Local Boards of Health as Linkages Between Local Health Departments and Health Care and Other Community Organizations.

INTRODUCTION: Efficient provision of essential public health services may be influenced by collaborative capacity of local health departments (LHDs). Local boards of health (LBoHs) are well positioned to facilitate partnerships. OBJECTIVES: We examined the degree to which LBoHs serve as a linkage between LHDs and 2 types of community organizations, health care providers and local government agencies, and the LBoH characteristics associated with tendency of LBoHs to perform such linkage function. METHODS: We analyzed data from a recent cross-sectional survey, the 2015 National Survey of Local Boards of Health. This survey used a probability sample of 685 LHDs stratified by the state of LHD location and the population size of LHD jurisdiction, resulting in 394 responses for a response rate of 58%. We used multivariate logistic regression to pursue the study objectives. RESULTS: LHD respondents reported that LBoHs served as a linkage with hospitals or other health care providers for 20% of LHDs and with local government agencies for 19% of LHDs. Significant association of LBoHs' performance of governance functions existed with their chances of linking LHDs with hospitals or other health care providers (adjusted odds ratio [AOR] = 1.25; P < .001) and with local government agencies (AOR = 1.23; P < .001). Among the factors associated with LBoHs serving as the linkage, the governance function oversight was the strongest, followed by governance functions policy development, continuous improvement, and resource stewardship. Legal authority had weakest association with both types of linkages. A strong positive association existed between LBoHs seeking community input from elected officials and LBoHs' tendency of serving as the linkage with both health care providers and local government agencies. CONCLUSIONS: The role of LBoHs in linking with hospitals, other health care providers, and government agencies could be further maximized, particularly given the high proportion of LBoHs that include members who are health care professionals.

Impact of Local Boards of Health on Local Health Department Accreditation, Community Health Assessment, Community Health Improvement Planning, and Strategic Planning.

INTRODUCTION: Local health departments (LHDs) are increasingly using national standards to meet the challenges presented by the complex environments in which these agencies operate. Local boards of health (LBoHs) might play an instrumental role in improving LHDs' engagement in activities to meet these standards. OBJECTIVES: To assess the impact of LBoH performance of governance functions on LHDs having a current (completed within 5 years) community health assessment (CHA), community health improvement plan (CHIP), strategic plan, and level of engagement in the Public Health Accreditation Board (PHAB) accreditation program. METHODS: Binary and multinomial logistic regression models were used to analyze linked data from 329 LHDs participating in both the 2015 Local Board of Health Survey and the 2016 National Profile of LHDs Survey. RESULTS: Higher performance of LBoH governance functions, measured by an overall scale of LBoH taxonomy consisting of 60 items, had a significant positive effect on LHDs having completed CHA (P < .001), CHIP (P = .01), and strategic plan (P < .001). LHDs operating in communities with a higher score on the overall scale of LBoH taxonomy had significantly higher odds (P = .03) of having higher level of participation in the PHAB national voluntary accreditation program-that is, being accredited, having submitted application for accreditation, or being in the e-PHAB system (eg, by submitting a letter of intent). CONCLUSIONS: LBoHs serve as governance bodies for roughly 71% of LHDs and can play a significant role in encouraging LHDs' participation in these practices. That positive influence of LBoHs can be seen more clearly if the complexity and richness of LBoH governance functions and other characteristics are measured appropriately. The study findings suggest that LBoHs are a significant component of the public health system in the United States, having positive influence on LHDs having a CHA, CHIP, strategic plan, and participation in accreditation.

Local Boards of Health Characteristics Influencing Support for Health Department Accreditation.

BACKGROUND: Local boards of health (LBoHs) serve as the governance body for 71% of local health departments (LHDs). PURPOSE: To assess the impact of LBoH governance functions and other characteristics on the level of LBoH support of LHD accreditation. METHODS: Data from 394 LHDs that participated in the 2015 Local Boards of Health Survey were used for computing summative scores for LBoHs for domains of taxonomy and performing logistic regression analyses in 2016. RESULTS: Increased odds of an LBoH directing, encouraging, or supporting LHD accreditation activities were significantly associated with (a) a higher overall combined score measuring performance of governance functions and presence of other LBoH characteristics (adjusted odds ratio [AOR] = 1.05; P < .001); (b) a higher combined score for the Governance Functions subscale (AOR = 1.06; P < .01); (c) the "continuous improvement" governance function (AOR = 1.15; P < .001); and (d) characteristics and strengths such as board composition (eg, LBoH size, type of training, elected vs nonelected members), community engagement and input, and the absence of an elected official on the board (AOR = 1.14; P = .02). CONCLUSIONS: LBoHs are evenly split by thirds in their attention to Public Health Accreditation Board accreditation among the following categories: (a) encouraged or supported, (b) discussed but made no recommendations, and (c) did not discuss. This split might indicate that they are depending on the professional leadership of the LHD to make the decision or that there is a lack of awareness. The study findings have policy implications for both LBoHs and initiatives aimed at strengthening efforts to promote LHD accreditation.

Creating a Taxonomy of Local Boards of Health Based on Local Health Departments' Perspectives.

OBJECTIVES: To develop a local board of health (LBoH) classification scheme and empirical definitions to provide a coherent framework for describing variation in the LBoHs. METHODS: This study is based on data from the 2015 Local Board of Health Survey, conducted among a nationally representative sample of local health department administrators, with 394 responses. The classification development consisted of the following steps: (1) theoretically guided initial domain development, (2) mapping of the survey variables to the proposed domains, (3) data reduction using principal component analysis and group consensus, and (4) scale development and testing for internal consistency. RESULTS: The final classification scheme included 60 items across 6 governance function domains and an additional domain-LBoH characteristics and strengths, such as meeting frequency, composition, and diversity of information sources. Application of this classification strongly supports the premise that LBoHs differ in their performance of governance functions and in other characteristics. CONCLUSIONS: The LBoH taxonomy provides an empirically tested standardized tool for classifying LBoHs from the viewpoint of local health department administrators. Future studies can use this taxonomy to better characterize the impact of LBoHs.

Assessment of Staffing, Services, and Partnerships of Local Health Departments - United States, 2015.

Beginning in 2008, the National Association of County and City Health Officials (NACCHO) periodically surveyed local health departments (LHDs) to assess the impact of the economic recession on jobs and budgets (1). In 2014, the survey was expanded to assess a wider range of factors affecting programs, services, and infrastructure in LHDs and renamed the Forces of Change survey (2). The survey was administered in to January-February 2015 to 948 LHDs across the United States to assess budget changes, job losses, changes in services, and collaboration with health care partners; 690 (73%) LHDs responded. Findings indicated a change in LHD infrastructure: compared with the previous fiscal year.* Overall, LHDs reported 3,400 jobs lost; 25% of LHDs reported budget decreases; 36% reported a reduction in at least one service area; and 35% reported serving fewer patients in clinics. In addition, up to 24% of LHDs reported expanding population-based prevention services, and LHDs reported exploring new collaborations with nonprofit hospitals and primary care providers (PCPs).

Local Health Departments' Approaches to Deal With Recession: What Strategies Are Used to Minimize the Negative Impact on Public Health Services to Community?

CONTEXT: Local health departments (LHDs) are crucial components in the public health system. As with their state counterparts, operating since the 2008 recession has proven financially difficult for the majority of the nation's 2800 LHDs. These health departments have elected to employ a variety of strategies to maintain operations and public-facing services and programs. OBJECTIVES: This study aimed to assess strategies used by LHDs to minimize the negative impact on services to community and to examine variation in these strategies by the size of population in LHD jurisdiction. DESIGN AND PARTICIPANTS: The design of this research brief report is observational, based on cross-sectional data from a nationally representative sample of 957 LHDs that enumerates and characterizes the nature of their responses to austerity. OUTCOMES MEASURES: The main outcome measures included 19 strategies. We used descriptive and bivariate analyses to highlight our study findings. RESULTS: LHDs use a variety of strategies to mitigate negative impacts on the public health services in their communities, focusing on workforce, funding, service referral, and several other areas. The most frequently used strategies include cross-training staff, increasing work hours, pursuing new funding, resource sharing, and seeking fees for services provided. Some minor variation by the size of jurisdiction population existed in frequency of top 10 strategies used by LHDs. CONCLUSIONS: Some of the LHD strategies to deal with the impact of recession address immediate issues caused by budget cuts and might be short-term fixes, including increasing workload of employees, and pay freezes. Other strategies, such as seeking new sources of revenues and resource sharing, can have potentially positive effects in the long run.

National Voluntary Public Health Accreditation: Are More Local Health Departments Intending to Take Part?

OBJECTIVE: This article examines local health department (LHD) participation and intentions to participate in national voluntary accreditation and reasons for not seeking accreditation. Specifically, it compares the results of national surveys among LHDs in 2010, 2013, and 2014. DESIGN: Longitudinal cohort study. SETTING: United States. PARTICIPANTS: LHDs that responded to the 2014 Forces of Change Survey and the 2010 and 2013 National Association of County and City Health Officials Profile studies. MAIN OUTCOME MEASURES: LHD level of engagement in Public Health Accreditation Board (PHAB) accreditation. RESULTS: Data of 2014 indicated that 1% of LHDs achieved accreditation and 11% had submitted an application or a statement of intent, compared with 6% of LHDs that submitted an application or a statement of intent in 2013. The percent of LHDs that indicated they planned to apply for accreditation but had not submitted a statement of intent declined from 27% in 2013 to 22% in 2014. In multivariate models, controlling for governance category and jurisdiction population size, LHDs in states where the state health department (SHD) participated in e-PHAB had higher odds of being favorably inclined toward accreditation than those located in states where the SHD was not in the e-PHAB system (odds ratio = 2.82, 95% confidence interval: 1.81-4.41). Across 2013 and 2014, and across small and large LHDs, the top 2 reasons for deciding not to apply for accreditation were the time/effort required exceeded the benefits (67%) and fees were too high (46%). CONCLUSIONS: SHDs are powerful mediators of LHDs' perceptions of the PHAB accreditation program. Health department governance structure and jurisdiction population size are associated with LHD accreditation participation decisions. With the launch of PHAB's program, fewer LHDs are undecided about accreditation participation and many have taken affirmative steps to become accredited. The top 2 reasons LHDs indicated for not proceeding with accreditation were time/effort exceed benefit and fees perceived as too high.

Local Health Department Engagement in Community Physical Activity Policy.

INTRODUCTION: This study assessed correlates of self-reported local health department (LHD) participation in community policy/advocacy activities that support physical activity. METHODS: In 2014, cross-sectional data from the nationally representative 2013 National Profile of Local Health Departments study administered by the National Association of County and City Health Officials were analyzed. Outcomes were participation in policy/advocacy activities related to urban design/land use, active transportation, and access to recreational facilities. Independent variables included structural characteristics, performance improvement efforts, and collaboration. Multivariate logistic regression models were computed. RESULTS: Representatives of 490 LHDs participated (79% response rate). Respondents reported similar participation in urban design/land use (25%); active transportation (16%); and recreational facility access (23%) policy/advocacy. LHDs with populations of ≥500,000 were more likely to report urban design/land use (p=0.004) as well as active transportation policy/advocacy participation (p=0.007) compared with those with populations of ≤50,000. LHDs with a community health improvement plan were more likely to participate in urban design/land use policy/advocacy (p=0.001). LHDs who regularly use the Community Guide were more likely to report policy/advocacy activity on active transportation (p=0.007) and expanding access to recreation facilities (p=0.009). LHDs engaged in a land use partnership were more likely to report urban design/land use (p<0.001) and active transportation (p=0.001) policy/advocacy participation. CONCLUSIONS: Participation in community physical activity policy/advocacy among LHDs was low in this study and varied by LHD characteristics. Intervention opportunities include assisting smaller LHDs and promoting performance improvement efforts and evidence-based practice resources.

The proof's in the partnerships: Are Affordable Care Act and Local Health Department accreditation practices influencing collaborative partnerships in community health assessment and improvement planning?

The strengthened requirement for nonprofit hospitals to complete a community health needs assessment and implementation plan in the Affordable Care Act, concurrent with a new voluntary accreditation process for local health departments that requires collaborative community health assessments and community health improvement plans, have led to a resurgence of interest in assessment and improvement planning. This study provides baseline data that will help determine whether the Affordable Care Act and public health accreditation will result in more collaborative community assessment and community health improvement activity by describing trends in collaborative community health assessment and community health improvement plan activities. Data sources include the National Profile of Local Health Departments studies and a database of community health assessment, community health needs assessment, community health improvement plan, and other implementation planning reports from across the country. The study finds that collaborative community assessment activity is positively associated with population size, governance type, and local health department and coalition-led efforts.

Public Health Agencies' level of engagement in and perceived barriers to PHAB National Voluntary Accreditation.

OBJECTIVE: This study examines local health departments' (LHDs') and state health agencies' (SHAs') engagement, LHDs' perceived barriers, and factors associated with level of engagement in accreditation. DESIGN: The study design is observational, cross-sectional, and based on census design surveys of all state and local health departments. METHODS: Data from the National Association of County & City Health Officials' 2013 profile of LHDs and the Association of State and Territorial Health Officials' 2012 profile of SHAs were analyzed in 2014. Logistic regression was performed with 2 levels of engagement as the outcome variable. RESULTS: Six percent of LHDs and 27% of SHAs had either submitted an application or statement of intent, whereas 15% of LHDs and 4% of SHAs had decided not to pursue accreditation. Significant factors associated with higher level of LHD engagement in accreditation included population size of the LHD jurisdiction, state and shared governance (vs local), MD degree of top executive, absence of a local board of health, LHD's collaboration with other organizations, per capita expenditures, and performance of 2 of the Public Health Accreditation Board accreditation prerequisites, namely, a community health improvement plan and an agency-wide strategic plan. The most frequently reported reasons for LHDs not pursuing accreditation were the time/effort required for accreditation exceeding the benefits (72%), the fee being too high (54%), and the standards exceeding the capacity of their LHD (39%). CONCLUSIONS: Accreditation is expected to provide pathways to accountability, consistency, and better fit between community needs and public health services. National strategies targeting rapid diffusion of accreditation among public health agencies should include elements that address the needs of LHDs with varying degrees of intent to pursue accreditation.

Public health workforce taxonomy.

Thoroughly characterizing and continuously monitoring the public health workforce is necessary for ensuring capacity to deliver public health services. A prerequisite for this is to develop a standardized methodology for classifying public health workers, permitting valid comparisons across agencies and over time, which does not exist for the public health workforce. An expert working group, all of whom are authors on this paper, was convened during 2012-2014 to develop a public health workforce taxonomy. The purpose of the taxonomy is to facilitate the systematic characterization of all public health workers while delineating a set of minimum data elements to be used in workforce surveys. The taxonomy will improve the comparability across surveys, assist with estimating duplicate counting of workers, provide a framework for describing the size and composition of the workforce, and address other challenges to workforce enumeration. The taxonomy consists of 12 axes, with each axis describing a key characteristic of public health workers. Within each axis are multiple categories, and sometimes subcategories, that further define that worker characteristic. The workforce taxonomy axes are occupation, workplace setting, employer, education, licensure, certification, job tasks, program area, public health specialization area, funding source, condition of employment, and demographics. The taxonomy is not intended to serve as a replacement for occupational classifications but rather is a tool for systematically categorizing worker characteristics. The taxonomy will continue to evolve as organizations implement it and recommend ways to improve this tool for more accurate workforce data collection.

Changes in public health workforce composition: proportion of part-time workforce and its correlates, 2008-2013.

BACKGROUND: State and local public health department infrastructure in the U.S. was impacted by the 2008 economic recession. The nature and impact of these staffing changes have not been well characterized, especially for the part-time public health workforce. PURPOSE: To estimate the number of part-time workers in state and local health departments (LHDs) and examine the correlates of change in the part-time LHD workforce between 2008 and 2013. METHODS: We used workforce data from the 2008 and 2013 National Association of County and City Health Officials (n=1,543) and Association of State and Territorial Health Officials (n=24) profiles. We employed a Monte Carlo simulation to estimate the possible and plausible proportion of the workforce that was part-time, over various assumptions. Next, we employed a multinomial regression assessing correlates of the change in staffing composition among LHDs, including jurisdiction and organizational characteristics, as well measures of community involvement. RESULTS: Nationally representative estimates suggest that the local public health workforce decreased from 191,000 to 168,000 between 2008 and 2013. During that period, the part-time workforce decreased from 25% to 20% of those totals. At the state level, part-time workers accounted for less than 10% of the total workforce among responding states in 2013. Smaller and multi-county jurisdictions employed relatively more part-time workers. CONCLUSIONS: This is the first study to create national estimates regarding the size of the part-time public health workforce and estimate those changes over time. A relatively small proportion of the public health workforce is part-time and may be decreasing.

Workforce turnover at local health departments: nature, characteristics, and implications.

BACKGROUND: Employee turnover, defined as total separations from employment, is expensive, can result in lost capacity, and can limit local health departments' (LHDs') ability to respond to public health needs. Despite the importance of workforce capacity in public health, little is known about workforce turnover in LHDs. PURPOSE: To examine the extent to which LHDs experience turnover and identify LHD characteristics that are associated with turnover. METHODS: A cross-sectional data set of employee turnover and LHD characteristics from the 2013 National Profile of LHDs was analyzed. Descriptive statistics and bivariate analyses were conducted in 2014 on turnover rates. The effect of the following LHD characteristics on turnover rates were examined: population size, governance type, degree of urbanization, top executive experience level, expenditures per capita, and LHD budget cuts. RESULTS: In 2013, LHDs experienced a mean turnover rate of 9.88%; approximately one third of turnover was due to retirements. LHDs with shared state and local governance experienced a higher turnover rate than LHDs with exclusive state or local governance. LHDs that are units of state agencies had a significantly higher retirement rate than those governed by local authorities. Top executive experience level, per capita expenditures, and LHD budget cuts were also related to turnover rates. CONCLUSIONS: LHDs experienced a lower overall turnover rate than state health departments in 2011 and lower than all local and state government agencies in 2012. Strengthening leadership skills of new top executives and ensuring adequate funding may reduce turnover in LHDs.

Profile-IQ: Web-based data query system for local health department infrastructure and activities.

OBJECTIVES: To demonstrate the use of National Association of County & City Health Officials' Profile-IQ, a Web-based data query system, and how policy makers, researchers, the general public, and public health professionals can use the system to generate descriptive statistics on local health departments. DESIGN: This article is a descriptive account of an important health informatics tool based on information from the project charter for Profile-IQ and the authors' experience and knowledge in design and use of this query system. CONCLUSION AND IMPLICATIONS: Profile-IQ is a Web-based data query system that is based on open-source software: MySQL 5.5, Google Web Toolkit 2.2.0, Apache Commons Math library, Google Chart API, and Tomcat 6.0 Web server deployed on an Amazon EC2 server. It supports dynamic queries of National Profile of Local Health Departments data on local health department finances, workforce, and activities. Profile-IQ's customizable queries provide a variety of statistics not available in published reports and support the growing information needs of users who do not wish to work directly with data files for lack of staff skills or time, or to avoid a data use agreement. Profile-IQ also meets the growing demand of public health practitioners and policy makers for data to support quality improvement, community health assessment, and other processes associated with voluntary public health accreditation. It represents a step forward in the recent health informatics movement of data liberation and use of open source information technology solutions to promote public health.

Evidence-based public health practice among program managers in local public health departments.

OBJECTIVES: We assessed the use of administrative-evidence based practices (A-EBPs) among managers of programs in chronic diseases, environmental health, and infectious diseases from a sample of local health departments (LHDs) in the United States. DESIGN: Program managers completed a survey consisting of 6 sections (biographical data, use of A-EBPs, diffusion attributes, use of resources, and barriers to, and competencies in, evidence-based public health), with a total of 66 questions. PARTICIPANTS: The survey was sent electronically to 168 program managers in chronic diseases, 179 in environmental health, and 175 in infectious diseases, representing 228 LHDs. The survey had previously been completed by 517 LHD directors. MEASURES: The use of A-EBPs was scored for 19 individual A-EBPs, across the 5 A-EBP domains, and for all domains combined. Individual characteristics were derived from the survey responses, with additional data on LHDs drawn from linked National Association of County & City Health Officials Profile survey data. Results for program managers were compared across the 3 types of programs and to responses from the previous survey of LHD directors. The scores were ordered and categorized into tertiles. Unconditional logistic regression models were used to calculate odds ratios and 95% confidence intervals, comparing individual and agency characteristics for those with the highest third of A-EBPs scores with those with the lowest third. RESULTS: The 332 total responses from program managers represented 196 individual LHDs. Program managers differed (across the 3 programs, and compared with LHD directors) in demographic characteristics, education, and experience. The use of A-EBPs varied widely across specific practices and individuals, but the pattern of responses from directors and program managers was very similar for the majority of A-EBPs. CONCLUSIONS: Understanding the differences in educational background, experience, organizational culture, and performance of A-EBPs between program managers and LHD directors is a necessary step to improving competencies in evidence-based public health.