Core function-related local public health practice effectiveness

This article assesses the extent to which the U.S. population in 1995 was being effectively served by public health's three core functions (assessment, policy development, and assurance). A random sample of local health departments (LHDs) stratified by population size and type of jurisdiction was asked to provide their opinion of, as well as indicate performance on 20 core function-related measures of local public health practice. The article concludes that, in 1995, the nation fell far short of its year 2000 national objective, which called for 90 percent of the population to be served by an LHD effectively carrying out public health's core functions. Considerable capacity building and performance improvement is needed within the public health system.

From measuring to improving public health practice

Efforts to measure public health practice have taken on various forms and focused on different aspects of the system of public health practice over the past century. Before 1990, measurement was primarily based on a series of self-assessment instruments initiated under the auspices of the Committee on Administrative Practice of the American Public Health Association. These instruments emphasized measurement of immediate results of local public health services although they also provided information on local resources and capacity to perform. Following the Institute of Medicine's report in 1988, efforts began to focus on performance related to public health's core functions. These more recent assessments suggest that the system of public health practice must be improved to achieve the targets of effectiveness established for the year 2000. Ultimately, a comprehensive national surveillance system for public health practice will need to both measure and examine the relationships among inputs (resources, capacity, etc), core function-related processes, outputs (services) as well as outcomes.

Local health department effectiveness in addressing the core functions of public health: essential ingredients

OBJECTIVES

Objective 8.14 of the U.S. Healthy People 2000 objectives calls for 90% of the population to be served by a local health department (LHD) which is effectively carrying out the core functions of public health (assessment, policy development, assurance). This study seeks to describe the structural and service characteristics of an effective LHD.

METHODS

Data from a 1993 national random sample survey of LHD practice were merged with data from the 1992-1993 National Association of Country and City Health Officials (NACCHO) profile of local health agencies. Using a definition of effectiveness related to the core functions of public health, the correlates of effectiveness were examined for 264 health departments in the matched sample.

RESULTS

Effectiveness of local health agencies was not related to jurisdiction size of type. Inputs (structural factors) associated with effectiveness included having a full-time agency head, a larger budget derived from a greater number of funding sources, and a larger number of staff. With respect to outputs (services), effective health departments were also more likely to provide a greater number of services directly, particularly personal preventive and treatment services.

CONCLUSIONS

Only a few inputs are correlated with core-function related effectiveness. However, a profile of an effective health department emerges. Effective LHDs appear more likely to have full-time leadership which is able to tap diverse funding sources to provide the mix and match of community and personal prevention and treatment services needed to address community needs and improve the public's health.

A strategy for measuring local public health practice

The national health objectives for the year 2000 call for 90% of the population to be served by a local health department (LHD) that is effectively addressing the core functions of public health. Achieving this objective requires approved definitions for effectiveness as well as a system for ascertainment. In 1990 when this objective was established, no baseline data were available, and no accepted methods of measuring health department effectiveness were in use. Our approach to the development of a surveillance system to measure the effectiveness of LHDs has been to translate the three core public health functions characterized by the Institute of Medicine and the 10 practices delineated by the Centers for Disease Control and Prevention (CDC) and the national public health practice organizations into practice performance measures that could be judged as met or not met at the level of a jurisdiction served by a LHD. As part of our effort to develop a surveillance system to measure local public health practice, performance measures that characterize the 10 public health practices and their related core functions were developed and field-tested with state local health liaison officials and local health departments over a two-year period. Obtaining input from these sources is essential to establishing their validity and is a critical aspect of building nationwide consensus for appropriate measures of effective local public health practice. The results of these efforts led to the establishment of a proposed surveillance instrument comprising 10 performance standards and 29 associated indicators. We describe two approaches to its use.

Roles for state-level local health liaison officials in local public health surveillance and capacity building

In 27 state health agencies, local health liaison units or officials (LHLOs) are formally assigned responsibility for fostering a close working relationship between the state health agency and local health departments (LHDs). Yet in most other states, other agency staff carry out these responsibilities informally. Even where formal LHLOs exist, the assigned functions and specific activities vary, with little consistency across states other than serving as a potential or, in most cases, a real and vital linkage between LHDs and the state agency. This linkage places the LHLO in a unique position to have extensive knowledge, data, and information on LHD activities and to play an important role in assessing and improving local public health practice. This report examines aspects of the LHLO-LHD relationship in terms of potential LHLO roles in LHD practice surveillance and capacity building. Surveys of LHLOs and LHDs indicate that both support the development of surveillance tools to measure LHD effectiveness as a means to enhance capacity building efforts. Although LHLOs may not know or have the specific information immediately available to assess local public health practice for LHDs in their state, they report being able to obtain the information if necessary and with sufficient time. Further, LHDs are willing to share information concerning local public health practice with their state health department, particularly with their state LHLO. These findings suggest that LHLOs could be extensively involved in surveillance strategies beyond merely collecting and aggregating information provided by LHDs.

Impact of a school-based AIDS prevention program on risk and protective behavior for newly sexually active students

This project assessed the impact of a school-based AIDS prevention program on student participation in sexual risk and protective behaviors such as use of condoms and use of condoms with foam and intention to participate in such behaviors. The paper focuses on students who became sexually active for the first time between the seventh and eighth grade ("changers," n = 312). The school-based intervention was developed using social cognitive theory and the social influences model of behavior change. Using an experimental, longitudinal design, 15 high-risk school districts were divided randomly into two treatment (10 districts) and one control (five districts) conditions. Students in both treatment conditions received a 10-lesson classroom program in the seventh grade with a five-lesson booster in the eighth grade, while control students received basic AIDS education (current practice in their districts) in compliance with state mandates. Results indicated classroom programs had an impact on certain protective behaviors and on frequency of sexual activity the past month. Post-intervention measures also indicated the program affected students' intentions to perform specific protective behaviors.

Correlates of HIV risk among young adolescents in a large metropolitan midwestern epicenter

This paper examines levels of participation in and correlates of AIDS-related risk behavior for young adolescents in high-risk communities as determined by proxy indicators such as rates of reported STDs and adolescent pregnancies. Seventh and eighth grade students from two middle schools and ninth grade students from the receiving high school were surveyed. Descriptive and inferential techniques examined grade, racial, behavioral, and gender differences in participation in risk (substance use and sexual activity) and protective (use of condoms and use of condoms and foam) behaviors. Grade, race, and sexual activity were significant correlates of both licit and illicit drug use. Gender, grade, race, and licit and illicit drug use were significant correlates of sexual activity. Results demonstrate that not only are adults and older teens at risk in these communities, but younger adolescents also are at risk. Findings indicate a need for comprehensive HIV prevention programs at younger ages.

The relationship between exposure during pregnancy to cigarette smoking and cocaine use and placenta previa

OBJECTIVE

This study examined the relationship between two maternal exposures, cigarette smoking and cocaine use, and placenta previa.

STUDY DESIGN

A hospital-based case-control study was conducted. Three hundred four cases of placenta previa were compared with 2732 controls with respect to demographic characteristics, substance use, and perinatal characteristics. Logistic regression was used to examine the individual effects of cigarette smoking and cocaine use on placenta previa, independent of other known risk factors.

RESULTS

A dose-response relationship between smoking cigarettes and placenta previa was observed independent of other known risk factors (ptrend < 0.01). Pregnant women who smoked > or = 20 cigarettes per day were over two times more likely to experience a placenta previa relative to nonsmokers (odds ratio 2.3, 95% confidence interval 1.5 to 3.5). Pregnant women who used cocaine were 1.4 times (95% confidence interval 0.8 to 2.4) as likely to experience a placenta previa as nonusers.

CONCLUSIONS

The previously observed association between smoking and placenta previa is supported by the dose-response relationship observed in this study. The potential association of cocaine with placenta previa needs more exploration.