risk is expressed indirectly.