Objectives. To investigate differences in funding and service delivery between rural and urban local health departments (LHDs) in the United States. Methods. In this repeated cross-sectional study, we examined rural–urban differences in funding and service provision among LHDs over time using 2010 and 2016 National Association of County and City Health Officials data. Results. Local revenue among urban LHDs (41.2%) was higher than that in large rural (31.3%) and small rural LHDs (31.2%; P < .05). Small (20.9%) and large rural LHDs (19.8%) reported greater reliance on revenue from Center for Medicare and Medicaid Services than urban LHDs (11.5%; P < .05). All experienced decreases in clinical revenue between 2010 and 2016. Urban LHDs provided less primary care services in 2016; rural LHDs provided more mental health and substance abuse services (P < .05). Conclusions. Urban LHDs generated more revenues from local sources, and rural LHDs generated more from the Center for Medicare and Medicaid Services and clinical services. Rural LHDs tended to provide more clinical services. Given rural LHDs’ reliance on clinical revenue, decreases in clinical services could have disproportionate effects on them. Public Health Implications. Differences in financing and service delivery by rurality have an impact on the communities. Rural LHDs rely more heavily on state and federal dollars, which are vulnerable to changes in state and national health policy.

background: Rural communities face numerous health disparities related to health behaviors, health outcomes, and access to medical care. LHDs serving rural communities have fewer resources to meet their community needs. The number and types of community organizations (hospitals, health clinics, not-for-profits), available to partner with may be limited geographically. These factors may affect availability of clinical services in rural communities. This study will assess LHD clinical service delivery levels based on rurality. data sets and sources: Data were obtained from the NACCHO 2013 National Profile of Local Health Departments Study. LHDs were coded as “urban”, “micropolitan”, or “rural” based on Rural/Urban Commuting Area (RUCA) Both “micropolitan” and “rural” categories are considered rural by the Federal Office of Rural Health Policy. analysis: Bivariate analysis for 25 clinical services offered by rurality . For each service, we compared the proportions of LHDs that: 1) directly performed, 2) contracted with organizations, and 3) reported that the service was provided independently by organizations in the community. principal findings: Analyses show significant differences in patterns of clinical services offered, contracted or provided by third parties based on rurality. LHDs in micropolitan areas provided more services directly than urban and rural LHDs (p≤0.001). Urban LHDs were more likely to contract with other organizations (p≤0.001). conclusions: Rural LHDs are less likely to offer, contract, or have services provided by another organization in the community, whereas larger rural (i.e., micropolitan) jurisdictions are more likely to directly provide these services. implications for public health practice and policy: Lower levels of clinical service delivery by rural LHDs may contribute to the access issues facing rural communities. Health care reform brings threats and opportunities for LHD clinical service delivery. Further analyses to assess impacts on rural LHDs and identify strategies to ensure access to clinical services is encouraged.

Background: Engagement in the core public health functions and ten essential services remains the standard for measuring local health department (LHD) performance; their role as providers of clinical services remains uncertain, particularly in rural and underserved communities. Purpose: To examine the role of LHDs as clinical service providers and how this role varies among rural and nonrural communities. Methods: The 2013 National Association of County and City Health Officials (NACCHO) Profile was used to examine the geographic distribution of clinical service provision among LHDs. LHDs were coded as urban, large rural, or small rural based on Rural/Urban Commuting Area codes. Bivariate analysis for clinical services was conducted by rural/urban status. For each service, the proportions of LHDs that directly performed the service, contracted with other organizations to provide the service, or reported provision of the service by independent organizations in the community was compared. Results: Analyses show significant differences in patterns of clinical services offered, contracted, or provided by others, based on rurality. LHDs serving rural communities, especially large rural LHDs, tend to provide more direct services than urban LHDs. Among rural LHDs, larger rural LHDs provided a broader array of services and reported more community capacity for delivery than small rural LHDs- particularly maternal and child health services. Implications: There are capacity differences between large and small rural LHDs. Limited capacity within small rural LHDs may result in providing less services, regardless of the availability of other providers within their communities. These findings provide valuable information on clinical service provision among LHDs, particularly in rural and underserved communities.

The purpose of this investigation was to examine the directional relationship between practicing school counselors' level of professional quality of life and self-efficacy to their programmatic service delivery activities. This investigation tested the theoretical model that practicing school counselors' level of professional quality of life (as measured by the Professional Quality of Life Scale [ProQOLs; Stamm, 2010]) and their self-efficacy (as measured by the School Counselor Self-Efficacy Scale [SCSEs; Bodenhorn & Skaggs, 2005]) contributes to their service delivery activity (as measured by the School Counselor Activity Rating Scale [SCARS; Scarborough, 2005]). Specifically, this study examined the hypothesized directional relationship that school counselors who have higher ProQOL scores (e.g., less burnout and compassion fatigue and higher compassion satisfaction) and higher self-efficacy scores (e.g., more confident about counseling skills) have increased levels of programmatic service delivery facilitation (e.g., they provide high levels of school counseling activities for students and stakeholders). In addition, this investigation examined the relationship between practicing school counselors' demographic factors and the constructs of professional quality of life, self-efficacy, and programmatic service delivery. Furthermore, the investigation examined the difference in response rate and school counselors' total mean score (as measured by the ProQOLs, SCSEs, and SCARS) based upon the: (a) sampling method (e.g., email web-based, paper-pencil mail-out survey, face-to-face survey administration), (b) token incentive type (e.g., monetary [$1.00, $2.00, or no incentive] or non-monetary [$1.00 donation to the American Red Cross or no donation]), and (c) sampling population (e.g., ASCA dataset or Common Core Dataset)? A review of the literature is presented, which provides conceptual theory and empirical research to support the constructs and their hypothesized relationship. A descriptive, correlational research design was employed to investigate the research hypothesis and exploratory research questions. The data was collected through diverse survey methodologies (e.g., email web-based, paper-pencil mail-out survey, face-to-face survey administration). The research hypothesis was tested through the utilization of structural equation modeling (SEM). In addition, multiple linear regression, spearmen rho correlation, Mann-Whitney U tests, Kruscal-Wallis H tests, and Chi Square tests of independence were used to analyze the data for the exploratory questions. The results of the investigation are presented and compared to current literature and prior research. Additionally, the limitations of the study are discussed and recommendations for future research are presented. Last, implications from this investigation are discussed in regards to practicing school counselors, school counselor educators, and school counseling researchers. The sample size for this investigation was 690 with 577 used for the data analysis after data cleaning. The results of the SEM analyses identified that practicing school counselors' professional quality of life contributed to their programmatic service delivery (1.21% of the variance explained). In addition, the results identified that practicing school counselors' self-efficacy contributed to their programmatic service delivery (34.81% of the variance explained). Furthermore, the analysis indicated that the covariance between professional quality of life and self-efficacy accounted for 26% of the shared variance between these two constructs of interest. Implications of the findings from the study include (a) school counselors' self-efficacy contributes to their programmatic service delivery (large effect size), (b) school counselors' professional quality of life and self-efficacy contribute to one another (medium to large effect size), and (c) school counselors' professional quality of life contributes to their service delivery (small effect size). Additionally, this study provides implications in regards to: (a) the psychometric properties of the ProQOLs, SCSEs, and SCARS with a national sample of practicing school counselors and (b) research methodology related to differences in school counselors' response rates and total mean score on the ProQOLs, SCSEs, and SCARS based upon the sampling method, incentive type, and sampling population.

Professional School Counselors (PSCs) have been called to be leaders for educational reform to support the academic, career, and personal/social development of all students through the coordination and facilitation of their comprehensive, developmental school counseling program (American School Counselor Association , 2005; National Model). The primary purpose of this study was to investigate the contributions of PSCs' values and leadership practices to their programmatic service delivery (counseling, coordinating, consulting, and curriculum). The three constructs and instruments investigated in this study were: (a) Schwartz Value Theory (the Schwartz Value Survey ; Schwartz, 1992), (b) the Leadership Challenge Theory (the Leadership Practices Inventory ; Posner & Kouzes, 1988), and (c) school counselors' programmatic service delivery (the School Counselors Activity Rating Scale ; Scarborough, 2005). The findings of this study contribute to the school counseling, counselor education, and leadership literature. The sample size for this study was 249 certified, practicing school counselors (elementary school, n = 83; middle school, n = 76; high school, n = 74; multi-level, n = 8) in the state of Florida (35% response rate). The participants completed an on-line surveys including a general demographic questionnaire, the SVS (Schwartz, 1992), the LPI (Posner & Kouzes, 1988), and the SCARS (Scarborough, 2005). The statistical procedures used to analyze the data included (a) structural equation modeling (path Analysis), (b) confirmatory factor analysis, (c) simultaneous multiple regression, (d) Pearson product-moment (2-tailed), and (e) Analysis of variance (ANOVA). The primary research hypothesis for the study was that practicing school counselors' values and leadership practice scores would contribute to their levels of programmatic service delivery. The statistical analyses of these data identified several significant findings. The path analysis models testing the contribution of school counselors' values and leadership practices on their service delivery did fit for these data. Specifically, the results indicated that values contributed minimally to the model fit (less than 1%); however, leadership practices made a significant contribution (39%) to the school counselors' service delivery. Additionally, 31% of the participants reported that their current school counseling program was consistent with how they perceive a successful school counseling program should be implemented, yet only 29% of the school counselors reported feeling comfortable in challenging their involvement in non-counseling related duties. Further, although these data indicated that the majority of the school counselors valued self-transcendence (accepting of rules and appreciating others); structural equation modification re-specification procedures revealed that the model fit supported the value type, self-enhancement (self-direction and personal success) as a more significant contributor in promoting leadership practices and effective service delivery. Implications for professional school counseling and counselor education are presented, along with areas for future investigation.

Grandfamilies, or families in which grandparents are raising their grandchildren, often form due to adverse childhood experiences (ACEs) experienced by the grandchildren. ACEs have been linked to multiple negative short- and long-term behavioral and emotional consequences for children. Yet, having an ACE history does not guarantee negative outcomes, as protective factors such as positive relationships with a safe and caring adult, healthy family functioning, and utilization of formal services can mitigate the negative effects of ACEs. Researchers have regularly called on families to seek timely intervention and services for ACEs; however, many grandparents raising grandchildren report negative interactions with service providers as well as service delivery. Limited research has explored the extent to which grandfamilies with ACEs may have experienced similar interactions while seeking and using formal services. Guided by Andersen's (1995) Behavioral Model of Health Service Use, this qualitative study sought to explore (1) the service needs of grandchildren with an ACE history who are being raised by their grandparents; (2) the service needs of grandparents raising grandchildren with an ACE history; (3) the process of seeking services when grandparents raising a grandchild with an ACE history look for services for their grandchild; and (4) best practices for delivering services to grandfamilies with an ACE history. The research questions were primarily addressed through via interviewing 10 grandparents from Central Appalachia who were raising a grandchild with an ACE history and by conducting two focus groups of 8 to 12 formal service providers with experience working with grandparents raising grandchildren with an ACE history. Interview data were analyzed using grounded theory and focus group data were analyzed through thematic analysis. Study findings indicated that grandchildren have emotional and developmental needs. Grandparents described needs related to the emotional impact of raising a grandchild with an ACE history, family and parent involvement, and parenting a grandchild with an ACE history. Study results also highlighted how grandparents can expect to encounter barriers throughout the service seeking and delivery process. Study results also highlighted the critical nature of having a strong relationship with a service provider and the importance of a service provider reducing barriers, being attentive to grandfamily needs, and involving the grandparent in the treatment process. Finally, results from the focus groups revealed best practices such as providing grandparents with education on ACEs, being aware of intergenerational ACE cycles, and engaging in assessment and intervention when working with this population. Implications for clinical practice as well as directions for future research are discussed. / Doctor of Philosophy / Historically, grandparents have long been called upon to assist with caring for their grandchildren. In the last forty years, grandparents have increasingly shifted to a new role—that of parent. Grandfamilies are commonly created due to adverse childhood experiences, or ACEs, which can include child abuse, child neglect, or household challenges such as parental substance abuse or parental incarceration. Experiencing ACEs does not guarantee negative outcomes in a child's life, but their presence and number can affect it, particularly when a child has experienced numerous ACEs. Professional services or treatment are one way to support these children. However, negative interactions with service providers or unfulfilled expectations with service delivery can dissuade grandparents from continuing services. This study sought to understand how grandparents raising a grandchild with an ACE history identify the grandchild's needs, come to the realization that their grandchild needs professional help, the process and experience of receiving that professional help, as well as what happened after the grandchild received professional services. After interviewing 10 grandparents raising a grandchild with an ACE history, study findings revealed how grandparents identify grandchild needs, and then manage those needs as well as grandchild behaviors. Study findings also illustrated a recursive relationship between grandparents managing grandchild needs and building a relationship of trust with the formal service provider once services have started. Building a relationship of trust with a formal service provider can then result in creating change or the grandparent deciding to end services. Finally, grandparent interview data revealed that throughout the entire process of service seeking, grandparents raising a grandchild with an ACE history commonly experience barriers hindering their access to services including personal, availability, and systemic barriers. Finally, the study sought to understand best practices for working with grandparents raising grandchildren with an ACE history, which include assessing for and creating interventions targeting ACEs, providing education on ACEs to grandparents, and being aware of intergenerational ACE cycles with these families. Strategies for clinical practice are also identified.

"If the [White House faith-based] initiative was going to have an impact on the local community, you had to begin to think of the initiative in local terms." – Brad Yarbrough, Director of the Oklahoma Office of Faith and Community Initiatives Charitable Choice and other faith-based initiatives attempt to provide faith-based organizations (FBOs) easier access to public funds for social service delivery in the community. Five years after Charitable Choice was included in the federal welfare reforms of 1996, President George W. Bush introduced the White House Office of Faith-Based & Community Initiatives in order to expand partnership opportunities between federal agencies and FBOs. The Bush administration actively recruited religious groups to apply for public dollars that would fund local social programs. The actions in Washington mirrored similar movements that took place in many states during the mid to late 1990s. Since then, so-called "faith-based social services" have received their share of media attention and public scrutiny. Much of the attention has been on political-philosophical debates and the legal challenges to church-state separation. Research by Bartkowski and Regis (1999), Kennedy and Bielefeld (2001), Gomez (2003), Vanderwoerd (2004) and Sager (2006) depict the efforts of individual states to implement Charitable Choice policies and the attitudes of FBOs towards partnerships with government. However, there has been inadequate research on the experience of local governments who engage faith-based providers on a daily basis. Much more can be learned about the themes that shape current collaborations between local social service agencies and the faith community in Virginia. Using a collective case study design, this research captures the experiences and perspectives of local public managers who have formed partnerships with FBOs mostly through non-financial means. The data shows that federal and state faith-based initiatives have little influence on the way local social service agencies in Virginia conduct their work. The typical partnerships with FBOs are the result of pre-existing, informal and non-financial relationships that have been fostered and sustained long before welfare reform or without the impetus of any faith-based initiatives. / Ph. D.

Organizational capacity is a concept that has garnered increased attention from the public and nonprofit management literature in recent years. Capacity, broadly defined as the ability of an organization to fulfill its goals, has been of particular focus of scholars interested in understanding the variables that impact organizational performance. Despite the increased focus on organizational capacity in the literature, the concept remains vague. Given the fuzziness of the concept of capacity, there is much opportunity to contribute to the field's knowledge and measurement of the concept. This dissertation adds depth to the capacity literature in public and nonprofit management by identifying, describing and measuring the different dimensions of capacity relevant to local social service delivery organizations. Utilizing a two-phase sequential mixed method design including both interview and survey data, the findings suggest that organizational capacity consists of a number organizational resources and capabilities that impact the functioning of the internal organization as well as its relationships with other relevant organizations and external stakeholders. In particular, six dimensions of capacity were identified: human resource, financial resource, information technology, knowledge, stakeholder commitment, and collaborative. The survey results indicate that the six dimensions are connected to the theoretical construct of organizational capacity. However, results from the discriminant validity tests of the six subscales are mixed. This finding implies that these dimensions represent broad constructs that impact the other dimensions directly. This finding also highlights the challenge of defining and measuring discreetly the specific dimensions of capacity. Future research should examine these discrepancies in order to further disentangle capacity as a theoretical construct. / Ph. D.

Service delivery and the access to specialized instructions to consumers, encounters many barriers within the profession of speech-language pathology. This state of affairs is largely due to the disparate distribution of speech language services (ASHA, 2005). This restricted access, or an inability to access services, is a result of a number of factors, which include lack of clinicians, insufficient number of facilities in geographic area, and transportation issues (ASHA, 2004e). As a result, students who require specialized reading instruction are not afforded the opportunity to access the necessary treatment. It is essential that the literacy needs of all children be addressed, including those who require specialized instruction (Foorman & Torgesen, 2001; Allington, 1994). Technology, specifically telepractice, is a potential solution to address this dilemma. The purpose of this study is to investigate the reliability and validity of systematic multisensory reading treatment for students who have been identified with a delay in foundational reading skills, addressing foundational reading skills via an internet-based video conferencing system. The results will establish the groundwork for the efficacy, reliability, and validity of internet-based video conferencing as a means of service delivery for foundational reading skills. The foundational reading skills targeted in this study are letter naming knowledge (LNK), letter sound knowledge (LSN) and decoding.

There is a national shortage of school-based Speech Language Pathologists (SLP). Schools located in rural and geographically remote areas are often impacted by the shortage, and as a result students with an autism spectrum disorder may not receive services that are mandated by their Individual Education Plan. This study examined the use of telepractice as a method of delivery of speech and language services to individuals with autism spectrum disorders in rural areas. A quasi-experimental, single-subject, time-series design was employed. The treatment conditions were manipulated. A counter-balancing methodology was used to control for order effects in this study. Inter-observer agreement on student progress and outcomes were determined by two other master-level clinicians. Progress was measured using pre/post intervention assessments and intervention data. A statistical analysis and comparison of the two service delivery methods (telepractice and traditional on-site) was conducted using the Improved Rate Difference and a Tau-U method. Group comparison was conducted using the Pearson's Correlation . A non-directional critical value for all parametric and non-parametric analysis was set at á = .05. If the null hypothesis was rejected, then there was a statistical difference between the progress students made when receiving telepractice as compared to on-site services. If the null hypothesis was not rejected, there was not a statistical difference between the progress students made when receiving telepractice as compared to on-site services Comparison at the group level resulted in a finding of non-significance between the two conditions. Findings at the individual level resulted in three out of the six participants demonstrating a finding of non-statistical difference between the on-site and telepractice conditions. For the remaining three participants a statistical difference was noted. When comparing the means of the outcome data between the two conditions, two participants responded more favorably to telepractice intervention, while the other responded better to on-site intervention. Overall, these findings suggest that a telepractice service delivery method is an effective and valid way to provide interventions to students with ASD