Targeted health department expenditures benefit birth outcomes at the county level

Structural barriers to health care as risk factors for preterm and small-for-gestational-age birth among US-born Black and White mothers

We develop county-level measures of structural and institutional barriers to care, and test associations between these barriers and birth outcomes for US-born Black and White mothers using national birth records for 2014-2017. Results indicate elevated odds of greater preterm birth severity for Black mothers in counties with higher uninsurance rates among Black adults, fewer Black physicians per Black residents, and fewer publicly-funded contraceptive services. Most structural barriers were not associated with small-for-gestational-age birth, and barriers defined for Black residents were not associated with birth outcomes for White mothers, with the exception of Black uninsurance rate. Structural determinants of care may influence preterm birth risk for Black Americans.

COVID-19 Revealed Shortcomings Of The US Public Health System And The Need To Strengthen Funding And Accountability

The US governmental public health system, which includes federal, state, and local agencies, is seen by many observers as having a money problem, stemming from a lack of resources. During the COVID-19 pandemic, this lack of resources has had unfortunate consequences for the communities that public health practice leaders are expected to protect. Yet the money problem is complex and involves understanding the nature of chronic public health underinvestment, identifying what money is spent in public health and what the country gets for it, and determining how much money is needed to do the work of public health in the future. This Commentary elucidates each of these issues and provides recommendations for making public health services more financially sustainable and accountable. Well-functioning public health systems require adequate funding, but a modernized public health financial data system is also key to the systems' success. There is a great need for standardization and accountability in public health finance, along with incentives and the generation of research evidence demonstrating the value of and most effective delivery for a baseline of public health services that every community should expect.

Addressing Health Disparities: The Health Department Nurse Lead Executive's Relationship to Improved Community Health

CONTEXT

The nurse-trained local health department (LHD) lead executive has been shown to be positively associated with LHD performance; however, no other research has explored whether this association translates to improved community health.

OBJECTIVE

To investigate the relationship between the type of LHD leadership-whether or not the lead executive is a nurse-and changes in health outcomes.

DESIGN

This study used a multivariate panel time series design. Each model was estimated as a pooled time series and using time and unit fixed effects, with a 1-year lag used for all covariates and the main predictor.

SETTING

A national, county-level data set was compiled containing variables pertaining to the LHD, community demographics, and health outcomes for the years 2010-2018.

PARTICIPANTS

The unit of analysis was the LHD. The data set was restricted to those counties with measurable mortality rates during at least 8 of the 9 time periods of the study, resulting in a total of 626 LHDs.

MAIN OUTCOME MEASURES

The outcomes of interest were changes in 15- to 44-year-old all-cause mortality, infant mortality, and entry into prenatal care.

RESULTS

In models with combined time and unit fixed effects, a significant relationship exists between a nurse-led LHD and reduced mortality in the 15- to 44-year-old Black population (-5.2%, P < .05) and a reduction in the Black-White mortality ratio (-6%, P < .05). In addition, there is a relationship between the nurse-led LHD and a reduction in the percentage of the population with late or no entry to prenatal care.

CONCLUSIONS

The evidence presented here helps connect the known positive association between nurse lead executives and LHD performance to improvements in community health. It suggests that nurse leaders are associated with health improvements in line with addressing health inequities.

Dance of Dollars: State Funding Effects on Local Health Department Expenditures

OBJECTIVE

We examined changes in total local health department (LHD) expenditures in the state of Washington following introduction of a new state funding program to support core public health services and infrastructure.

METHODS

We used a pre/posttest design regression model to evaluate changes in LHD expenditures 1, 2, and 6 years into the new state program. To address potential endogeneity in the model, we repeated all 3 analyses using 2-stage least squares regression.

RESULTS

In the base case, overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program (2008 and 2009). However, those increases were not sustained over the longer term (2013). In subpopulation analyses, total LHD spending increased more among larger LHDs.

CONCLUSIONS

Between 2006 and 2013, new state investments in core public health functions increased Washington State LHD expenditures in the short term, but those increases did not persist over time. For public health financial modernization efforts to translate into public health infrastructure modernization successes, the way new investments are structured may be as important as the amount of funding added.

Local Health Department Revenue Diversification and Revenue Volatility: Can One Be Used to Manage the Other?

OBJECTIVE

Revenue volatility-particularly in the form of sudden and significant reductions in funding-has been shown to negatively affect local health departments (LHDs) by impacting the amount and type of services delivered. This study examined the potential effectiveness of revenue diversification as a means of managing LHD financial risk. More specifically, we examine the relationship between revenue diversification and revenue volatility among LHDs in Washington State.

DESIGN AND SETTING

We applied fixed-effects linear regression models with robust standard errors to revenue data reported during 1998-2014 by all LHDs operating in Washington State. We also assessed the robusticity of our results to alternative specifications for revenue diversification and volatility.

MAIN OUTCOME MEASURES

LHD revenue and revenue volatility.

RESULTS

Between 1998 and 2014, LHDs in Washington State were exposed to considerable upside and downside fiscal risks. While average revenue volatility was close to 0 (0.2%), observed values ranged from -35% to 63%. LHD revenues were already highly diversified: as measured using a reversed Herfindahl-Hirschman Index, diversification values ranged between 0.56 and 1.00. There is little evidence to suggest the existence of a statistically significant relationship between revenue diversification and volatility.

CONCLUSIONS

Revenue volatility presents LHDs with important short- and long-term operational challenges. Our models suggest that revenue diversification did not reduce revenue volatility among Washington State LHDs in 1998-2014. Further research will need to examine whether revenue diversification reduces LHD financial risk in other settings.

Analytic Approaches to Assess the Impact of Local Spending on Sexually Transmitted Diseases

OBJECTIVE

To compare the estimated associations between annual STD (sexually transmitted diseases) expenditures per capita and STD rates among Florida and Washington local health departments (LHDs) from 2001-2017, using two approaches--a longitudinal regression model with lagged STD spending, and a regression model with the Arellano-Bond panel estimator.

DATA SOURCES

Secondary data for LHDs were obtained from Florida and Washington state government offices and combined with county sociodemographic and health system data from the federal government.

STUDY DESIGN

We examined LHDs in Florida and Washington using a longitudinal panel study design to estimate ecological relationships between annual STD expenditures per capita and annual STD incidence rates from 2001 to 2017 with LHDs as the unit of analysis. We compared two regression models: generalized estimating equations (GEE) and the Arellano-Bond panel estimator (an instrumental variable approach).

DATA COLLECTION

The secondary data were combined to build a longitudinal panel database for LHDs in Florida and Washington from 2001 to 2017.

PRINCIPAL FINDINGS

In the GEE model with both states, greater STD spending in a prior year was associated unexpectedly with greater STD incidence rates in succeeding years. The Arellano-Bond models for both states had the expected inverse associations but were not significant. In the Arellano-Bond models for Florida, a $1 increase in STD spending in previous years was followed by decreases in STD incidence rates ranging between 29 and 59 points in succeeding years (0.09 ≥ p ≥ 0.04).

CONCLUSIONS

In longitudinal panel data for LHDs in two states, the Arellano-Bond estimator, or other instrumental variable approach, is preferred over conventional regression models to obtain unbiased estimates of the relationship between annual STD spending rates and annual STD rates. Future studies will require accurate, standardized, and detailed longitudinal data and rigorous analytic approaches, such as those illustrated in our study. This article is protected by copyright. All rights reserved.

The Cost of Providing the Foundational Public Health Services in Ohio

OBJECTIVES

To examine levels of expenditure and needed investment in public health at the local level in the state of Ohio pre-COVID-19.

DESIGN

Using detailed financial reporting from fiscal year (FY) 2018 from Ohio's local health departments (LHDs), we characterize spending by Foundational Public Health Services (FPHS). We also constructed estimates of the gap in public health spending in the state using self-reported gaps in service provision and a microsimulation approach. Data were collected between January and June 2019 and analyzed between June and September 2019.

PARTICIPANTS

Eighty-four of the 113 LHDs in the state of Ohio covering a population of almost 9 million Ohioans.

RESULTS

In FY2018, Ohio LHDs spent an average of $37 per capita on protecting and promoting the public's health. Approximately one-third of this investment supported the Foundational Areas (communicable disease control; chronic disease and injury prevention; environmental public health; maternal, child, and family health; and access to and linkages with health care). Another third supported the Foundational Capabilities, that is, the crosscutting skills and capacities needed to support all LHD activities. The remaining third supported programs and activities that are responsive to local needs and vary from community to community. To fully meet identified LHD needs in the state pre-COVID-19, Ohio would require an additional annual investment of $20 per capita on top of the current $37 spent per capita, or approximately $240 million for the state.

CONCLUSIONS

A better understanding of the cost and value of public health services can educate policy makers so that they can make informed trade-offs when balancing health care, public health, and social services investments. The current environment of COVID-19 may dramatically increase need, making understanding and growing public health investment critical.

Regional variation in Black infant mortality: The contribution of contextual factors

BACKGROUND

Compared to other racial/ethnic groups, infant mortality rates (IMR) are persistently highestamong Black infants in the United States, yet there is considerable regional variation. We examined state and county-level contextual factors that may explain regional differences in Black IMR and identified potential strategies for improvement.

METHODS AND FINDINGS

Black infant mortality data are from the Linked Birth/Infant Death files for 2009-2011. State and county contextual factors within social, economic, environmental, and health domains were compiled from various Census databases, the Food Environment Atlas, and the Area Health Resource File. Region was defined by the nine Census Divisions. We examined contextual associations with Black IMR using aggregated county-level Poisson regression with standard errors adjusted for clustering by state. Overall, Black IMR varied 1.5-fold across regions, ranging from 8.78 per 1,000 in New England to 13.77 per 1,000 in the Midwest. In adjusted models, the following factors were protective for Black IMR: higher state-level Black-White marriage rate (rate ratio (RR) per standard deviation (SD) increase = 0.81, 95% confidence interval (CI):0.70-0.95), higher state maternal and child health budget per capita (RR per SD = 0.96, 95% CI:0.92-0.99), and higher county-level Black index of concentration at the extremes (RR per SD = 0.85, 95% CI:0.81-0.90). Modeled variables accounted for 35% of the regional variation in Black IMR.

CONCLUSIONS

These findings are broadly supportive of ongoing public policy efforts to enhance social integration across races, support health and social welfare program spending, and improve economic prosperity. Although contextual factors accounted for about a third of regional variation, further research is needed to more fully understand regional variation in Black IMR disparities.

Relationships Between the Great Recession and Widening Maternal and Child Health Disparities: Findings From Washington and Florida

The purpose of this study was to explore relationships between the Great Recession in the United States and maternal and child health (MCH) disparities in prenatal care, birth weight, gestational age, and infant mortality. Using annual, 2005-2011 individual-level Washington (WA) and Florida (FL) birth certificate data, we analyzed MCH outcome rates and disparities among subpopulation component groups (e.g., subpopulation 'maternal ethnicity' divided into component groups such as non-Hispanic White, non-Hispanic Black). We focused on whether disparities widened during two recession periods: Period 1 (December 2007-June 2009-official dates of Great Recession) and Period 2 (January 2010-December 2011) and compared these to a Baseline Period 0 (January 2005-March 2007). Subpopulations (n=14) and component groups (n=47) were identified a priori. Results indicate that disparities widened on at least one MCH outcome for 22 component groups in WA during Period 1 and 37 component groups during Period 2, compared to baseline. In FL, disparities widened for 25 component groups during Period 1 and 31 during Period 2. Disparities increased in both periods on the same outcomes for 11 WA component groups and 7 component groups in FL. Disparity increases tended to cluster among those with young age, low education, and among members of minority race/ethnicity groups-particularly Black mothers. Findings support hypothesized relationships between expected increases in need during the Great Recession, and worsening MCH outcomes and disparities. Compared to baseline, there were more disparity increases in Period 2 than 1. Additional research regarding specific factors influencing changes in disparities are needed.

The effect of women, infant, and children (WIC) services on birth weight before and during the 2007-2009 great recession in Washington state and Florida: a pooled cross-sectional time series analysis

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been shown to have positive effects in promoting healthy birth outcomes in the United States. We explored whether such effects held prior to and during the most recent Great Recession to improve birth outcomes and reduce differences among key socio-demographic groups.

METHODS

We used a pooled cross-sectional time series design to study pregnant women and their infants with birth certificate data. We included Medicaid and uninsured births from Washington State and Florida (n = 226,835) before (01/2005-03/2007) and during (12/2007-06/2009) the Great Recession. Interactions between WIC enrollment and key socio-demographic groupings were analyzed for binary and continuous birth weight outcomes.

RESULTS

Our study found beneficial WIC interaction effects on birth weight. For race, prenatal care, and maternal age we found significantly better birth weight outcomes in the presence of WIC compared to those without WIC. For example, being Black with WIC was associated with an increase in infant birth weight of 53.5 g (baseline) (95% CI = 32.4, 74.5) and 58.0 g (recession) (95% CI = 27.8, 88.3). For most groups this beneficial relationship was stable over time.

CONCLUSIONS

This paper supports previous research linking maternal utilization of WIC services during pregnancy to improved birth weight (both reducing LBW and increasing infant birth weight in grams) among some high-disadvantage groups. WIC appears to have been beneficial at decreasing disparity gaps in infant birth weight among the very young, Black, and late/no prenatal care enrollees in this high-need population, both before and during the Great Recession. Gaps are still present among other social and demographic characteristic groups (e.g., for unmarried mothers) for whom we did not find WIC to be associated with any detectable value in promoting better birth weight outcomes. Future research needs to examine how WIC (and/or other maternal and child health programs) could be made to work better and reach farther to address persistent disparities in birth weight outcomes. Additionally, in preparation for future economic downturns it will be important to determine how to preserve and, if possible, expand WIC services during times of increased need.

TRIAL REGISTRATION

Not applicable, this article reports only on secondary retrospective data (no health interventions with human participants were carried out).

Maternal Mortality and Public Health Programs: Evidence from Florida

Policy Points US maternal mortality rates (MMRs) display considerable racial disparities and exceed those of other developed countries. While worldwide MMRs have dropped sharply since the 1990s, the US MMR appears to be rising. We provide strong evidence of the effectiveness of pregnancy-related public health spending on improvements in maternal health. Using longitudinal data from Florida counties, we found that spending on public health significantly reduced the MMR among black mothers and narrowed black-white outcome disparities. Each 10% increase in pregnancy-related public health expenditures was associated with a 13.5% decline in MMR among blacks and a 20.0% reduction in black-white disparities.

CONTEXT

Maternal mortality rates in the United States exceed those of other developed countries. Moreover, these rates show considerable racial disparities, in which black mothers are at three to four times the risk compared with their white counterparts. With more than half of all maternal deaths deemed to be preventable, public health interventions have the potential to improve maternal health along with other pregnancy outcomes. This rigorous longitudinal study examines the impact of a package of pregnancy-related public health programs on maternal mortality rates.

METHODS

We analyzed administrative data on pregnancy-related public health expenditures, maternal mortality rates, and sociodemographic factors from all 67 Florida counties between 2001 and 2014. Florida provides consistent counts of maternal deaths for the entire period of this analysis. We estimated both fixed-effects ordinary least squares regressions (OLS) and generalized method of moments (GMM) models. GMM enabled us to identify the impact of public health expenditures on maternal mortality rates while also addressing both potential endogeneity and serial correlation problems. We also provide a series of robustness and falsification tests.

FINDINGS

Overall, a 10% increase in targeted public health expenditures led to a weakly significant decline in overall maternal mortality rates of 3.9%. The estimated effect for white mothers was not statistically significant. However, we found statistically significant improvements for black mothers. Specifically, a 10% increase in pregnancy-related public health spending led to a 13.5% decline in maternal mortality rates among black mothers and a 20.0% reduction in the black-white maternal mortality gap.

CONCLUSIONS

Our analysis provides strong evidence of the effectiveness of public health programs in reducing maternal mortality rates and addressing racial disparities.

Social determinants of health and disparities in prenatal care utilization during the Great Recession period 2005-2010

BACKGROUND

Early, regular prenatal care utilization is an important strategy for improving maternal and infant health outcomes. The purpose of this study is to better understand contributing factors to disparate prenatal care utilization outcomes among women of different racial/ethnic and social status groups before, during, and after the Great Recession (December 2007-June 2009).

METHODS

Data from 678,235 Washington (WA) and Florida (FL) birth certificates were linked to community and state characteristic data to carry out cross-sectional pooled time series analyses with institutional review board approval for human subjects' research. Predictors of on-time as compared to late or non-entry to prenatal care utilization (late/no prenatal care utilization) were identified and compared among pregnant women. Also explored was a simulated triadic relationship among time (within recession-related periods), social characteristics, and prenatal care utilization by clustering individual predictors into three scenarios representing low, average, and high degrees of social disadvantage.

RESULTS

Individual and community indicators of need (e.g., maternal Medicaid enrollment, unemployment rate) increased during the Recession. Associations between late/no prenatal care utilization and individual-level characteristics (including disparate associations among race/ethnicity groups) did not shift greatly with young maternal age and having less than a high school education remaining the largest contributors to late/no prenatal care utilization. In contrast, individual maternal enrollment in a supplemental nutrition program for women, infants, and children (WIC) exhibited a protective association against late/no prenatal care utilization. The magnitude of association between community-level partisan voting patterns and expenditures on some maternal child health programs increased in non-beneficial directions. Simulated scenarios show a high combined impact on prenatal care utilization among women who have multiple disadvantages.

CONCLUSIONS

Our findings provide a compelling picture of the important roles that individual characteristics-particularly low education and young age-play in late/no prenatal care utilization among pregnant women. Targeted outreach to individuals with high disadvantage characteristics, particularly those with multiple disadvantages, may help to increase first trimester entry to utilization of prenatal care. Finally, WIC may have played a valuable role in reducing late/no prenatal care utilization, and its effectiveness during the Great Recession as a policy-based approach to reducing late/no prenatal care utilization should be further explored.

Associations between local government expenditures and low birth weight incidence: Evidence from national birth records

Local governments play an integral role in providing public services to their residents, yet the population health benefits are frequently overlooked, especially when services are outside the traditional health domain. With data from the U.S. Census of Governments and national birth records (spanning from 1992 to 2014), we examined whether local government expenditures on parks and recreation services (PRS) and housing and community development (HCD) predicted county low birth weight outcomes (population incidence and black-white disparities). Hypotheses were tested using bias-corrected county-by-period fixed effects models in a sample of 956 U.S. counties with a total of 3619 observations (observations were defined as three-year pooled estimates), representing 24 million births. Adjusting for prior county low birth weight incidence, levels of total operational, health, and hospital expenditures, and time-varying county sociodemographics, an increase in per capita county PRS expenditures of $50 was associated with 1.25 fewer low birth weight cases per 1000. Change in county HCD expenditures was not associated with low birth weight incidence, and, contrary to hypotheses, neither expenditure type was linked to county black-white disparities. Further examination of the benefits to birth outcomes from increasing parks and recreation services is warranted.

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Rising parks and recreation expenditures are linked to declining low birth weight.

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Housing and community expenditures are not associated with low birth weight.

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‘Health’ was the only expenditure type linked to black-white perinatal disparities.

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Benefits of parks and recreation services may include healthier birth outcomes.

Nurses on the move: Robert Wood Johnson Foundation nurse faculty scholars and their action on the social determinants of health

OBJECTIVE

Medical care alone cannot adequately improve population health or eliminate inequities; social determinants of health (SDH) must be addressed. This study's purpose was to describe the research, teaching, service, and clinical practice activities implemented by RWJF Nurse Faculty Scholars to act on the SDH.

DESIGN

A cross-sectional survey design was used with a sample of RWJF Nurse Faculty Scholars, chosen because they were provided specialized mentoring, grants, and other support that allowed them to explore SDH.

RESULTS

Respondents (n = 57) addressed SDH in their research (86.0%), teaching (68.4%), service (66.7%), and clinical practice (33.3%). Leading research foci were quality of health care (56.1%), social and physical environmental stressors (54.4%), and access to health care services (49.1%). Leading SDH areas in teaching were discrimination in society against vulnerable populations (54.4%), quality of health care received by vulnerable populations (50.9%), and vulnerable populations' access to health care services (50.9%). Service activities included addressing discrimination against diverse populations. Leading SDH areas in clinical practice were quality of health care received by vulnerable populations (28.1%), vulnerable populations' access to health care services (22.8%), and discrimination in society against vulnerable populations (19.3%). Respondents also addressed SDH through personal mentoring (71.9%); efforts to recruit and/or retain underrepresented faculty (59.6%); developing a diverse pipeline of nurses (59.6%); and participation on a diversity committee (40.4%).

CONCLUSION

The RWJF Nurse Faculty Scholars were able to leverage their awards to address SDH; however, further research is needed to assess the impact of the SDH work conducted. Knowledge from this study can be used as a road map for SDH elements and areas of professional work that nurses and other health professionals could address SDH in research, teaching, service, and practice.

Assessing The Value Of 40 Years Of Local Public Expenditures On Health

The US public and private sectors now spend more than $3 trillion on health each year. While critical studies have examined the relationship between public spending on health and health outcomes, relatively little is known about the impact of broader public-sector spending on health. Using county-level public finance data for the period 1972-2012, we estimated the impact of local public hospital spending and nonhospital health spending on all-cause mortality in the county. Overall, a 10 percent increase in nonhospital health spending was associated with a 0.006 percent decrease in all-cause mortality one year after the initial spending. This effect was larger and significant in counties with greater proportions of racial/ethnic minorities. Our results indicate that county nonhospital health spending has health benefits that can help reduce costs and improve health outcomes in localities across the nation, though greater focus on population-oriented services may be warranted.

Development of the PHAST model: generating standard public health services data and evidence for decision-making

Objective

Standardized data regarding the distribution, quality, reach, and variation in public health services provided at the community level and in wide use across states and communities do not exist. This leaves a major gap in our nation's understanding of the value of prevention activities and, in particular, the contributions of our government public health agencies charged with assuring community health promotion and protection. Public health and community leaders, therefore, are eager for accessible and comparable data regarding preventive services that can inform policy decisions about where to invest resources.

Methods

We used literature review and a practice-based approach, employing an iterative process to identify factors that facilitate data provision among public health practitioners.

Results

This paper describes the model, systematically developed by our research team and with input from practice partners, that guides our process toward maximizing the uptake and integration of these standardized measures into state and local data collection systems.

Discussion

The model we developed, using a dissemination and implementation science framework, is intended to foster greater interest in and accountability for data collection around local health department services and to facilitate spatial exploration and statistical analysis of local health department service distribution, change, and performance.

Conclusion

Our model is the first of its kind to thoroughly develop a means to guide research and practice in realizing the National Academy of Medicine's recommendation for developing systems to measure and track state and local public health system contributions to population health.

How Much Do We Spend? Creating Historical Estimates of Public Health Expenditures in the United States at the Federal, State, and Local Levels

The United States has a complex governmental public health system. Agencies at the federal, state, and local levels all contribute to the protection and promotion of the population's health. Whether the modern public health system is well situated to deliver essential public health services, however, is an open question. In some part, its readiness relates to how agencies are funded and to what ends. A mix of Federalism, home rule, and happenstance has contributed to a siloed funding system in the United States, whereby health agencies are given particular dollars for particular tasks. Little discretionary funding remains. Furthermore, tracking how much is spent, by whom, and on what is notoriously challenging. This review both outlines the challenges associated with estimating public health spending and explains the known sources of funding that are used to estimate and demonstrate the value of public health spending.

Racial Disparities in Children's Health: A Longitudinal Analysis of Mothers Based on the Multiple Disadvantage Model

This secondary data analysis of 4373 mothers and their children investigated racial disparities in children's health and its associations with social structural factors, social relationships/support, health/mental health, substance use, and access to health/mental health services. The study drew on longitudinal records for mother-child pairs created from data in the Fragile Families and Child Wellbeing Study. Generalized estimating equations yielded results showing children's good health to be associated positively with mother's health (current health and health during pregnancy), across three ethnic groups. For African-American children, good health was associated with mothers' education level, receipt of informal child care, receipt of public health insurance, uninsured status, and absence of depression. For Hispanic children, health was positively associated with mothers' education level, receipt of substance-use treatment, and non-receipt of public assistance. Implications for policy and intervention are discussed.

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

OBJECTIVE

Local health departments (LHDs) have essential roles to play in ensuring the promotion of physical activity (PA) in their communities in order to reduce obesity. Little research exists, however, regarding the existence of these PA interventions across communities and how these interventions may impact community health.

DESIGN

In this exploratory study, we used cluster analysis to identify the structure of co-occurring PA interventions, followed by regression analysis to quantify the association between the patterns of PA interventions and prevalence of PA and obesity at a population level.

SETTING

Our study setting included local health jurisdictions in Colorado, Florida, Minnesota, New Jersey, Tennessee, and Washington.

PARTICIPANTS

Participating jurisdictions were those 218 local health jurisdictions (mostly counties) from which LHD leaders had provided data in 2013 for the Multi-Network Practice and Outcome Variation Examination Study.

MAIN OUTCOME MEASURES

We obtained unique public health activities data on PA interventions conducted in 2012 from 218 LHDs in 6 participating states. We categorized jurisdictions using cluster analysis, based on PA intervention approaches indicated by LHD leaders as available in their communities and then examined associations between categories and prevalence of obesity and of residents engaged in PA.

RESULTS

We identified 5 distinct PA intervention categories representing community-wide approaches-Comprehensive Approach, Built Environment, Personal Health, School-Based Interventions, and No Apparent Activities. Prevalence rates of obesity and PA among jurisdictions in the intervention clusters were significantly different from jurisdictions with No Apparent Activities, with more population-level approaches most significantly related to beneficial outcomes.

CONCLUSION

Our findings suggest the importance of standardized public health services data for generating evidence regarding health-related outcomes. The intervention categories we identified appear to reflect broad, local community-wide prevention approaches and demonstrated that population-level PA interventions can be testable and may have particularly beneficial relationships to community health. Widespread adoption of such standardized data depicting local public health prevention activity could support monitoring practice change, performance improvement, comparisons across communities that could reduce unnecessary variation, and the generation of evidence for public health practice and policy-making.

Developing the Evidence for Public Health Systems to Battle Vaccine Preventable Disease at the Local Level: Data Challenges and Strategies for Advancing Research

CONTEXT

Generally decreasing local health department (LHD) resources devoted to immunization programs and changes in LHD roles in immunization services represent major shifts in a core LHD service.

OBJECTIVE

Within a rapidly changing immunization landscape and emerging vaccine preventable disease outbreaks, our objective was to examine how LHD immunization expenditures are related to county-level immunization coverage and pertussis rates.

DESIGN

We used a practice-based approach in which we collaborated with practice partners and uniquely detailed LHD immunization expenditure data. Our analyses modeled the ecologic relationship between LHD immunization expenditures and LHD system performance and health outcomes.

SETTING

This study was launched through a consortium of public health Practice-Based Research Network states as part of a suite of studies examining the relationship between various LHD service-related expenditures and health outcomes.

PARTICIPANTS

We investigated and sought to include all LHDs in the states of Florida, New York (except New York City's LHD), and Washington.

OUTCOME MEASURES

With LHD immunization expenditures as our independent variable, our outcomes were 1 year of jurisdiction-level rates of toddler immunization completeness, to measure immunization system performance, and 11 years of annual jurisdiction-level numbers of pertussis cases per 100 000 population, to measure related health outcomes.

RESULTS

Immunization completeness and pertussis rates varied greatly, but our models did not produce significant results despite numerous analytic approaches and while controlling for other factors.

CONCLUSION

While our study was part of a suite of studies using similar methods and producing significant results, this study was instead challenged by serious data limitations and highlighted the gap in consistent, standardized data that can support critically needed evidence regarding immunization rates and disease. With LHDs at the epicenter of reducing vaccine preventable disease, it is vital to utilize emerging opportunities to understand the nature of their efforts in immunization coverage and disease prevention.

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

BACKGROUND

The United States spends more than most other countries per capita on maternal and child health (MCH), and yet lags behind other countries in MCH outcomes. Local health departments (LHDs) are responsible for administering various maternal and child health programs and interventions, especially to vulnerable populations. The goal of this study was to identify local health department jurisdictions (LHDs) that had exceptional maternal and child health outcomes compared to their in-state peers - positive deviants (PDs) - in Washington, Florida and New York in order to support the identification of strategies that can improve community health outcomes.

METHODS

We used MCH expenditure data for all LHDs in FL (n = 67), and WA (n = 35), and most LHDs in NY (n = 48) for 2009-2010 from the Public Health Activities and Services Tracking (PHAST) database. We conducted our analysis in 2014-2015. Data were linked with variables depicting local context and LHD structure. We used a cross-sectional study design to identify communities with better than expected MCH outcomes and multiple regression analysis to control for factors outside of and within LHD control.

RESULTS

We identified 50 positive deviant LHD jurisdictions across 3 states: WA = 10 (29 %); FL = 24 (36 %); NY = 16 (33 %). Overall, internal factor variables improved model fit for identifying PD LHD jurisdictions, but individual variables were not significant.

CONCLUSIONS

We empirically identified LHD jurisdictions with better MCH outcomes compared to their peers. Research is needed to assess what factors contributed to these exceptional MCH outcomes and over which LHDs have control. The positive deviance method we used to identify high performing local health jurisdictions in the area of maternal and child health outcomes can assist in better understanding what practices work to improve health outcomes. We found that funding may not be the only predictor of exceptional outcomes, but rather, there may be activities that positive deviant LHDs are conducting that lead to improved outcomes, even during difficult financial circumstances. This method can be applied to other outcomes, communities, and/or services.

Assuring a strong foundation for our nation's public health systems

BACKGROUND

A strong public health infrastructure is necessary to assure that every community is capable of carrying out core public health functions (assessment of population health, assurance of accessible and equitable health resources, and development of policies to address population health) to create healthy conditions. Yet, due to budget cuts and inconsistent approaches to base funding, communities are losing critical prevention and health promotion services and staff that deliver them.

PURPOSE

This article describes key components of and current threats to our public health infrastructure and suggests actions necessary to strengthen public health systems and improve population health.

DISCUSSION

National nursing and public health organizations have a duty to advocate for policies supporting strong prevention systems, which are crucial for well-functioning health care systems and are fundamental goals of the nursing profession.

CONCLUSION

We propose strengthening alliances between nursing organizations and public health systems to assure that promises of a reformed health system are achieved.

Does More Public Health Spending Buy Better Health?

Background:

In this article, we attempt to address a persistent question in the health policy literature: Does more public health spending buy better health? This is a difficult question to answer due to unobserved differences in public health across regions as well as the potential for an endogenous relationship between public health spending and public health outcomes.

Methods:

We take advantage of the unique way in which public health is funded in Georgia to avoid this endogeneity problem, using a twelve year panel dataset of Georgia county public health expenditures and outcomes in order to address the “unobservables” problem.

Results:

We find that increases in public health spending lead to increases in mortality by several different causes, including early deaths and heart disease deaths. We also find that increases in such spending leads to increases in morbidity from heart disease.

Conclusions:

Our results suggest that more public health funding may not always lead to improvements in health outcomes at the county level.

Local health department food safety and sanitation expenditures and reductions in enteric disease, 2000-2010

OBJECTIVES

In collaboration with Public Health Practice-Based Research Networks, we investigated relationships between local health department (LHD) food safety and sanitation expenditures and reported enteric disease rates.

METHODS

We combined annual infection rates for the common notifiable enteric diseases with uniquely detailed, LHD-level food safety and sanitation annual expenditure data obtained from Washington and New York state health departments. We used a multivariate panel time-series design to examine ecologic relationships between 2000-2010 local food safety and sanitation expenditures and enteric diseases. Our study population consisted of 72 LHDs (mostly serving county-level jurisdictions) in Washington and New York.

RESULTS

While controlling for other factors, we found significant associations between higher LHD food and sanitation spending and a lower incidence of salmonellosis in Washington and a lower incidence of cryptosporidiosis in New York.

CONCLUSIONS

Local public health expenditures on food and sanitation services are important because of their association with certain health indicators. Our study supports the need for program-specific LHD service-related data to measure the cost, performance, and outcomes of prevention efforts to inform practice and policymaking.

Building the evidence for decision-making: the relationship between local public health capacity and community mortality

OBJECTIVES

We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina.

METHODS

We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality.

RESULTS

Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and children's services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05).

CONCLUSIONS

Our findings, in the context of other studies, provide support for investment in local public health services to improve community health.

Classifying local health departments on the basis of the constellation of services they provide

OBJECTIVES

We explored service variation among local health departments (LHDs) nationally to allow systematic characterization of LHDs by patterns in the constellation of services they deliver.

METHODS

We conducted latent class analysis by using categorical variables derived from LHD service data collected in 2008 for the National Profile of Local Health Departments Survey and before service changes resulting from the national financial crisis.

RESULTS

A 3-class solution produced the best fit for this data set of 2294 LHDs. The 3 configurations of LHD services depicted an interrelated set of narrow or limited service provision (limited), a comprehensive (core) set of key services provided, and a third class of core and expanded services (core plus), which often included rare services. The classes demonstrated high geographic variability and were weakly associated with expenditure quintile and urban or rural location.

CONCLUSIONS

This empirically derived view of how LHDs organize their array of services is a unique approach to categorizing LHDs, providing an important tool for research and a gauge to monitor how changes in LHD service patterns occur.

Updating the definition and role of public health nursing to advance and guide the specialty

National changes in the context for public health services are influencing the nature of public health nursing practice. Despite this, the document that defines public health nursing as a specialty--The Definition and Role of Public Health Nursing--has remained in wide use since its publication in 1996 without a review or update. With support from the American Public Health Association (APHA) Public Health Nursing Section, a national Task Force, was formed in November 2012 to update the definition of public health nursing, using processes that reflected deliberative democratic principles. A yearlong process was employed that included a modified Delphi technique and various modes of engagement such as online discussion boards, questionnaires, and public comment to review. The resulting 2013 document consisted of a reaffirmation of the one-sentence 1996 definition, while updating supporting documentation to align with the current social, economic, political, and health care context. The 2013 document was strongly endorsed by vote of the APHA Public Health Nursing Section elected leadership. The 2013 definition and document affirm the relevance of a population-focused definition of public health nursing to complex systems addressed in current practice and articulate critical roles of public health nurses (PHN) in these settings.