1. Jane Suen, Dr.P.H., Kim Gadsden-Knowles, M.P.H. and Med Sohani, M.S. Centers for Disease Control and Prevention (CDC), 4770 Buford Highway, Atlanta, GA 30341 APHA 130 th Annual Meeting (Session 4109.0) Philadelphia, PA (11/12/02) Jane Suen, Dr.P.H., Kim Gadsden-Knowles, M.P.H. and Med Sohani, M.S. Centers for Disease Control and Prevention (CDC), 4770 Buford Highway, Atlanta, GA 30341 APHA 130 th Annual Meeting (Session 4109.0) Philadelphia, PA (11/12/02) Public Health Jurisdiction Capabilities: Assessment of Core Function-Related Performance Public Health Jurisdiction Capabilities: Assessment of Core Function-Related Performance

2. Objective This is to provide: National estimates of capacity of local public health jurisdictions Identification of selected determinants of performance This session presents findings of a national survey conducted between July 2000 and April 2002 using 20 indicator questions to measure overall capabilities and the three core functions of public health: assessment, policy development, and assurance.

3. Methods SURVEY DEVELOPMENT: A collaboration between the University of North Carolina and University of Illinois-Chicago investigators in 1995 (Miller, Turnock and others) led to the development of a panel of 20 questions: 6 assessment measures, 6 policy development measures, and 8 assurance measures. 1 A slightly modified set of 20 consensus questions was used in this study 2 to assess community-level public health capacity. We examined mean performance levels overall and for each of the three core public health functions (assessment, policy development, assurance) by population size and jurisdiction type. SURVEY METHOD: In 1999, the FY 1999 State Domestic Preparedness Equipment Program of the U.S. Department of Justice (DOJ) was initiated to provide grants to States for the acquisition of equipment, and included several assessments. A collaborative effort between the DOJ and the CDC resulted in the Public Health Assessment section which contained 2 surveys. The data for this study was obtained from the first survey of 20 questions, “ Overview of Capabilities of Local Public Health Jurisdiction ”. We did not include data from the second survey of public health emergency preparedness built around the 10 essential services of public health. Each local public health jurisdiction user submitted data on-line to their state central point of contact. Data was sent to DOJ, from there it was sent to CDC. In this report we removed all identifiers and only aggregated data are presented.

4. Methods DATA ANALYSIS: All analyses were conducted using SAS version 8.2 and Microsoft Excel 2000. Respondents in each jurisdiction completed the 20 question survey with a “Yes” or “No” response. The scoring methodology developed is as follows: For the mean overall score, the numerator was the number of “Yes” responses to questions 1-19 and the number of “No” responses to question 20. The denominator was the number of jurisdictions multiplied by 20 (the total number of questions). This ratio was multiplied by 100 to obtain a percent. The same methodology was applied to each of the core functions: the assessment (questions 1-6), the policy development (questions 7-12), and the assurance (questions 13- 20) with their respective denominators derived from the number of questions representing each function; and “Yes” responses for questions 1-19 and “No” response for question 20. POPULATION STUDIED: We analyzed usable data from 2,007 public health jurisdictions located in 47 states, the District of Columbia, and 4 U.S. territories (Guam, American Samoa, Northern Mariana Islands, and Puerto Rico). One state and 1 territory did not respond. Two states and 1 territory responded but were not included in the analysis as the criteria for data inclusion were not met.

5. Principal Findings We report these findings for 2,007 local public health jurisdictions: The mean overall capability score was 65.4%. The mean scores for assessment, policy development, and assurance were 66.8%, 67.4%, and 63.0%, respectively. That as the population size increased from 1-24,999 to 500,000+, the mean summary scores increased from 58.1% to 74.4%. Four jurisdiction types (City/County, County, District, and Regional) had scores in the 64.1% to 67.7% range. The City/Municipal had the lowest score of 54.8%. Although the State jurisdictional types had the highest score (75%), they comprised only 0.2% of the total population.

6. Discussion This study provides the first national profile of the capabilities and core functions of local public health jurisdictions in 47 states, the District of Columbia, and 4 U.S. territories. As a self-reported measure, the data was collected through responses to the 20 indicator questions. FUTURE CONSIDERATIONS: As this questionnaire was slightly modified, consideration should be given to reassessing reliability and validity. This would increase its utility as an instrument to monitor future improvement efforts using the national baseline data for local public health core functions measurement as reported in this study. We find that the mean summary scores increased with population size. Other potentially useful studies may be to further explore the relationships between the scores and various characteristics that affect stronger public health performance. And additionally, to relate these scores to other studies that assessed the performance of the three core functions of public health in the community.

7. Data Limitations REFERENCES: 1.Turnock BJ, Handler AS, Miller CA. Core Function-Related Local Public Health Practice Effectiveness. J Public Health Manage Practice. 1998; 4(5): 26–32. 2.Fiscal Year 1999 State Domestic Preparedness Equipment Program, Assessment and Strategy Development Tool Kit. Pub. No. NCJ181200. Washington, DC: US Dept of Justice; 1999. There were several limitations to the data. The data were self-reported and subjective. We had to develop a process to systematically clean the variables for the jurisdiction population and jurisdiction type in the demographic inventory section to correct missing and inaccurate values. There may be limitations in the interpretation of this category by the respondents.

8. Overview of Core Functions and Capabilities of Local Public Health Jurisdictions ASSESSMENT QUESTIONS 1. For the jurisdiction served by your local health department, is there a community needs assessment process that systematically describes the prevailing health status in the community? 2. In the past three years in your jurisdiction, has the local public health agency surveyed the population for behavioral risk factors? 3. For the jurisdiction served by your local health agency, are timely investigations of adverse health events, including communicable disease outbreaks and environmental health hazards, conducted on an ongoing basis? 4. Are the necessary laboratory services available to the local public health agency to support investigations of adverse health events and that meet routine diagnostic and surveillance needs? 5. For the jurisdiction served by your local public health agency, has an analysis been completed of the determinants and contributing factors of priority health needs, adequacy of existing health resources, and the population groups most impacted? 6. In the past three years in your jurisdiction, has the local public health agency conducted an analysis of age-specific participation in preventive and screening services?

9. Overview of Core Functions and Capabilities of Local Public Health Jurisdictions POLICY DEVELOPMENT QUESTIONS 7. For the jurisdiction served by your local public health agency, is there a network of support and communication relationships that includes health-related organizations, the media, and the general public? 8. In the past year in your jurisdiction, has there been a formal attempt by the local public health agency at informing elected officials about the potential public health impact of decisions under their consideration? 9. For the jurisdiction served by your local public health agency, has there been a prioritization of the community health needs that have been identified from a community needs assessment? 10. In the past years in your jurisdiction, has the local public health agency implemented community health initiatives consistent with established priorities? 11. For the jurisdiction served by your local public health agency, has a community health action plan been developed with community participation to address community health needs? 12. During the past three years in your jurisdiction, has the local public health agency developed plans to allocate resources in a manner consistent with community health action plans?

10. Overview of Core Functions and Capabilities of Local Public Health Jurisdictions ASSURANCE QUESTIONS 13. For the jurisdiction served by your local public health agency, have resources been deployed as necessary to address priority health needs identified in the community health needs assessment? 14. In the past three years in your jurisdiction, has the local public health agency conducted an organizational self-assessment? 15. For the jurisdiction served by your local public health agency, are age-specific priority health needs effectively addressed through the provision of, or linkage to appropriate services? 16. Within the past year in your jurisdiction, has the local public health agency provided reports to the media on a regular basis? 17. For the jurisdiction served by your local public health agency, have there been regular evaluations of the effects of public health services on community health status? 18. In the past three years in your jurisdiction, has the local public health agency used professionally recognized processes and outcome measures to monitor programs and to redirect resources as appropriate? 19. In your jurisdiction, is the public regularly provided with information about current health status, health care needs, positive health behaviors, and health care policy issues? 20. In the past three years in your jurisdiction, has there been an instance in which the local public health agency has failed to implement a mandated program or service?

11. Figure 1. Mean Summary Scores (%) of Local Jurisdiction, N=2,007

12. Figure 2. Mean Summary Scores (%) of Local Jurisdiction by Population Size, N=2,007* N = 836N = 419N = 290N = 350N = 108 * 4 missing

13. Figure 3. Mean Summary Scores (%) of Local Jurisdiction by Jurisdiction Type, N=2,007 N = 52N = 266N = 1,513N = 130N = 42N = 4