Hypertension is a leading risk factor for cardiovascular disease and a significant contributor to preventable morbidity, mortality, and health care delivery system costs in the United States. According to the National Center for Health Statistics (NCHS), hypertension was a primary or contributing cause to more than 670 000 deaths nationwide in 2020.1 While the overall prevalence of hypertension among US adults is estimated at 45.4%, significant disparities exist among geographic regions, racial and ethnic groups, and socioeconomic status levels.2,3 Serious sequelae of uncontrolled hypertension, including heart disease and stroke, are also inequitably distributed nationwide.4
Like many other chronic conditions, hypertension-associated morbidity and mortality can be mitigated at multiple levels of prevention. Chronic disease prevention is widely recognized as a foundational public health service informing the activities of local health departments (LHDs).5 The role of LHDs in chronic disease prevention frequently includes access to secondary prevention via screenings. According to nationally representative survey data collected by the National Association of County and City Health Officials (NACCHO), blood pressure (BP) screening is a common LHD function, endorsed by 54% of LHDs nationwide in 2016 and 59% in 2019.6
For most LHDs, routine services—including BP screening and other chronic disease prevention work—were interrupted during the initial public health emergency response to the COVID-19 pandemic. Reasons for routine service interruptions included facility closures, local stay-at-home orders, and the reassignment of LHD staff from their usual duties to support the pandemic response workflow.
These changes to LHD service provision and staffing have occurred against the backdrop of an evolving and increasingly inequitable chronic disease risk environment. Since the spring of 2020, lifestyle disruptions have contributed to changes in health behaviors for many US individuals and communities. Individual-level risk factors associated with altered physical activity, diet, and substance use patterns are well documented7 and have often been compounded by economic hardships, caregiving duties, grief, and other stressors. Health care system access and utilization patterns have changed as well, including delayed preventive care, interrupted medication access, loss of insurance coverage, and other barriers to clinical care have been widespread.8 Recognizing that the burden of these and other risk factors will affect certain populations more severely than others, some LHDs launched or prioritized initiatives targeted to people with chronic conditions during service disruptions.
NACCHO's Forces of Change (FoC) survey is a periodic survey fielded to a sample of LHDs across the United States to assess changes in LHD capacity driven by trends in public health. The 2020 FoC survey focused on impacts to LHD infrastructure in the context of the COVID-19 pandemic. The survey was administered electronically through Qualtrics9 and was distributed to a population of 2392 LHDs. All LHDs in the study population received a common core set of questions from November 2020 to March 2021 (n = 583; response rate = 24%). In addition to the core questionnaire sent to the population of LHDs, a stratified random sample of 905 LHDs was invited to complete a module questionnaire on topics such as pandemic preparedness, recovery, and equity, with strata defined by the size of the population served by the LHD (n = 237; response rate = 26%).
Statistics were computed using poststratification weights to adjust for oversampling and nonresponses by jurisdiction size proportionate to their distribution in the United States. This analysis provides national estimates for all LHDs in the United States by using weighted survey results based on the size of population served.
A majority of LHDs responding to the 2020 FoC survey reported a reduction in 1 or more routine public health services during the COVID-19 emergency response.10 Of the LHDs that reported having provided BP screening services at any time during calendar year 2019, more than two-thirds (67.2%) indicated that these services were reduced during the pandemic response, and only 1.4% reported that they had expanded screening services. In contrast, in NACCHO's 2019 National Profile of Local Health Departments survey, only 7.3% LHDs had reported reductions in BP screening between calendar years 2017 and 2018, while 13.8% had expanded these services.6
Reductions in BP screening services were reported more frequently by LHDs serving large populations (populations >500 000; 85.9%) than by those serving small (<50 000) and medium (50 000-500 000) populations (67.2% and 63.9%, respectively). State-governed LHDs (36.2%) were less likely to report BP screening service reductions than LHDs with shared or local governance structure (89.6% and 75.4%, respectively) (Table).
BP Screening Service Changes, Reassignment of Chronic Disease Prevention Staff, and LHDs That Prioritized Chronic Care Initiatives as Reported in Forces of Change 2020
||LHDs That Provided BP Screening Services at Any Time in Calendar Year 2019 (n = 202)
||LHDs That Reduced BP Screening Services During the COVID-19 Pandemic Responsea (n = 116)
||LHDs That Reassigned Chronic Disease Prevention During Pandemic Responseb (n = 513)
||LHDs Prioritizing Initiatives for People With Chronic Conditions During COVID-19 Service Disruptionsc (n = 225)
|50 000-499 999
|Type of governance
Abbreviations: BP blood pressure; LHD, local health department.
aLHDs selecting response option “Reduced services” to question: “Between the start of our COVID-19 response and today, my LHD....” This response option was available only to LHDs reporting that they had provided BP screening at any time in calendar year 2019.
bLHDs selecting response option “Chronic disease” to question: “From which of the following program areas have staff been reassigned from their regular duties to perform duties in support of your LHD's COVID-19 response?”
cLHDs selecting response option “Clinical care for people with chronic conditions during service disruptions” to question: “Please indicate if your LHD has prioritized or developed targeted initiatives to address these issues at any time between the start of your COVID-19 response and today.”
A significant factor in the reduction in services may have been the reassignment of staff. In 2020, 4 in 5 (82%) LHDs reassigned staff from normal duties to support COVID-19 response activities. More than 2 in 5 LHDs (43%) reported reassigning chronic disease staff to perform duties in support to the COVID-19 response. This differed by population size served (Table): 81.9% of LHDs serving large populations reassigned chronic disease staff, compared with 32.7% of LHDs serving small populations.
In response to a question about targeted initiatives to address population health issues exacerbated by the pandemic, only 1 in 5 LHDs (20%) endorsed “clinical care for people with chronic conditions during service disruptions” as a priority. Commitment to targeted clinical care initiatives did not vary greatly by LHDs' population size, type of governance, or Census region (Table).
A majority of LHDs reduced BP screening services during the COVID-19 pandemic response. Higher rates of pandemic-associated service reductions were observed among LHDs serving large populations and LHDs with state or shared governance structure.
Most LHDs did not name people with chronic conditions as a priority issue to address via targeted initiatives during the 2020-2021 pandemic response. This may have been due to competing public health priorities, limited funding, or lack of staff capacity or because other stakeholders in the community were perceived as filling this gap.
BP screening is only one component of LHD chronic disease prevention programming, which may also include primary prevention activities (eg, health promotion and community education activities, advocacy for healthier built environments) and facilitating access to medical care for community members living with chronic conditions.
Given the inequitable impact that the COVID-19 pandemic has made on cardiovascular health risks and outcomes in the United States, an equity-focused approach is recommended for LHDs looking to continue, relaunch, or start new BP screening programs as part of their chronic disease prevention strategies. LHDs should utilize existing community-level data to assess the distribution of risk factors, protective factors, and pertinent outcomes. Geospatial data analysis tools such as the Centers for Disease Control and Prevention's PLACES project11 and the Interactive Atlas of Heart Disease and Stroke12 can help LHDs as they plan where, when, and how to deliver screening services. These data should be supplemented with both quantitative and qualitative data from key stakeholders, including community members, medical providers, local government, and community-based organizations. LHDs should also recognize the syndemic nature of behavioral health issues and chronic disease, forming interdisciplinary partnerships and working as an integrated health promotion and care delivery system.
LHDs are uniquely positioned to address the chronic disease health debt introduced by the COVID-19 pandemic due to their knowledge of local contexts, relationships with key stakeholders, and capacity to provide or facilitate access to low-barrier preventive care to the community.
The present analysis is not without limitations. Survey data were self-reported and were not verified independently by NACCHO. In addition, NACCHO's FoC is a cross-sectional survey reflecting a point in time; LHDs may have revised their priorities and established programming since completing this survey. Finally, nonresponse bias may impact the results presented here, due to a low response rate during the COVID-19 public health emergency response.
Directions for future work
As LHDs enact pandemic recovery plans, many will resume or initiate BP screening and other chronic disease screening programs. Whether service provision will return to pre-2020 frequencies will depend on local priorities, as well as LHD funding levels and workforce capacity. Analysts of future LHD surveys should examine the associations of service provision with workforce and budget indicators, with community-level indicators of the social determinants, and with indicators of relevant population health outcomes.
1. Centers for Disease Control and Prevention, National Center for Health Statistics. About Multiple Cause of Death, 1999-2020. CDC WONDER. Atlanta, GA: Centers for Disease Control and Prevention; 2022. https://wonder.cdc.gov/mcd-icd10.html
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2. Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension Prevalence Among Adults Aged 18 and Over: United States, 2017-2018. Hyattsville, MD: National Center for Health Statistics; 2020. NCHS Data Brief No. 364. https://www.cdc.gov/nchs/products/databriefs/db364.htm
. Accessed September 26, 2022.
3. Commodore-Mensah Y, Turkson-Ocran RA, Foti K, Cooper LA, Himmelfarb CD. Associations between social determinants and hypertension, stage 2 hypertension, and controlled blood pressure among men and women in the United States. Am J Hypertens. 2021;34:707–717.
4. Wadhera RK, Figueroa JF, Rodriguez F, et al. Racial and ethnic disparities in heart and cerebrovascular disease deaths during the COVID-19 pandemic in the United States. Circulation. 2022;143(24):2346–2354.
5. The Public Health National Center for Innovations. Foundational Public Health Services [issue brief]. https://phnci.org/uploads/resource-files/FPHS-Factsheet-2022.pdf
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8. Ruth L, Alongi J, Robitscher J. Confronting the health debt: the impact of COVID-19 on chronic disease prevention and management. Health Affairs Blog. Posted 2021. https://www.healthaffairs.org/do/10.1377/forefront.20210914.220940
. Accessed September 28, 2022.
9. Qualtrics [Computer software]. Version May 2022. Provo, UT: Qualtrics; 2005.
10. NACCHO. Forces of Change 2020: the COVID-19 edition. https://www.naccho.org/uploads/downloadable-resources/2020-Forces-of-Change-The-COVID-19-Edition.pdf
. Published 2022. Accessed September 28, 2022.
11. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. PLACES: local data for better health. https://www.cdc.gov/places/index.html
. Published 2022. Accessed October 3, 2022.
12. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. Interactive Atlas of Heart Disease and Stroke. https://www.cdc.gov/dhdsp/maps/atlas/index.htm
. Published 2020. Accessed October 3, 2022.