Implementing Health Impact Assessment Programs in State Health Agencies: Lessons Learned From Pilot Programs, 2009-2011.

CONTEXT: Health Impact Assessment (HIA) has emerged as a promising tool to integrate health considerations into decision making. The growth and success of HIA practice in the United States will be dependent on building the capacity of practitioners. OBJECTIVE: This article seeks to identify the role of state health agencies (SHAs) in building capacity for conducting HIAs and the key components of initiatives that produced effective HIAs and HIA programs. The authors proposed to answer 3 research questions: (1) What can be the role of the SHA in HIA? (2) What are the characteristics of successful state HIA programs? and (3) What are some effective strategies for building capacity for HIA in SHAs and local health departments? DESIGN: The authors reviewed program reports from the ASTHO's pilot state health agencies (California, Minnesota, Oregon, and Wisconsin) that, between 2009 and 2011, created HIA programs to provide HIA training, conduct HIAs, and build practitioner networks. MAIN OUTCOME MEASURES: Program reports were examined for shared themes on the role of SHAs in a statewide HIA initiative, the characteristics of successful programs, and effective strategies for building capacity. RESULTS: Despite differences among the programs, many shared themes existed. These include stressing the importance of a basic, sustained infrastructure for HIA practice; leveraging existing programs and networks; and working in partnership with diverse stakeholders. CONCLUSIONS: SHAs can build capacity for HIA, and SHAs can both lead and support the completion of individual HIAs. States and territories interested in starting comprehensive statewide HIA initiatives could consider implementing the strategies identified by the pilot programs.

Communicating the Value of the Preventive Health and Health Services Block Grant.

The Preventive Health and Health Services (PHHS) Block Grant (Block Grant) continues to offer public health leadership a major lever to promote health and ensure the delivery of essential public health services. This column describes reasons why public health leaders must maintain strong participation in defining and communicating the collective and localized benefits of this flexible funding program for prevention.

State and Territorial Infrastructure for Health Equity and Minority Health.

OBJECTIVE: With support from the National Partnership for Action to End Health Disparities, the Association of State and Territorial Health Officials conducted a survey of state and territorial health agencies (STHAs) to identify agencies' infrastructure and capacity for addressing health equity and improving minority health outcomes. DESIGN: The Minority Health Infrastructure Survey was a census design survey distributed to STHAs in 2007, 2010, and 2014. Both cross-sectional and select longitudinal data are presented. METHODS: Descriptive data from the Association of State and Territorial Health Officials' Minority Health Infrastructure Survey were recorded, and χ tests were performed on selected variables. RESULTS: In 2007, 95.7% of jurisdictions had a primary contact person for health equity initiatives. That number rose to 98.0% in 2010 and to 100% in 2014. In STHAs with a primary contact person, that individual worked full-time on health equity initiatives in 63.6% of STHAs in 2007, 82.0% of STHAs in 2010, and 81.1% of STHAs in 2014. The proportion of STHAs with an organizational unit devoted to minority health was 78.3% in 2007, 90.2% in 2010, and 84.9% in 2014. In 2014, 92.6% of STHAs had included minority health in an agencywide or dedicated strategic plan. The most common strategies for addressing health equity included in strategic plans were collecting and tracking disparities data (91.8%), leveraging and engaging public/private partners in solutions for health disparities (87.8%), and increasing cultural competency or health literacy (87.8%). All respondents collaborated with external partners on health equity initiatives in some way. CONCLUSIONS: STHAs increased their organizational resources to address minority health between 2007 and 2010, but resources leveled off or decreased in some areas between 2010 and 2014. Closing the disparities gap will require substantial nationwide investment and implementing strategies with the potential to make a lasting impact.

The Public Health Workforce Interests and Needs Survey: The First National Survey of State Health Agency Employees.

CONTEXT: Public health practitioners, policy makers, and researchers alike have called for more data on individual worker's perceptions about workplace environment, job satisfaction, and training needs for a quarter of a century. The Public Health Workforce Interests and Needs Survey (PH WINS) was created to answer that call. OBJECTIVE: Characterize key components of the public health workforce, including demographics, workplace environment, perceptions about national trends, and perceived training needs. DESIGN: A nationally representative survey of central office employees at state health agencies (SHAs) was conducted in 2014. Approximately 25,000 e-mail invitations to a Web-based survey were sent out to public health staff in 37 states, based on a stratified sampling approach. Balanced repeated replication weights were used to account for the complex sampling design. SETTING AND PARTICIPANTS: A total of 10,246 permanently employed SHA central office employees participated in PH WINS (46% response rate). MAIN OUTCOME MEASURES: Perceptions about training needs; workplace environment and job satisfaction; national initiatives and trends; and demographics. RESULTS: Although the majority of staff said they were somewhat or very satisfied with their job (79%; 95% confidence interval [CI], 78-80), as well as their organization (65%; 95% CI, 64-66), more than 42% (95% CI, 41-43) were considering leaving their organization in the next year or retiring before 2020; 4% of those were considering leaving for another job elsewhere in governmental public health. The majority of public health staff at SHA central offices are female (72%; 95% CI, 71-73), non-Hispanic white (70%; 95% CI, 69-71), and older than 40 years (73%; 95% CI, 72-74). The greatest training needs include influencing policy development, preparing a budget, and training related to the social determinants of health. CONCLUSIONS: PH WINS represents the first nationally representative survey of SHA employees. It holds significant potential to help answer previously unaddressed questions in public health workforce research and provides actionable findings for SHA leaders.

Setting budgets and priorities at state health agencies.

CONTEXT: State health departments across the country are responsible for assuring and improving the health of the public, and yet financial constraints grow only more acute, and resource allocation decisions become even more challenging. Little empirical evidence exists regarding how officials working in state health departments make these tough allocation decisions. DESIGN: Through a mixed-methods process, we attempted to address this gap in knowledge and characterize issues of resource allocation at state health agencies (SHAs). First, we conducted 45 semistructured interviews across 6 states. Next, a Web-based survey was sent to 355 public health leaders within all states and District of Columbia. In total, 207 leaders responded to the survey (66% response rate). PARTICIPANTS: Leaders of SHAs. RESULTS: The data suggest that state public health leaders are highly consultative internally while making resource allocation decisions, but they also frequently engage with the governor's office and the legislature-much more so at the executive level than at the division director level. Respondents reported that increasing and decreasing funding for certain activities occur frequently and have a moderate impact on the agency or division budget. Agencies continue to "thin the soup," or prefer cutting broadly to cutting deeply. CONCLUSIONS: Public health leaders report facing significant tradeoffs in the course of priority-setting. The authorizing environment continues to force public health leaders to make challenging tradeoffs between unmet need and political considerations, and among vulnerable groups.

Budget- and priority-setting criteria at state health agencies in times of austerity: a mixed-methods study.

OBJECTIVES: We examined critical budget and priority criteria for state health agencies to identify likely decision-making factors, pressures, and opportunities in times of austerity. METHODS: We have presented findings from a 2-stage, mixed-methods study with state public health leaders regarding public health budget- and priority-setting processes. In stage 1, we conducted hour-long interviews in 2011 with 45 health agency executive and division or bureau leaders from 6 states. Stage 2 was an online survey of 207 executive and division or bureau leaders from all state health agencies (66% response rate). RESULTS: Respondents identified 5 key criteria: whether a program was viewed as "mission critical," the seriousness of the consequences of not funding the program, financing considerations, external directives and mandates, and the magnitude of the problem the program addressed. CONCLUSIONS: We have presented empirical findings on criteria used in state health agency budgetary decision-making. These criteria suggested a focus and interest on core public health and the largest public health problems with the most serious ramifications.

Thinking beyond the silos: emerging priorities in workforce development for state and local government public health agencies.

CONTEXT: Discipline-specific workforce development initiatives have been a focus in recent years. This is due, in part, to competency-based training standards and funding sources that reinforce programmatic silos within state and local health departments. OBJECTIVE: National leadership groups representing the specific disciplines within public health were asked to look beyond their discipline-specific priorities and collectively assess the priorities, needs, and characteristics of the governmental public health workforce. DESIGN: The challenges and opportunities facing the public health workforce and crosscutting priority training needs of the public health workforce as a whole were evaluated. Key informant interviews were conducted with 31 representatives from public health member organizations and federal agencies. Interviews were coded and analyzed for major themes. Next, 10 content briefs were created on the basis of priority areas within workforce development. Finally, an in-person priority setting meeting was held to identify top workforce development needs and priorities across all disciplines within public health. PARTICIPANTS: Representatives from 31 of 37 invited public health organizations participated, including representatives from discipline-specific member organizations, from national organizations and from federal agencies. RESULTS: Systems thinking, communicating persuasively, change management, information and analytics, problem solving, and working with diverse populations were the major crosscutting areas prioritized. CONCLUSIONS: Decades of categorical funding created a highly specialized and knowledgeable workforce that lacks many of the foundational skills now most in demand. The balance between core and specialty training should be reconsidered.