The National Association of County and City Health Officials (NACCHO), in collaboration with the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention, conducted the sixth National Profile of Local Health Departments study in 2010. NACCHO conducted prior Profile studies in 1989, 1992–1993, 1996–1997, 2005, and 2008. The Profile studies collect information on local health department (LHD) jurisdictions and infrastructure, including governance, financing, leaders, workforce, and activities. The Profile questionnaire is distributed to every US LHD, defined for the purpose of this study as “an administrative or service unit of local or state government concerned with health and carrying some responsibility for the health of a jurisdiction smaller than the state.”
The purpose of this article is to inform the public health research community, practitioners, and policymakers about the availability and potential of the Profile study as a rich source of data to support creation of research evidence for practice and policymaking. To provide a sense of kinds of information available from the study, the article includes study results from the 2010 Profile on selected topics—LHD accreditation, aging of the workforce, emergency preparedness, and access to health care.
Uses of Data and Information From the Profile Study
The Profile studies comprise the nation's surveillance system for LHDs. No other survey gives a comprehensive picture of LHDs and allows for assessment of changes over time. Up-to-date information about LHDs is important to organizations like NACCHO, which support and represent LHDs, and to public health practitioners and policymakers at the state and federal levels. Data and information from the Profile study are used in many ways beyond serving as the nation's surveillance system for LHDs. The LHDs use the information to benchmark themselves nationally and against LHDs that are similar to their own. As one LHD leader said, “We can compare things like our range of services with the national average and our capacity and funding. We continually compare ourselves to other departments in our state, [to] other metro areas, and to other large LHDs in the data set.”
The Profile data are one of the most important and frequently used data sets in the field of public health systems and services research. The Profile studies' national reach, wide range of topics, and high response rates (recent Profile has achieved response rates of 80% or higher) contribute to the value of these data for research. In addition, the inclusion of many questions in multiple Profile questionnaires supports longitudinal analyses. Since 2006, NACCHO has provided data from the Profile studies for use in more than 130 different studies. A university researcher said, “NACCHO data have been our best source of national data on public health organizations and service delivery issues. I use the data for analysis and also as a sampling frame for launching new primary data collection activities.”
Profile data are used to educate others about LHDs by both university faculty and public health practitioners. An LHD leader said, “I use the Profile for public speaking. The data are real. [The data] tell a good story and provide important information.” In addition, 2 leading textbooks on public health practice use data from the Profile to describe LHDs.
Highlights From the 2010 Profile Study
The 2010 Profile study included 2656 LHDs and achieved an overall response rate of 82%. In addition to the core topics included in each Profile study, the 2010 questionnaire included modules (asked of nationally representative stratified random samples of approximately 625 LHDs) with questions on quality improvement, accreditation preparation, emergency preparedness, information technology, practice-based research, access to health care services, and public health and the law. The paragraphs below summarize a few findings from the 2010 Profile study.
The Public Health Accreditation Board launched a voluntary national accreditation program for state, local, tribal, and territorial public health agencies in September 2011. Responses to questions in the 2010 Profile about intent to seek voluntary national accreditation suggest a high level of interest among LHDs in the national accreditation program. Sixteen percent of respondents strongly agreed and 34% agreed that their LHD would seek national accreditation. Furthermore, 8% of LHDs strongly agreed and 21% agreed that their LHD would seek national accreditation within the first 2 years of the program.
The Public Health Accreditation Board has established certain prerequisites for LHDs that wish to apply for national accreditation, including completing a community health assessment, community health improvement plan, and agency-wide strategic plan within the past 5 years. Data from the 2010 Profile study suggest that only 20% of LHDs have met all 3 of these prerequisites, and there is little difference in completion of the 3 prerequisites based on interest in seeking accreditation. These findings suggest that, although a relatively large number of LHDs are interested in seeking national accreditation, many of them have not completed all of the assessment and planning activities required for accreditation. These assessment and planning activities are time- and resource-intensive and require specific skill sets. Many LHDs, particularly those that have experienced funding and staff reductions, may be challenged to marshal the resources required to complete the accreditation prerequisites.
Aging of the LHD workforce
The aging of the US workforce is well documented. Between 1977 and 2007, employment of workers aged 65 years and older increased 101%, compared with a much smaller increase of 59% for total employment (aged 16 years and older).1 Several Profile studies have collected data on age of LHD top executives, and these data confirm that their age distribution is shifting upward. The median age of an LHD top executive increased from 52 years in 2005 to 54 years in 2010. Furthermore, the percentage of LHD top executives between ages 60 and 69 years increased from 13% in 2005 to 21% in 2010. The percentage of LHD top executives younger than 50 years decreased over this period (37% in 2005 to 32% in 2010).
The shift to an older age distribution of LHD top executives means that a large wave of top executive retirements may take place in the future. Changes in leadership can present opportunities for positive change but can be disruptive if individuals with appropriate skills and experience are not available to take on the newly vacated positions. Thoughtful succession planning and developing potential public health leaders are key steps to ensuring that qualified individuals are available to assume these leadership positions. Data from the 2008 Profile study show that more than 60% of LHD top executives reached their position through either an internal promotion (40%) or through positions at other LHDs (22%).2 This suggests that current LHD staff members, such as middle managers, are important targets for leadership development. In the current economic climate, funds to support LHD staff training are limited, and many employees have taken on additional responsibilities in response to staffing cuts. This scarcity in both time and money presents great challenges to workforce development at a critical time.
A wave of top executive retirements also has the potential to accelerate the trends of shared resources (eg, one top executive serving multiple LHDs) and agency consolidation, especially in a time of budget cuts. In several states where jurisdiction consolidation has occurred during the past decade (eg, Connecticut, New Jersey, Ohio), retirement of the top executive has been cited as a factor that facilitated these “mergers.” Sharing the costly resource of a top executive, via either shared services or agency consolidation, could be particularly beneficial for LHDs serving small populations.
Although the Profile study is not intended to assess LHDs' level of public health emergency preparedness and response (EP), the Profile questionnaire includes some items on EP-specific funding and staffing. The median amount of LHD revenue for EP activities (from all sources) reported in the 2010 Profile was $67 000 or $2 per capita, a small proportion of overall LHD funding. (For reference, median LHD revenue per capita from all sources was $44 based on 2010 Profile data.) Federal funds passed through from state health agencies are the most common funding source for LHD preparedness activities. Eighty-four percent of LHDs received preparedness funding from this source, and 59% of LHDs relied exclusively on federal funding to carry out their preparedness activities. Data from the 2010 Profile demonstrate that LHDs rely heavily on both their own non-EP staff and volunteers to respond to all-hazards events. On average, LHDs used up to 70% of staff not otherwise dedicated to EP when responding to the H1N1 influenza outbreak and 30% of staff when responding to a natural disaster. Consequently, staff cuts have reduced many LHDs' capacity to respond to emergencies. Nearly all LHDs engage volunteers for EP, most frequently from Medical Reserve Corps units, Community Emergency Response Teams, and the American Red Cross. The median number of registered volunteers ranged from 278 per 100 000 people for LHDs serving jurisdictions with populations of less than 25 000 to 37 per 100 000 people for LHDs serving jurisdictions with populations of 500 000 or more. The importance of LHDs' role in EP underscores the need for a robust preparedness and response plan and a trained workforce. Proper training of volunteers and non-EP staff is important to ensure the quality of LHDs' response to emergencies.
Access to health care services
The Patient Protection and Affordable Care Act (PPACA) of 2010 has reinvigorated the health care delivery and policy focus on prevention and health promotion rather than on sick care.3 This development will likely increase LHDs' existing interest in disease prevention through improved access to primary care in their communities. By ensuring timely and affordable access to primary care, LHDs can play a major role in preventing unnecessary suffering, death, and hospitalization costs.
The Profile study results show that, although LHDs are already involved in promoting access to care, their role can be expanded. During the 12 months prior to the 2010 survey, most LHDs actively promoted access to medical, dental, and behavioral health care services within their jurisdictions. Nearly two-thirds were involved in assessing gaps in access to 1 or more health care services. The same proportion implemented some strategies to increase accessibility of services. Two in 3 LHDs also implemented strategies to target the health care needs of underserved populations. Nearly half of the LHDs directly provided clinical care services to address the needs of underserved populations.
Improvement in public health capacity is one of the central canons of the PPACA. The PPACA includes initiatives that focus on removing barriers to accessing clinical preventative services and developing healthier communities. The Centers for Disease Control and Prevention has already announced grants for state health departments, large LHDs, and community-based organizations to improve health in their communities.3 , 4 The LHDs should prepare to seize these opportunities, which are intended to promote the goals that are also central to their mission—creating healthier communities.
Accessing Profile Information and Data
Information from the Profile studies is available in many formats, most of which can be accessed online at www.naccho.org/profile. Reports that detail the Profile studies' findings are available for all Profile studies except the 1996 Profile. Additional products that examine some issues in greater detail (eg, LHD workforce) are available for the more recent Profile studies. Many figures from the 2008 and 2010 Profile main reports are available as graphic images and PowerPoint slides, respectively, allowing users to incorporate the figures into their own presentations or reports. The Profile Web site also includes resources for researchers who wish to use the Profile data files, including copies of the instruments for each Profile study, codebooks, and an application form for obtaining Profile data. NACCHO has developed geographic information system shapefiles for LHDs in the Profile study population, which facilitates research that involves linking infrastructure data from the Profile with other kinds of data, such as indicators of community health status.
NACCHO will soon launch Profile-IQ, a Web-based data query system (available at www.naccho.org/profile) that allows users to generate selected statistics (in table, graph, or map format) on LHD finances, workforce, and activities (currently includes data from 2010 Profile only). Profile-IQ allows users to select variables, measures, subgroups for comparison, and subsets of LHDs to produce summary statistics about these topics. The NACCHO hopes that Profile-IQ will make accessing and using Profile data easier for practitioners, policymakers, students, and others.