Several recent developments are shaping public health administrative practices and services in important ways. The public health practice community's awareness of these developments is crucial to make public health practice consistent with these desirable trends. Cross-jurisdictional sharing of resources is one example of a trend, which can help with issues of scale and scope, and it can take a variety of forms.1 More than one-half of all local health departments (LHDs) are engaged in the sharing of resources.2 , 3 Desirability of cross-jurisdictional sharing is resulting in initiatives for facilitating this important development.4 For instance, funded by the Robert Wood Johnson Foundation, the Center for Sharing Public Health Services was recently established for helping communities learn how to work across jurisdictional boundaries to deliver essential public health services.5
A focus on quality improvement (QI) is another recent development for local and state health departments, which is supported by the Public Health Accreditation Board's standards for accreditation. State health agencies (SHAs) engage in a variety of frameworks and approaches to QI. According to the 2012 Association of State and Territorial Health Officials (ASTHO) Profile of SHAs, the use of most of these frameworks increased from 2010 to 2012.6 More than two-thirds of all SHAs reported formal QI activities implemented in specific programmatic/functional areas, but not agency-wide. Similarly, 55% of LHDs have formal QI programs, most often in specific program areas.7 National initiatives such as the Community of Practice for Public Health Improvement8 and its predecessor the Multi-State Learning Collaborative,9 National Public Health Improvement Initiative,10 and Public Health Quality Improvement Exchange11 are a few examples driving the spread of QI activity at health departments.
Evidence-based public health (EBPH) is also aimed at increasing the effectiveness of public health practice in the same manner in which evidence-based medicine (EBM) has transformed the practice of medicine. The success of EBM has led to a broader adoption of evidence-based approaches in a number of fields and has fostered the development of EBPH.12 The urgency to use EBPH was noted more than 10 years ago.13 EBPH encompasses decision making based on best available scientific evidence, systematically using data and information systems, applying program planning frameworks, engaging the community in decision making, conducting sound evaluation, and disseminating what is learned.14 Harris et al15 found that LHD directors and managers were in strong agreement on the relative advantage of LHDs using evidence-based decision making. Lovelace et al16 found that workforce capacity mattered more than other resources in improving the use of EBPH practice.
Health in All Policies (HiAP) is a horizontal, complementary policy-related strategy with a high potential for contributing to population health. The HiAP approach is based on the recognition that population health is not merely a product of health sector activities, but to a large extent it is determined by living conditions and other societal and economic factors, and therefore often best influenced by policies and actions beyond the health sector.17 These developments have led to a rediscovery and revisiting of the Adelaide Recommendations on Healthy Public Policy, adopted at the Second International Conference on Health Promotion in Adelaide in 1988.18 The Institute of Medicine (recently renamed the National Academy of Medicine) has addressed the need and benefits of the HiAP approach.19 Key elements of the HiAP approach and examples of implementation from various cities are provided in a follow-up discussion article by Rudolph et al.20 HiAP is the theme for the American Public Health Association's 2015 annual meeting.
While aimed at improving effectiveness and efficiency of public health practice, the following recent developments are also shaping collaboration between the public health and health care sectors. Passed in 2010, the Patient Protection and Affordable Care Act (ACA) set out a series of payment reforms designed to curb the cost of health care, reducing the financial burden on the federal government in the short term, and creating a fiscally sustainable health care system in the long term. It requires integration of historically separate components of the public health and health care delivery sectors.21 Community health workers can support the effective implementation of the ACA.22 The CHNA needs to incorporate input from a broad range of community stakeholders. Laymon et al23 found that slightly more than half of LHDs currently collaborate with nonprofit hospitals in their community health assessments. Starfield et al24 described the evidence of the health-promoting influence of primary care and documented the association of primary care with improved health outcomes. An Institute of Medicine report was dedicated to exploring the integration of primary care and public health to improve population health, recognizing the various degrees of integration that can occur.25
Health informatics, or systematic use of information technology to improve public health administrative practices and services, is essential for public health agencies to be effective and efficient in this post–recession era. The ACA has resulted in national strategies that primarily target health care practitioners and institutions for improved use of health informatics through “meaningful use” of electronic health records. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under Title XIII of the American Recovery and Reinvestment Act of 2009, spurred the adoption and use of health IT in the United States, especially electronic health records.26 , 27 However, public health involvement is currently very limited28–30 although critical for many of the promises of HITECH to be attained.
The type of research that investigates these developments is Public Health Systems and Services Research (PHSSR), which aims to increase the scientific knowledge about how to best organize, finance, and deliver the right combinations of prevention and public health strategies across the nation's diverse demographic, socioeconomic, political, and physical landscape.31 , 32 The National Coordinating Center for PHSSR works to expand the production and application of scientific evidence on how to best organize, finance, and deliver public health strategies that improve population health.33 , 34 PHSSR data sets are available for researchers.35 Shah et al36 found that about 62% of LHDs participated in at least one research activity, and significant variation existed by size, governance type, and other organizational characteristics. The Public Health Practice-Based Research Networks program supports research networks nationwide comprising local and state governmental public health agencies, community partners, and collaborating academic research institutions.
The extent to which the public health workforce is familiar with these important developments and trends in public health is unknown. Following the “technology, organization, and environment” conceptual framework of Tornatzky37 and the Handler, Issel, and Turnock model,38 the purpose of this research is to examine the extent to which state and local public health agency workforces are familiar with important developments and trends in public health and to explore individual, institutional, organizational, and environmental factors and other relevant factors that may explain the individual-level variation in awareness of these public health trends.
We performed secondary analyses of data from the Public Health Workforce Interests and Needs Survey (PH WINS) conducted by the Association of State and Territorial Health Officials (ASTHO). This survey used a complex sampling design (described in the study by Leider et al39), with a total of 19 171 completed surveys, of which 10 246 were completed by the state central office. Since our research focused on comparison of the local and state health department employees, our analyses included those states for which representative samples for the LHD employees were also available. These selected states included Alaska, Arkansas, Delaware, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, South Dakota, Tennessee, Virginia, Vermont, Washington, Wisconsin, and Wyoming. The total number of valid responses included in our analysis for LHD and SHD employees is shown in Table 1. Additional details about the PH WINS survey methodology and statistical weights are available in the study by Leider et al.39
Operationalization of variables
Employees level of awareness about public health trends, the dependent variable for this analysis, was based on the question, “How much, if anything, have you heard about the following trends in public health?” with the 8 trends presented in Table 1 (eg, cross-jurisdictional sharing, fostering a culture of QI, leveraging electronic health information), each containing 4 response categories: nothing at all, not much, a little, and a lot. For the multivariable analysis, responses for these individual trends were converted into a scale. Before computing this awareness scale, the 4 response categories were converted into dichotomous dummy variables by coding “not at all and not much” responses as “0” and “a lot and a little” responses as “1.” Therefore, the scale had a possible value between 0 and 8, with the latter noting the highest level of awareness. Before computing the scale, factor analysis of the individual items was performed using principal component analysis, which indicated that all items loaded predominantly on a single component, with correlation coefficients ranging from 0.64 to 0.83.
Work environment of the public health agency employees was operationalized through a 20-item question with a 5-item Likert scale, strongly disagree to strongly agree. Responses for these individual items were converted into a scale, based on items relating to work environment, selected on the basis of factor analysis. The final scale included 11 items, each coded as 1 if response categories strongly agreed or agreed were selected and “0” if other response options were selected. The items included in the scale were as follows: (1) employees have sufficient training to fully utilize technology needed for their jobs; (2) my training needs are assessed; (3) communication between senior leadership and employees is good in my organization; (4) creativity and innovation are rewarded; (5) my workload is reasonable; (6) I recommend my organization as a good place to work; (7) I am satisfied that I have the opportunities to apply my talents and expertise; (8) the work I do is important; (9) I am determined to give my best effort at work every day; (10) I feel completely involved in my work; and (11) I know how my work relates to the agency's goals and priorities. Other independent variables included employee age (age ≤30, 31-40, 41-50, 51-60, ≥61 years), governance (centralized/largely centralized, shared/largely shared, decentralized/largely decentralized, mixed), whether employees are involved in academic collaboration (yes, no), education (degree) (bachelor's, master's, and doctoral; bachelor's and master's; bachelor's and doctoral; bachelor's; no bachelor's degree of any kind), gender of the employee (male, female), and supervisory status (nonsupervisor, team leader, supervisor, manager, executive).16
All analyses for this research were conducted in STATA Statistics/Data Analysis, version 13.0 (StataCorp LP, College Station, TX). To account for the complex sampling design, we used the survey commands included in STATA to produce weighted estimates using balanced repeated replication (Table 1). The number of emerging public health trends was described using frequencies and percentages. We used 2 separate negative binomial regression models (Tables 2 and 3) to analyze the association between characteristics of health department employees and the count of emerging public health trends, one for the SHA employees and the other for LHD employees. Poisson regression was inappropriate for these multivariable analyses because the analyses showed overdispersion of the dependent variable. For presenting the results of the multivariable analysis, we reported both marginal effects to highlight the direction of the effect and the incidence rate ratios (IRRs) to show unexponentiated size of association between independent variables and the number of emerging public health trends of which employees were aware. The project was approved by the institutional review board of Georgia Southern University.
PHSSR is the public health trend both local and state health department staff had heard about the least, among all 8 trends (Table 1). Only 26.6% (95% CI, 26.7-29.7) of LHD staff and 28.1% (95% CI, 25.4-27.9) of the SHA staff had heard about this trend “a little” or “a lot”. The second least heard of trend was HiAP, wherein 29.3% of staff (95% CI, 28.2-30.5) and 28.5% of SHA staff (95% CI, 27.0-30.0) were aware of this trend. In both of these trends, the CI for the LHD and SHA employees overlapped, indicating no significant differences. Roughly half of the SHA employees (95% CI, 47.5-52.1) and a significantly smaller number of LHD employees (45.6%; 95% CI, 44.3-46.9) had heard about the cross-jurisdictional sharing. Approximately 1 in 2 LHD employees (95% CI, 48.4-50.5) had heard about integration of public health and primary care, whereas a significantly higher proportion of SHA employees (56.5%; 95% CI, 54.6-58.4) had heard of this trend.
The public health trends about which the highest proportion of public health employees had heard “a little” or “a lot” were implementation of the ACA (local 79.1% and state 80.6%) and fostering a culture of QI with awareness level significantly higher (67.9%) for state employees than LHD employees (64.9%). The third most frequently known trend for state employees was EBPH; for the LHD employees it was leveraging electronic health information.
Factors associated with LHD employees' awareness regarding emerging trends
Table 2 displays adjusted coefficients of the negative binomial regression of level of LHD employees' awareness of emerging public health trends, measured as the number of public health trends employees had heard of “a lot or a little” as opposed to “not at all or not much.” Work environment was among the most influential variables associated with a higher awareness level (adjusted IRR = 1.04; P = .000). In other words, LHD employees had higher levels of awareness of public health trends in instances in which work environment was considered positive according to characteristics stated in the Methods section.
Supervisory status of employees was also significantly associated with a higher level of awareness about emerging public health trends. Compared with nonsupervisory staff, employees in executive positions were 1.4 times more likely to be aware of an additional trend than nonsupervisory staff (adjusted IRR = 1.4; P = .000; 95% CI, 1.31-1.49). Team leaders, supervisors, and managers were also significantly more likely to have heard about a greater number of emerging public health trends than nonsupervisory staff (P = .000 for all supervisory categories). Employee education was significantly associated with awareness about these trends. Compared with employees who had all 3 degrees (doctoral, master's, and bachelor's), those with a combination of bachelor's and doctoral degrees together, or a bachelor's degree alone, or less than a bachelor's degree education, had heard of a significantly fewer number of emerging public health trends. Level of awareness of emerging public health trends was significantly higher for younger employees (age ≤30 years) than for those aged 31 to 40 years (for age 31-40: IRR = 0.90; P = .001; 95% CI, 0.86-0.96). Female employees of LHDs were significantly more likely to be aware of the trends than male employees (IRR = 1.166; P = .000; 95% CI, 1.087-1.251).
Factors associated with SHA employees' awareness of emerging trends
Table 3 shows factors associated with SHA employees' awareness of emerging public health trends. These factors had a similar association with the level of LHD employees' awareness about the emerging public health trends, with 2 exceptions: the type of state-level governance of public health agencies was relatively more significantly impactful for the SHA staff than for the LHD staff and the relationship to age was not significant for state employees. For SHA employees, work environment scale was among the strongest correlate of higher awareness level (P = .000). Supervisory status of employees was also significantly associated with higher level of awareness for state employees with 1 difference. A team leader in an SHA did not have a significantly different level of awareness than did nonsupervisory staff. In comparison with nonsupervisory staff, likelihood of having higher awareness level about the emerging public health trends was significantly higher among employees who were supervisors (IRR = 1.058; P = .046), manager (IRR = 1.114; P = .016), and executives (IRR = 1.278; P = .000). For state employees, influence of education was not significant for all education-level combinations. Compared with employees who had all 3 degrees (doctoral, master's, and bachelor's), those with a bachelor's degree alone (IRR = 0.814; P = .000), and those with less than a bachelor's degree (IRR = 0.727; P = .000) had heard about significantly fewer emerging public health trends. Like LHD employees, female employees of state public health agencies were also significantly more likely than male employees to have heard of these trends (IRR = 1.116; P = .000).
Discussion and Conclusion
Health departments are operating in the post–recession, post–Public Health Accreditation Board accreditation era,40 , 41 while trying to be efficient through improved administrative practices and proficient delivery of essential public health services. Knowledge about emerging public health developments is likely to be helpful to public health agencies in their quest to provide best services in face of limited budgets and reduced staff capacities. Our study showed the poorest levels of awareness about PHSSR among local and state health department employees alike. While Shah et al36 showed that 62% of LHDs participated in at least 1 research activity, the results of this research indicate that practitioners may not know if the research they participated in falls under the umbrella of PHSSR or is called PHSSR. A potential disconnect might exist between PHSSR findings and the ability to implement practice-based research findings to actually help improve public health practice.
For 2 trends, ACA and QI, we observed the highest overall awareness, indicating that the impact of the national dialogue was directly tied to practitioner involvement in that initiative. Studies of LHDs have shown that more than half of respondents have formal QI activities.42 Furthermore, awareness may be linked to the growing national movement toward voluntary public health department accreditation (specifically domain 9). Accreditation may be the pivotal factor to strengthen QI practice.43 Also, QI support and accreditation support have been funded by national partner organizations. There is evidence that health departments are witnessing reductions in client volume for some public health programs, such as immunizations and breast and cervical cancer screening, which are believed to be an effect of implementation of the ACA.44 These finding suggest how practitioners' daily work may be influenced by the ACA, thus contributing to their higher awareness of that particular development in the field.
Our findings about cross-jurisdictional sharing showed that roughly half of respondents are aware of cross-jurisdictional sharing. This is consistent with the findings that one-half of LHDs engage in sharing of resources.2 Our study found that EBPH was the third most well-known trend among LHDs and fourth by SHAs, which is really encouraging. Harris et al15 found that LHD directors and managers were in strong agreement on the relative advantage of LHDs using evidence-based decision making, which supports more than half knowing about EBPH. Leveraging electronic health information is important in that LHD informatics capacity can assist with care coordination, assess immunization completion rates, and perform electronic syndromic surveillance to detect influenza-like illnesses, bioterrorism events, and food-borne illness.45 Informatics capacity also cuts across many emerging trends. For instance, the ACA fosters partnerships of eligible providers and hospitals with LHDs for compliance with specific federal standards for meaningfully information, thus promoting integration of public health and health care.46 Our findings about relatively lower overall awareness of public health emerging trends among employees of LHDs (vs SHAs) is noteworthy, perhaps indicating the effect of resource availability and scale of operations. It might also imply that policies for getting improved awareness of these trends should particularly focus on LHD employees. In addition, it is encouraging to note that general awareness of trends among individuals with supervisory status was higher than those individuals not in a supervisory role. Efforts to enhance the awareness of these trends by frontline staff should be considered.
Findings about work environment being associated with higher levels of awareness of these emerging trends point to opportunities for changes in work environment. Examples of work environment included having met employees' training needs, having open communications, rewarding innovation, having employees' report feeling that one's work is important, and having employees report feeling that their work relates to the agency's goals and priorities. Academic collaboration is associated with higher awareness levels, which is aligned with the model on which Practice-Based Research Networks operate.47
Future studies can help address several aspects of the research. Further investigation of linkage between greater awareness of emerging public health trends and the manner and extent to which it affects public health performance might be useful. Inability to establish this linkage is also a limitation of this research, as it is not known if familiarity is related to implementation or application of this development in some way. Furthermore, the limiting of sampling for LHDs creates challenges for broader generalization. Further investigation is also needed to understand why some trends are relevant to practitioners and others not. It will also be important to understand the drivers of awareness and what role such awareness plays on an organization's ability to perform well and carry out essential services.
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Keywords:Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Patient Protection and Affordable Care Act; cross-jurisdictional sharing; electronic health information; evidence-based public health practice; Health in All Policies (HiAP); PHSSR; primary care; quality improvement