Local public health delivery of maternal child health services: are specific activities associated with reductions in Black-White mortality disparities?

The Impact of Public Health Funding on Population Health Outcomes

Abstract The objective of this study was to assess the impact of local health department (LHD) expenditures on population health measures using counties as the unit of analysis. An observational research design is used to examine whether public health benefits are associated with higher levels of public health funding. Linear probability multivariate regression models with the use of local level cross-sectional and panel data are employed. A 1-year and a 2-year lag structure are also used to quantify the longer term public health effects of changes in LHD expenditures. Analyses were performed at the county level using local data representing 2120 LHDs, covering 48 US states. Expenditure data from the National Association of County and City Health Officials Profile Surveys and public health measures from County Health Rankings Annual Reports are used. Four public health measures are examined-obesity prevalence, sexually transmitted diseases, diabetes prevalence, and human immunodeficiency virus prevalence. Results from cross-sectional, pooled ordinary least squares, and panel data with fixed effects reveal that increased LHD expenditures per capita were not associated with any of the population health outcomes studied. Multivariate linear regression results using a 1- and 2-year lag structure reveal similar results: funding was not significantly predictive of better public health outcomes. The study design did not control for the potential endogeneity of public health funding. More detailed data and robust research approaches are needed to disentangle the effect and effectively answer whether increased public funding translates to improved population health.

Society for Maternal-Fetal Medicine Consult Series #62: Best practices in equitable care delivery-Addressing systemic racism and other social determinants of health as causes of obstetrical disparities

The Centers for Disease Control and Prevention define social determinants of health as "the conditions in the places where people live, learn, work, and play" that can affect health outcomes. Systemic racism is a root cause of the power and wealth imbalances that affect social determinants of health, creating disproportionate rates of comorbidities and adverse outcomes in the communities of racial and ethnic minority groups. Focusing primarily on disparities between Black and White individuals born in the United States, this document reviews the effects of social determinants of health and systemic racism on reproductive health outcomes and recommends multilevel approaches to mitigate disparities in obstetrical outcomes.

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.

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.

Associations Between County Wealth, Health and Social Services Spending, and Health Outcomes

INTRODUCTION

Each year, the County Health Rankings rate the health outcomes of each county in the U.S. A common refrain is that poor counties perform worse than wealthier ones. This article examines that assumption and specifically analyzes characteristics of counties that have performed better in terms of health outcomes than their wealth alone would suggest.

METHODS

Data from the 2013 County Health Rankings were used, as were 2012 financial and demographic information collected by the U.S. Census Bureau. A logistic model was constructed to examine the odds of a county "overperforming" in the rankings relative to community wealth. Analyses were performed in 2016.

RESULTS

Communities that were wealthier performed better on the rankings. However, more than 800 of 3,141 counties overperformed by ranking in a better health outcomes quartile than their county's wealth alone would suggest. Regression analyses found that for each additional percentage point of total public spending that was allocated toward community health care and public health, the odds of being an overperformer increased by 3.7%.

CONCLUSIONS

Community wealth correlates with health, but not always. Population health outcomes in hundreds of counties overperform what would be expected given community wealth alone. These counties tend to invest more in community health care and public health spending and other social services. Although the level of a community's wealth is outside the control of practitioners, shifting the proportion of spending to certain social services may positively impact population health.

Federally Qualified Health Center Substitution of Local Health Department Services

INTRODUCTION

Strategic and budgetary considerations have shifted local health departments (LHDs) away from safety net clinical services and toward population-focused services. Federally Qualified Health Centers (FQHCs) play an increasing role in the safety net, and may complement or substitute for LHD clinical services. The authors examined the association between FQHC service levels in communities and the presence of specific LHD clinical services in 2010 and 2013.

METHODS

Data from LHD surveys and FQHC service data were merged for 2010 and 2013. Multivariate regression and instrumental variable methods were used to examine FQHC service levels that might predict related LHD service presence or discontinuation from 2010 to 2013.

RESULTS

There were modest reductions in LHD service presence and increases in FQHC service volume over the time period. LHD primary care and dental service presence were inversely associated with higher related FQHC service volume. LHD prenatal care service presence, as well as a measure of change in general service approach, were not significantly associated with FQHC service volume.

CONCLUSIONS

LHDs were less likely to provide certain clinical services where FQHCs provide a greater volume of services, suggesting a substitution effect. However, certain clinical services, such as prenatal care, may complement the public health mission-and LHDs may be strategically placed to continue to deliver these services.

Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome

Rates of maternal morbidity and mortality are rising in the United States. Non-Hispanic Black women are at highest risk for these outcomes compared to those of other race/ethnicities. Black women are also more likely to be late to prenatal care or be inadequate users of prenatal care. Prenatal care can engage those at risk and potentially influence perinatal outcomes but further research on the link between prenatal care and maternal outcomes is needed. The objective of this article is to review literature illuminating the relationship between prenatal care utilization, social determinants of health, and racial disparities in maternal outcome. We present a theoretical framework connecting the complex factors that may link race, social context, prenatal care utilization, and maternal morbidity/mortality. Prenatal care innovations showing potential to engage with the social determinants of maternal health and address disparities and priorities for future research are reviewed.

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.

Local Health Departments' Activities to Address Health Disparities and Inequities: Are We Moving in the Right Direction?

Context: Health disparities are among the critical public health challenges. Objectives: To analyze the extent to which local health departments (LHDs) perform activities for addressing health disparities, changes in proportion of LHDs’ performing those activities since 2005, and factors associated with variation in such engagement. Methods: We used the 2013 National Profile of LHDs Survey to perform Logistic Regression of activities LHDs performed to address health disparities. Results: About 20 percent of LHDs did not perform any activity to address health disparities. Significant decreases occurred since 2005 in the proportion of LHDs that performed health disparity reduction/elimination activities for four activities. LHD characteristics significantly associated (p≤0.05) with the increased likelihood of performing activities to address health disparities were: recent completion of community health assessment, community health improvement plan and agency wide strategic plan. Other significant positive impacts on such activities included per capita expenditures, local governance, having one or more local boards of health, larger population size and metropolitan status of the LHD jurisdiction. Conclusions: Reduced infrastructural capacity of LHDs has resulted in fewer LHDs addressing health disparities in their jurisdictions. LHD characteristics associated with higher performance of activities for health disparity reduction identified by this research have important policy implications.

Addressing psychological, mental health and other behavioural healthcare needs of the underserved populations in the United States: the role of local health departments

Aims:

(1) To assess the extent to which local health departments (LHDs) implement and evaluate strategies to target the behavioural healthcare needs for the underserved populations and (2) to identify factors that are associated with these undertakings.

Methods:

Data for this study were drawn from the 2013 National Profile of Local Health Departments Study conducted by National Association of County and City Health Officials. A total of 505 LHDs completed the Module 2 questionnaire of the Profile Study, in which LHDs were asked whether they implemented strategies and evaluated strategies to target the behavioural healthcare needs of the underserved populations. To assess LHDs’ level of engagement in assuring access to behavioural healthcare services, descriptive statistics were computed, whereas the factors associated with assuring access to these services were examined by using logistic regression analyses. To account for complex survey design, we used SVY routine in Stata 11.

Results:

Only about 24.9% of LHDs in small jurisdiction (<50,000 population) and 35.3% of LHDs in medium-size jurisdiction implemented/evaluated strategies to target the behavioural healthcare services needs of underserved populations in their jurisdiction in 2013. Logistic regression model results showed that LHDs having city/multicity jurisdiction (adjusted odds ratio (AOR) = .16, 95% confidence interval (CI): .04–.77), centralised governance (AOR = .12, 95% CI: .02–.85), and those located in South Region (AOR = .25, 95% CI: .08–.74) or the West Region (AOR = .36, 95% CI: 14–.94), were less likely to have implemented/evaluated strategies to target the behavioural healthcare needs of the underserved.

Conclusions:

The extent to which the LHDs implemented or evaluated strategies to target the behavioural healthcare needs of the underserved population varied by geographic regions and jurisdiction types. Different community needs or different state Medicaid programmes may have accounted for these variations. LHDs could play an important role in improving equity in access to care, including behavioural healthcare services in the communities.

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.

Public health spending and population health: a systematic review

CONTEXT

This systematic review synthesizes what is known about the relationship between public health spending and population health outcomes, as well as the pathways that may explain how outcomes vary with spending. It also discusses the limitations of the existing literature and identifies areas in need of future research.

EVIDENCE ACQUISITION

Studies included in this review were retrieved through an iterative process, primarily through key word searches in two literature databases (PubMed and JSTOR) conducted in 2013. All retrieved studies underwent initial and secondary screening. Articles were included if they (1) examined the link between spending and outcomes or (2) explored pathways that mediate the relationship between spending and outcomes.

EVIDENCE SYNTHESIS

Seventeen empirical studies and five literature reviews published between 1985 and 2012 were included in this review. Existing evidence suggests that increases in public health spending are associated with improved population health, at least for some outcomes. However, there is little evidence to suggest that increased spending contributes to meaningful reductions in health disparities. Moreover, the pathways through which greater spending translates into better outcomes are not well understood.

CONCLUSIONS

Although the complexity of the public health delivery system makes it difficult to demonstrate definitive associations between spending and outcomes, financial investments in public health have the potential to improve community health. Additional research is needed to explore the pathways that mediate this relationship. This research would benefit public health practitioners who need evidence on how to best spend financial resources to achieve better health outcomes.

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.

Targeted health department expenditures benefit birth outcomes at the county level

BACKGROUND

Public health leaders lack evidence for making decisions about the optimal allocation of resources across local health department (LHD) services, even as limited funding has forced cuts to public health services while local needs grow. A lack of data has also limited examination of the outcomes of targeted LHD investments in specific service areas.

PURPOSE

This study used unique, detailed LHD expenditure data gathered from state health departments to examine the influence of maternal and child health (MCH) service investments by LHDs on health outcomes.

METHODS

A multivariate panel time-series design was used in 2013 to estimate ecologic relationships between 2000-2010 LHD expenditures on MCH and county-level rates of low birth weight and infant mortality. The unit of analysis was 102 LHD jurisdictions in Washington and Florida.

RESULTS

Results indicate that LHD expenditures on MCH services have a beneficial relationship with county-level low birth weight rates, particularly in counties with high concentrations of poverty. This relationship is stronger for more targeted expenditure categories, with expenditures in each of the three specific examined MCH service areas demonstrating the strongest effects.

CONCLUSIONS

Findings indicate that specific LHD investments in MCH have an important effect on related health outcomes for populations in poverty and likely help reduce the costly burden of poor birth outcomes for families and communities. These findings underscore the importance of monitoring the impact of these evolving investments and ensuring that targeted, beneficial investments are not lost but expanded upon across care delivery systems.