The value of prevention: experiences of a public health agency

Where is obesity prevention on the map?: distribution and predictors of local health department prevention activities in relation to county-level obesity prevalence in the United States

CONTEXT

The system of local health departments (LHDs) in the United States has the potential to advance a locally oriented public health response in obesity control and reduce geographic disparities. However, the extent to which obesity prevention programs correspond to local obesity levels is unknown.

OBJECTIVE

This study examines the extent to which LHDs across the United States have responded to local levels of obesity by examining the association between jurisdiction-level obesity prevalence and the existence of obesity prevention programs.

DESIGN

Data on LHD organizational characteristics from the Profile Study of Local Health Departments and county-level estimates of obesity from the Behavioral Risk Factor Surveillance System were analyzed (n = 2300). Since local public health systems are nested within state infrastructure, multilevel models were used to examine the relationship between county-level obesity prevalence and LHD obesity prevention programming and to assess the impact of state-level clustering.

SETTING

Two thousand three hundred local health department jurisdictions defined with respect to county boundaries.

PARTICIPANTS

Practitioners in local health departments who responded to the 2005 Profile Study of Local Health Departments.

MAIN OUTCOME MEASURES

Likelihood of having obesity prevention activities and association with area-level obesity prevalence.

RESULTS

The existence of obesity prevention activities was not associated with the prevalence of obesity in the jurisdiction. A substantial portion of the variance in LHD activities was explained by state-level clustering.

CONCLUSIONS

This article identified a gap in the local public health response to the obesity epidemic and underscores the importance of multilevel modeling in examining predictors of LHD performance.

Lessons from cost-effectiveness research for United States public health policy

The application of cost-effectiveness analysis to health care has been the subject of previous reviews. We address the use of economic evaluation methods in public health, including case studies of population-level policies, e.g., environmental regulations, injury prevention, tobacco control, folic acid fortification, and blood product safety, and the public health promotion of clinical preventive services, e.g., newborn screening, cancer screening, and childhood immunizations. We review the methods used in cost-effectiveness analysis, the implications for cost-effectiveness findings, and the extent to which economic studies have influenced policy and program decisions. We discuss reasons for the relatively limited impact to date of economic evaluation in public health. Finally, we address the vexing question of how to decide which interventions are cost effective and worthy of funding. Policy makers have funded certain interventions with rather high cost-effectiveness ratios, notably nucleic acid testing for blood product safety. Cost-effectiveness estimates are a decision aid, not a decision rule.