The National Profile of Local Health Departments (Profile) study is the only survey of its kind that collects information on local health department (LHD) infrastructure and practice at the national level. Several characteristics of the study make Profile uniquely valuable to LHDs, policy makers, public health researchers, and the public health community at large. First, the Profile questionnaire is distributed to every LHD in the United States (not a sample), so it provides the most complete picture of local public health. Second, the National Association of County & City Health Officials (NACCHO) has collected data on LHD jurisdictions, finances, workforce, and activities 8 times starting in 1989. These data are used to track how LHD infrastructure and practices have changed over time. Third, Profile adds questions over time to assess emerging and crosscutting areas such as informatics, accreditation, and policy development. Finally, the Profile study captures information on many topics that represent the diversity of public health, making the Profile data one of the most important and frequently used data sets in the field of public health systems and services research. The purpose of this article was to demonstrate how LHD infrastructure and practice have changed over time by presenting select findings from the most recent Profile study.
The Profile study defines an LHD 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 2016 Profile survey was administered from January to April 2016. All 2533 LHDs in the study population received the core questionnaire, and 2 groups of randomly selected LHDs received one of the 2 sets of supplemental questions (or modules). The overall response rate for the 2016 Profile was 76%.
Nationally representative statistics using estimation weights to account for sampling and nonresponse were generated using Stata 14 to provide descriptive statistics for all respondents and by LHD characteristics, including size of population served by the LHD (small, <50 000 people; medium, 50 000-499 999 people; large, ≥500 000 people).
Size of LHD workforce
NACCHO has documented numbers of jobs lost by LHDs in its Job Loss and Program Cuts1 and Forces of Change2 surveys. The Profile data can be used to generate estimates of the size of the LHD workforce nationwide. Comparing these statistics from several Profile studies shows the net change over time in the size of the LHD workforce (accounting for both jobs lost and jobs added). Figure 1 illustrates the decline in the size of the LHD workforce from its prerecession size of 190 000 employees to an estimated size of 147 000 employees in early 2016. This is a loss of 43 000 employees, representing 22% of the LHD workforce in 2008. In per capita terms, the workforce capacity of LHDs in the United States decreased from 5.3 to 4.2 full-time equivalent (FTE) per 10 000 people. The annual job loss and gain statistics from the 2016 Profile offer hope that the decline may have ceased. LHDs reported more jobs gained than lost in 2015, although the net gain was only 850 jobs. In previous NACCHO surveys dating back to 2008, the numbers of jobs lost always exceeded the numbers of jobs gained.3
Tenure of top executive
Strong and sustainable leadership is becoming even more critical for LHDs, as these organizations adapt into the role of “community chief health strategist.”4 As the LHD top executive is the face of the LHD, he or she must develop the broad range of skills required to lead the organization for this role and making the necessary connections within the community. These efforts take years to develop and implement. In contrast to the relatively short average tenure of a state health official at nearly 4 years,5 the average tenure of an LHD top executive remained stable at nearly 9 years between 2008 and 2013. However, in 2016, the average tenure for all top executives decreased to 7.5 years. Data from the 2016 Profile on top executive tenure (not shown) show that 28% of LHD top executives had held their positions for 2 years or less compared with 20% in 2013. The decrease in top executive tenure generates an increased need for training and mentoring programs that will help upcoming LHD leaders strengthen the skills they need to be effective as they transition into their new role (Figure 2).
Changes in LHD services
The Profile study collects data on which LHDs provide a list of 87 public health services and activities. This is a high-level metric (whether or not an LHD provides that service) that does not measure the scale or scope of a service or activity. Nonetheless, Profile data can document major changes in the service mix of LHDs, which reflect the changing roles of LHDs in many communities. The Table shows that many LHDs have increased their capacity to be a source of health information for their communities. Between 2008 and 2016, the percentages of LHDs providing syndromic, behavioral risk, chronic disease, and environmental surveillance increased by at least 10 percentage points. These data also show that some LHDs are no longer providing a number of health screening programs (including high blood pressure, diabetes, cardiovascular disease, and cancer screenings). In many cases, LHDs made strategic decisions to discontinue these services and refer clients to other health care providers (such as community health centers). In some cases, these decisions were driven by budget considerations.
Completion of PHAB accreditation prerequisites
The Public Health Accreditation Board (PHAB) was formed in 2007 to create standards and a process for voluntary accreditation of public health agencies, with an overarching goal of improving and protecting the health of the public.6 PHAB launched the accreditation process in 2011. To be nationally accredited, LHDs must provide documentation of completing a community health assessment (CHA), developing a community health improvement plan (CHIP), and developing an agency-wide strategic plan (SP) within the past 5 years.7
The Profile study has collected data on LHDs' participation in these activities for more than a decade, allowing us to compare levels of participation before and after the establishment of these standards and the launch of the national accreditation process (Figure 3). In 2016, 78% of all LHDs completed a CHA, an 18 percentage point increase in activity since 2010. Two-thirds of all LHDs completed a CHIP (67%), a 16 percentage point increase since 2010. Approximately half of all LHDs completed an SP (53%), a 22 percentage point increase since 2010. Thus, the number of LHDs meeting these prerequisites for accreditation more than doubled during this 6-year period. In 2016, 44% of all LHDs completed all 3 processes within the past 5 years compared with the 20% that completed these activities prior to the launch of PHAB's accreditation process.
Local public health practice has undergone many changes in the past decade, adapting to changes in the economy, demographics, health care systems, new initiatives (such as accreditation), and community needs. Without a regular and well-conducted survey, we cannot reliably confirm anecdotal observations about change, nor can we understand how trends differ among LHDs serving different jurisdiction sizes, with different levels of funding, or in different parts of the country.
In addition to serving as a surveillance system for LHD infrastructure and practice, Profile also provides data for research that explores the relationships between public health systems and services and health outcomes in the community. Since 2008, NACCHO has provided Profile data for 176 public health research studies. Making Profile data available to researchers reduces survey burden on busy LHD staff, who do not need to repeatedly provide these basic data that are needed for many studies.
NACCHO uses Profile data to educate policy makers about LHDs and the challenges and opportunities facing them. Information on LHD trends provided through the Profile survey also helps NACCHO develop or advocate for programs that are responsive to the changing needs of LHDs.
1. Ye J, Leep C, Newman S. Reductions of budgets, staffing, and programs among local health departments: results from NACCHO's economic surveillance surveys, 2009-2013. J Public Health Manag Pract. 2015;21(2):126–133.
2. Newman S, Ye J, Leep C, Hasbrouck L, Zometa C. Assessment of staffing, services, and partnerships of local health departments—United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(24):646–649.
3. National Association of County and City Health Officials. 2016 National Profile of Local Health Departments. http://nacchoprofilestudy.org/reports-publications/2016_national_profile. Manuscript in preparation.
4. National Association of County & City Health Officials. Statement of policy: community health strategist. http://http://www.naccho.org
/uploads/downloadable-resources/16-02-Community-Health-Strategist.pdf. Published 2015. Accessed October 31, 2016.
5. Association of State and Territorial Health Officials. Profile of State Public Health. Volume 3. Arlington, VA: Association of State and Territorial Health Officials; 2014.
6. Institute of Medicine. The Future of the Public's Health in the 21st Century. Washington, DC: National Academies Press; 2003.
7. Bender K, Kronstadt J, Wilcox R, Lee TP. Overview of the Public Health Accreditation Board. J Public Health Manag Pract. 2014;20(1):4–6.