Governance typology: a consensus classification of state-local health department relationships

Enumerating the State and Local Public Health Workforce During the COVID-19 Response

Objectives. To understand the landscape of the nonfederal governmental public health workforce and to identify replicable methods for future enumerations. Methods. This enumeration of the state and local public health workforce was conducted from 2023 to 2024 and triangulated the National Association of County and City Health Officials (NACCHO) Profile 2022 and the Association of State and Territorial Health Officials (ASTHO) Profile 2022. We utilized Public Health Workforce Interests and Needs Survey (PH WINS) data from 2021 to assess demographic distributions across Department of Health and Human Services (HHS) regions in the United States. Results. A total of 239 000 staff were employed in state and local health departments in 2022, a 2% increase since 2012. Sixteen states-including 6 in the Southeast-lost staff relative to population growth. Conclusions. An uneven landscape of public health workforce density reflects chronic underinvestment in public health. The process of enumeration itself was also fraught with pitfalls and data limitations. Public Health Implications. We recommend building on federal investments to develop dedicated funding streams for state and local public health. We also recommend amending federal efforts around enumeration to include governmental public health at all levels. (Am J Public Health. 2025;115(5):716-725. https://doi.org/10.2105/AJPH.2024.307964).

The cross-sectional association between state-level public health funding per capita and physical health among adults in the United States

OBJECTIVES

This study examined the association between state-level public health funding per capita and the odds of poor physical health.

STUDY DESIGN

Cross-sectional.

METHODS

Data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) were used. Participants' self-reported physical health was reported using the CDC Healthy Days Core Module. State-level public health funding per capita was obtained from the State Health Access Data Assistance Center website. Multilevel logistic regression was used to adjust for self-reported individual-level characteristics and state-level characteristics from the 2018 American Community Survey. We also tested whether household income or education attainment moderated any observed associations.

RESULTS

A one SD increase in state-level public health funding per capita was not associated with the odds ≥  14 days of poor physical health (OR = 0.96, 95% CI: 0.90, 1.01). However, heterogeneity across household income was observed. Greater public health funding per capita was associated with lower predicted probabilities of reporting ≥  14 days of poor physical health among respondents from low household income backgrounds ( <$35,000 USD) compared to participants with high household incomes (>$75,000 USD). No associations were observed among those with moderate ($35,000 - $70,000 USD) household incomes. A similar finding was observed among participants with less than high school education when compared to participants with post-secondary education.

CONCLUSION

Greater state-level public health funding per capita appears to have a protective association against reporting ≥  14 days of poor physical health in individuals with lower household incomes and may be helpful in reducing health inequities. Future research is needed to determine whether this association is causal.

Local Health Department Values and Organizational Authorities Guiding Cross-Sector Work During COVID-19

OBJECTIVE

The COVID-19 pandemic highlighted the role that local health departments (LHDs) have in cross sector can address alone, including the work of value alignment and the strategic use of organizational authorities. The practices by which LHDs used their authorities to conduct cross-sector work during the pandemic need exploration.

METHOD

We conducted semi-structured interviews with 19 public health leaders from metropolitan LHDs across the United States. Our interview guide assessed the values that LHD leadership prioritized in their cross-sector work as well as the range of organizational authorities they leveraged to influence external decision-making in other sectors.

RESULTS

We found that LHDs approached cross-sector work by leaning on diverse values and authorities, each with unique implications for their work. The LHDs emphasized their approach to value alignment on a sector-by-sector basis, strategically using diverse organizational authorities-economic, political, moral, scientific, and logistical. While each authority and value we assessed was present across all interviewees, how each shaped action varied. Internally, LHDs emphasized certain authorities more than others to the degree that they more closely aligned with prioritized core values.

CONCLUSION

Our findings highlight the ongoing need for LHD leadership to improve their ability to effectively communicate public health values and the unique authorities by which health-supporting work can be facilitated, including how this message must be adapted, depending on the specific sectors with which the LHD needs to partner and the governance arrangement in which the LHD is situated.

The Impacts of Politicization on Public Health Workers: The COVID-19 Pandemic in Oregon and Montana

CONTEXT

The contributions from the field of public health to human society are numerous and are often taken for granted. The COVID-19 pandemic thrust the largely invisible public health workforce into the public eye. Like other career civil servants at the intersection of the citizen-state encounter, reports of uncooperative, hostile, and even violent confrontations between public health workers and those they serve are on the rise. This study explores the attitudes of public health professionals in two states in the American West.

METHODS

The authors conducted an anonymous web-based survey of public health professionals in Montana and Oregon one year into the COVID-19 pandemic.

FINDINGS

Public health workers who responded to the survey reported beliefs that the COVID-19 pandemic was politicized by actors in the government, both major political parties, the media, and the public broadly. This politicization affected workers' abilities to do their jobs, with respondents in Montana experiencing more negative impacts than those in Oregon.

CONCLUSIONS

Public health workers face growing antagonism from the public and pressure from political leaders, which poses a significant concern for the public health workforce and for communities as they prepare to address and overcome future public health challenges.

The Opportunity Cost of COVID for Public Health Practice: COVID-19 Pandemic Response Work and Lost Foundational Areas of Public Health Work

This article has been temporarily removed by the publisher, Wolters Kluwer, due to a data quality issue. We regret any confusion this may have caused. This article will be published once production is complete on the Public Health Workforce Interest and Needs Survey supplemental issue.

CONTEXT

There is little empirical evidence regarding the magnitude of the COVID-19 response across the public health workforce and the extent to which other public health programs were called upon to contribute to the response, potentially leading to less work being done in other public health programs during the COVID-19 pandemic.

OBJECTIVES

To assess the composition of the workforce that contributed to the COVID-19 pandemic response during 2020-2022.

DESIGN

A large, cross-sectional, nationally representative survey of the state and local public health agency workforce through the Public Health Workforce Interest and Needs Survey (PH WINS).

SETTING

Nearly all state health agency-central offices (SHA-COs) and Big City Health Coalition (BCHC) member public health departments as well as a nationally representative sample of other local health departments (LHDs) with more than 25 staff members and serving more than 25 000 people participated in fall 2021.

PARTICIPANTS

A sample of all individuals working at each SHA-CO or LHD as part-time or full-time employees, contractors, or other employee types was used. A total of 44 732 responses (35% of eligible respondents) were received.

MAIN OUTCOME MEASURE

Main outcomes included the proportion of full-time equivalent (FTE) effort devoted to COVID-19 response work by quarter (Q) from Q1 2020 through Q1 2022. Predictors of interest included individual- and agency-level demographics, most notably an individual's self-reported public health program area.

RESULTS

Staffing and hiring for the COVID-19 pandemic response was an ongoing effort that began in 2020 and lasted through 2022. During the pandemic, all public health program areas contributed at least 20% of their workforce time to COVID-19 response, peaking at 47-83% of the staff time, depending on the program area.

CONCLUSIONS

There was a considerable public health opportunity cost to the public health systems' large and prolonged COVID-19 response. Persistent understaffing in the public health system remains an important issue.

PH WINS 2021 Methodology Report

CONTEXT

The Public Health Workforce Interests and Needs Survey (PH WINS) was fielded in 2014 and 2017 and is the largest survey of the governmental public health workforce. It captures individual employees' perspectives on key issues such as workplace engagement and satisfaction, intention to leave, training needs, ability to address public health issues, as well as collects demographic information. This article describes the methods used for the 2021 PH WINS fielding.

PH WINS

PH WINS 2021 was fielded to a nationally representative sample of staff in State Health Agency-Central Offices (SHA-COs) and local health departments (LHDs) from September 13, 2021, to January 14, 2022. The instrument was revised to assess the pandemic's potential toll on the workforce, including deployment to COVID-19 response roles and well-being, and the country's renewed focus on health equity and "Racism as a Public Health Crisis." PH WINS 2021 had 3 sampling frames: SHAs, Big Cities Health Coalition (BCHC) members, and LHDs. All participating agencies were surveyed using a census approach.

PARTICIPATION

Overall, staff lists for 47 SHAs, 29 BCHC members, and 259 LHDs were collected, and the survey was sent to 137 446 individuals. PH WINS received a total of 44 732 responses, 35% of eligible respondents. The nationally representative SHA-CO frame includes a total of 14 957 individuals, and the nationally representative LHD frame includes 26 933 individuals from 439 LHDs (decentralized and nondecentralized).

CONSIDERATIONS FOR ANALYSIS

PH WINS now offers a multiyear, nationally representative sample of both SHA-CO and LHD staff. Both practice and academia can use PH WINS to better understand the strengths, needs, and opportunities of the workforce. When using PH WINS for additional data analysis, there are a number of considerations both within the 2021 data set and when conducting multiyear and multiple cross-sectional analyses.

Telehealth for Contraceptive Care During the Initial Months of the COVID-19 Pandemic at Local Health Departments in 2 US States: A Mixed-Methods Approach

OBJECTIVES

This study examined implementation of telehealth for contraceptive care among health departments (HDs) in 2 Southern US states with centralized/largely centralized governance structures during the early phase of the COVID-19 pandemic. Sustaining access to contraceptive care for underserved communities during public health emergencies is critical. Identifying facilitators and barriers to adaptive service provision helps inform state-level decision making and has implications for public health policy and practice, particularly in states with centralized HD governance.

DESIGN

Mixed-methods study including a survey of HD clinic administrators and key informant interviews with clinic- and system-level staff in 2 states conducted in 2020.

SETTING

Health department clinics in 2 Southern US states.

PARTICIPANTS

Clinic administrators (survey) and clinic- and system-level respondents (key informant interviews). Participation in the research was voluntary and de-identified.

MAIN OUTCOME MEASURES

(1) Telehealth implementation for contraceptive care assessed by survey and measured by the percentage of clinics reporting telehealth service provision during the pandemic; and (2) facilitators and barriers to telehealth implementation for contraceptive care assessed by key informant interviews. For survey data, bivariate differences between the states in telehealth implementation for contraceptive care were assessed using χ2 and Fisher exact tests. Interview transcripts were coded, with emphasis on interrater reliability and consensus coding, and analyzed for emerging themes.

RESULTS

A majority of HD clinics in both states (60% in state 1 and 81% in state 2) reported a decrease in contraceptive care patient volume during March-June 2020 compared with the average volume in 2019. More HD clinics in state 1 than in state 2 implemented telehealth for contraceptive services, including contraceptive counseling, initial and refill hormonal contraception, emergency contraception and sexually transmitted infection care, and reported facilitators of telehealth. Medicaid reimbursement was a predominant facilitator of telehealth, whereas lack of implementation policies and procedures and reduced staffing capacity were predominant barriers. Electronic infrastructure and technology also played a role.

CONCLUSIONS

Implementation of telehealth for contraceptive services varied between state HD agencies in the early phase of the pandemic. Medicaid reimbursement policy and directives from HD agency leadership are key to telehealth service provision among HDs in centralized states.

Past local government health spending was not correlated with COVID-19 control in US counties

Context

Wide variation in state and county health spending prior to 2020 enables tests of whether historically better state and locally funded counties achieved faster control over COVID-19 in the first 6 months of the pandemic in the Unites States prior to federal supplemental funding.

Objective

We used time-to-event and generalized linear models to examine the association between pre-pandemic state-level public health spending, county-level non-hospital health spending, and effective COVID-19 control at the county level. We include 2,775 counties that reported 10 or more COVID-19 cases between January 22, 2020, and July 19, 2020, in the analysis.

Main outcome measure

Control of COVID-19 was defined by: (i) elapsed time in days between the 10th case and the day of peak incidence of a county's local epidemic, among counties that bent their case curves, and (ii) doubling time of case counts within the first 30 days of a county's local epidemic for all counties that reported 10 or more cases.

Results

Only 26% of eligible counties had bent their case curve in the first 6 months of the pandemic. Government health spending at the county level was not associated with better COVID-19 control in terms of either a shorter time to peak in survival analyses, or doubling time in generalized linear models. State-level public spending on hazard preparation and response was associated with a shorter time to peak among counties that were able to bend their case incidence curves.

Conclusions

Increasing resource availability for public health in local jurisdictions without thoughtful attention to bolstering the foundational capabilities inside health departments is unlikely to be sufficient to prepare the country for future outbreaks or other public health emergencies.

•

Substantial variation in county and state health spending in the US before the COVID-19 pandemic.

•

County level non-hospital health spending before pandemic not associated with early control over COVID-19.

•

State level spending on hazard preparation is associated with early control over COVID-19 in some model specifications.

•

Results offer no support for pouring funds into public health system to prepare for future outbreaks.

Building a Sustainable Governmental Public Health Workforce: A Look at the Millennial Generation

CONTEXT

Millennials have had a profound impact on society, the economy, and the US workforce. This study used generational definitions published by the Pew Research Center. Millennials includes respondents who reported an age between 21 and 36 years (born in 1981-1996) at the time the 2017 Public Health Workforce Interests and Needs Survey (PH WINS) was administered. Generation X includes respondents who reported an age between 37 and 52 years (born in 1965-1980), and the baby boom generation (baby boomers) includes respondents between 53 and 71 years of age (born in 1946-1964). Public sector agencies, including governmental public health, are increasingly interested in figuring out how to attract and retain millennials. As the governmental public health workforce anticipates upcoming retirements, knowledge about the motivations and organizational characteristics that appeal to millennials is crucial to understanding the millennial workforce and workplace dynamics for decades to come. In 2017, millennials made up 22% of the governmental public health workforce, Generation X 40%, and baby boomers 37%.

OBJECTIVE

This study examined opinions, expectations, and important workplace environment factors of millennials working in governmental public health compared with other generations.

DESIGN

We performed bivariate analyses and fit a logistic regression model to evaluate the association of generation with responses to a set of satisfaction and engagement PH WINS survey questions.

SETTING AND PARTICIPANTS

Data were drawn from the 2017 PH WINS of governmental health department employees, including state health agency and local health department staff. PH WINS excludes local health departments with fewer than 25 staff members or serving fewer than 25 000 people. PH WINS included responses from 47 604 staff members, which reflected a 48% overall response rate.

RESULTS

The generations that were examined (millennials, Generation X, and baby boomers) were similarly satisfied with their jobs, organizations, and pay security, and millennials intended to leave their jobs for similar reasons as other generations. Millennials reported more strongly than other generations that their supervisors treated them with respect, that they had sufficient training to utilize technology, that their training needs are assessed, and that creativity and innovation were rewarded. They, however, reported less strongly that they were completely involved in their work and determined to give their best every day.

CONCLUSIONS

Millennials in governmental public health agencies (excluding local health departments with <25 staff members or serving <25 000 people) may not be as different from other generations as previously thought. Governmental public health agencies should focus on highlighting workplace environment factors rated highly by millennials and on showcasing how careers in governmental public health could be attractive career options for millennials.

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 Methods of PH WINS 2017: Approaches to Refreshing Nationally Representative State-Level Estimates and Creating Nationally Representative Local-Level Estimates of Public Health Workforce Interests and Needs

Supplemental Digital Content is Available in the Text.

Context:

The Public Health Workforce Interests and Needs Survey (PH WINS) was first fielded in 2014 and is the largest public health workforce survey in the nation. This article elucidates the methods used for the 2017 PH WINS fielding.

Program or Policy:

PH WINS was fielded to a nationally representative sample of State Health Agency Central Office (SHA-CO) staff, as well as local health department (LHD) staff. The instrument largely mirrored 2014, though the training needs section was revised, and a validated item measuring burnout in staff was added.

Implementation:

Staff lists were collected directly from all participating state and local agencies. Forty-seven state health agencies (SHAs), 26 large LHDs, and 71 midsize LHDs participated. All SHAs were surveyed using a census approach. The nationally representative SHA-CO frame is representative of all central office staff members. The nationally representative local frame was a complex survey design, wherein staff from LHDs were randomly sampled across 20 strata, based on agency size and geographic region. Staff were also contributed with certainty from large LHDs in nondecentralized states. The frame is representative of staff at LHDs serving more than 25 000 people and with 25 or more staff members. Other LHDs are excluded, and so PH WINS is not representative of smaller LHDs. Balanced repeated replication weights were used to adjust variance estimates for the complex design.

Evaluation:

Overall, 47 604 people responded to PH WINS in 2017 across all frames. PH WINS 2017 achieved a response rate of 48%. The design effect for the SHA-CO frame was 1.46 and was 16.42 for the local frame.

Discussion:

PH WINS now offers a nationally representative sample of both SHA-CO and LHD staff across 4 major domains: workplace environment, training needs, emerging concepts in public health, and demographics. Both practice and academia can use PH WINS to better understand the perceptions and needs of staff, address training gaps, and work to recruit and retain quality staff.

Regional Training Needs Assessment: A First Look at High-Priority Training Needs Across the United States by Region

Supplemental Digital Content is Available in the Text.

Context:

Although core scientific skills remain a priority to public health, preventing and responding to today's leading causes of death require the workforce to build additional strategic skills to impact the social, community-based, and economic determinants of health. The 2017 Public Health Workforce Interests and Needs Survey allows novel regional analysis of training needs, both individually and across 8 strategic skill domains.

Objective:

The purpose of this article is to describe the training needs of public health staff nationally, across the 10 Department of Health and Human Services Regions.

Design:

The Public Health Workforce Interests and Needs Survey was a Web-based survey fielded to 100 000 staff nationwide across 2 major frames: state health agency-central office and local health department. State-based respondents were fielded on a census approach, with locals participating in a more complex sampling design. Balanced repeated replication weights were used to address nonresponse and sampling.

Setting:

State and local health departments.

Participants:

Respondents from state and local health departments.

Main Outcome Measures:

This article draws from the training needs portion of Public Health Workforce Interests and Needs Survey. Descriptive statistics are generated, showing training needs gaps. Inferential analyses pertain to gaps across Region and supervisory status, using Pearson χ² test and Rao-Scott design–adjusted χ² test.

Results:

Training needs varied across regions and work setting. Certain strategic skills tended to see larger, consistent gaps regardless of Region or setting, including Budgeting & Finance, Change Management, Systems Thinking, and Developing a Vision for a Healthy Community.

Conclusions:

Overall, the data suggest substantial interregional variation in training needs. Until now, this picture has been incomplete; disparate assessments across health departments, Regions, and disciplines could not be combined into a national picture. Regionally focused training centers are well situated to address Region-specific needs while supporting the broader building of capacity in strategic skills nationwide.

Unleashing the Creativity and Innovation of Our Greatest Resource-The Governmental Public Health Workforce

Context:

Creativity and innovation in the governmental public health workforce will be required to generate new ideas to solve complex problems that extend beyond traditional public health functions such as disease surveillance and monitoring. Creativity and innovation can promote and advance necessary organizational transformation as well as improve organizational culture and workplace environment by motivating employees intrinsically. However, there is little empirical evidence on how rewarding creativity and innovation in governmental public health departments is associated with organizational culture and workplace environments.

Objective:

This study describes (1) the degree to which creativity and innovation are rewarded in governmental public health agencies and (2) associations between rewarding creativity and innovation and worker satisfaction, intent to leave, and workplace characteristics.

Design:

The cross-sectional Public Health Workforce Interests and Needs Survey (PH WINS) was administered using a Web-based platform in fall 2017.

Settings and Participants:

Data used for these analyses were drawn from the 2017 PH WINS of governmental health department employees. This included state health agency and local health department staff. PH WINS included responses from 47 604 staff members, which reflected a 48% overall response rate. PH WINS excludes local health departments with fewer than 25 staff or serving fewer than 25 000 people.

Results:

Fewer than half of all workers, regardless of demographic group and work setting, reported that creativity and innovation were rewarded in their workplace. Most measures of worker satisfaction and workplace environment were significantly more positive for those who reported that creativity and innovation were rewarded in their workplace.

Conclusion:

This research suggests that promoting creativity and innovation in governmental public health agencies not only could help lead the transformation of governmental public health agencies but could also improve worker satisfaction and the workplace environment in governmental public health agencies.

Master's-Level Education in the Governmental Public Health Workforce

OBJECTIVES

More than 16 000 graduate degrees in public health are awarded annually. Yet only 14% of the governmental public health workforce has formal public health training of any kind, and 8% has a master of public health (MPH) degree. We characterized the differences among governmental staff members with master's degrees across US health departments.

METHODS

We used data from the 2017 Public Health Workforce Interests and Needs Survey, a national survey of state and local public health departments (43 669 responses; response rate, 48%). We examined the characteristics of the workforce by educational attainment and compared respondents who had obtained a "terminal" (ie, highest degree obtained) MPH degree with respondents who had obtained a terminal non-public health (non-PH) master's degree.

RESULTS

Respondents who had a non-PH master's degree were as likely as respondents who had an MPH degree to hold a supervisory role (43% vs 41%; P = .67). We found only 1 significant difference between the 2 groups: respondents aged ≤40 with a terminal MPH degree were significantly less likely than respondents aged ≤40 with a non-PH master's degree to earn more than the national average salary (adjusted odds ratio = 0.67; 95% CI, 0.47-0.97; P = .03).

CONCLUSIONS

We found only marginal differences in career outcomes for people working in governmental public health who had a terminal MPH degree vs a terminal non-PH master's degree. This finding does not necessitate a full reconsideration of the MPH as it relates to governmental public health practice but a greater recognition that there are multiple paths into practice.

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.

The Methods Behind PH WINS

Supplemental Digital Content is Available in the Text.

This article outlines the conceptualization, development, and implementation of the Public Health Workforce Interests and Needs Survey, as well as considerations and limitations.

The Public Health Workforce Interests and Needs Survey (PH WINS) has yielded the first-ever nationally representative sample of state health agency central office employees. The survey represents a step forward in rigorous, systematic data collection to inform the public health workforce development agenda in the United States. PH WINS is a Web-based survey and was developed with guidance from a panel of public health workforce experts including practitioners and researchers. It draws heavily from existing and validated items and focuses on 4 main areas: workforce perceptions about training needs, workplace environment and job satisfaction, perceptions about national trends, and demographics. This article outlines the conceptualization, development, and implementation of PH WINS, as well as considerations and limitations. It also describes the creation of 2 new data sets that will be available in public use for public health officials and researchers—a nationally representative data set for permanently employed state health agency central office employees comprising over 10 000 responses, and a pilot data set with approximately 12 000 local and regional health department staff responses.

Practitioner perspectives on foundational capabilities

Supplemental Digital Content is Available in the Text.

This article examines the attitudes, perceptions, and practices of public health practitioners with respect to the concept of foundational capabilities.

Context:

National efforts are underway to classify a minimum set of public health services that all jurisdictions throughout the United States should provide regardless of location. Such a set of basic programs would be supported by crosscutting services, known as the “foundational capabilities” (FCs). These FCs are assessment services, preparedness and disaster response, policy development, communications, community partnership, and organizational support activities.

Objective:

To ascertain familiarity with the term and concept of FCs and gather related perspectives from state and local public health practitioners.

Design:

In fall 2013, we interviewed 50 leaders from state and local health departments. We asked about familiarity with the term “foundational capabilities,” as well as the broader concept of FCs. We attempted to triangulate the utility of the FC concept by asking respondents about priority programs and services, about perceived unique contributions made by public health, and about prevalence and funding for the FCs.

Setting:

Telephone-based interviews.

Participants:

Fifty leaders of state and local health departments.

Main Outcome Measures:

Practitioner familiarity with and perspectives on the FCs, information about current funding streams for public health, and the likelihood of creating nationwide FCs that would be recognized and accepted by all jurisdictions.

Results:

Slightly more than half of the leaders interviewed said that they were familiar with the concept of FCs. In most cases, health departments had all of the capabilities to some degree, although operationalization varied. Few indicated that current funding levels were sufficient to support implementing a minimum level of FCs nationally.

Conclusions:

Respondents were not able to articulate the current or optimal levels of services for the various capabilities, nor the costs associated with them. Further research is needed to understand the role of FCs as part of the foundational public health services.

State Public Health Enabling Authorities: Results of a Fundamental Activities Assessment Examining Core and Essential Services

CONTEXT

Public health enabling authorities establish the legal foundation for financing, organizing, and delivering public health services. State laws vary in terms of the content, depth, and breadth of these fundamental public health activities. Given this variance, the Institute of Medicine has identified state public health laws as an area that requires further examination. To respond to this call for further examination, the Centers for Disease Control and Prevention's Public Health Law Program conducted a fundamental activities legal assessment on state public health laws.

OBJECTIVE

The goal of the legal assessment was to examine state laws referencing frameworks representing public health department fundamental activities (ie, core and essential services) in an effort to identify, catalog, and describe enabling authorities of state governmental public health systems.

DESIGN

In 2013, Public Health Law Program staff compiled a list of state statutes and regulations referencing different commonly-recognized public health frameworks of fundamental activities. The legal assessment included state fundamental activities laws available on WestlawNext as of July 2013. The results related to the 10 essential public health services and the 3 core public health functions were confirmed and updated in June 2016.

RESULTS

Eighteen states reference commonly-recognized frameworks of fundamental activities in their laws. Thirteen states have listed the 10 essential public health services in their laws. Eight of these states have also referenced the 3 core public health functions in their laws. Five states reference only the core public health functions.

CONCLUSIONS

Several states reference fundamental activities in their state laws, particularly through use of the essential services framework. Further work is needed to capture the public health laws and practices of states that may be performing fundamental activities but without reference to a common framework.

Laying the groundwork for evidence-based public health: why some local health departments use more evidence-based decision-making practices than others

We examined variation in the use of evidence-based decision-making (EBDM) practices across local health departments (LHDs) in the United States and the extent to which this variation was predicted by resources, personnel, and governance. We analyzed data from the National Association of County and City Health Officials Profile of Local Health Departments, the Association of State and Territorial Health Officials State Health Departments Profile, and the US Census using 2-level multilevel regression models. We found more workforce predictors than resource predictors. Thus, although resources are related to LHDs' use of EBDM practices, the way resources are used (e.g., the types and qualifications of personnel hired) may be more important.

Evidence-based public health practice among program managers in local public health departments

OBJECTIVES

We assessed the use of administrative-evidence based practices (A-EBPs) among managers of programs in chronic diseases, environmental health, and infectious diseases from a sample of local health departments (LHDs) in the United States.

DESIGN

Program managers completed a survey consisting of 6 sections (biographical data, use of A-EBPs, diffusion attributes, use of resources, and barriers to, and competencies in, evidence-based public health), with a total of 66 questions.

PARTICIPANTS

The survey was sent electronically to 168 program managers in chronic diseases, 179 in environmental health, and 175 in infectious diseases, representing 228 LHDs. The survey had previously been completed by 517 LHD directors.

MEASURES

The use of A-EBPs was scored for 19 individual A-EBPs, across the 5 A-EBP domains, and for all domains combined. Individual characteristics were derived from the survey responses, with additional data on LHDs drawn from linked National Association of County & City Health Officials Profile survey data. Results for program managers were compared across the 3 types of programs and to responses from the previous survey of LHD directors. The scores were ordered and categorized into tertiles. Unconditional logistic regression models were used to calculate odds ratios and 95% confidence intervals, comparing individual and agency characteristics for those with the highest third of A-EBPs scores with those with the lowest third.

RESULTS

The 332 total responses from program managers represented 196 individual LHDs. Program managers differed (across the 3 programs, and compared with LHD directors) in demographic characteristics, education, and experience. The use of A-EBPs varied widely across specific practices and individuals, but the pattern of responses from directors and program managers was very similar for the majority of A-EBPs.

CONCLUSIONS

Understanding the differences in educational background, experience, organizational culture, and performance of A-EBPs between program managers and LHD directors is a necessary step to improving competencies in evidence-based public health.