This dissertation is about the factors that influence heat wave preparedness of Midwestern health departments, and the climate change perceptions of public health officials. Heat waves have historically impacted the Midwest and, due to the variable pattern of these events, are full of uncertainties. Climate change intensifies the threat of heat waves; therefore, it is important for public health officials to incorporate methods for addressing climate change into their short and long term plans and preparedness models. This study is unique, because it goes beyond previous work that has been done with heat wave preparedness by speaking with public health officials to understand the complexities of heat wave planning. Applying a comparative case study methodology to this study was important to see how three states, in varying stages of climate change preparedness, function regarding emergency planning, decision making, and collaboration. Further, interview discussions regarding climate change demonstrate the need to further assist public health with their mitigation and adaptation efforts. Topics within Chapter One describe the study framework, study significance, discuss the incorporated methodology, and the dissemination of results. In Chapter Two, I construct the scholarly framework for this study by examining climate change and public health impacts, how policy shapes program planning with regard to heat waves, the sociological implications of heat waves including communicative properties and community organizing, and heat wave preparedness plan evaluation. Chapter Three focuses on the methodology guiding this project as well as the research questions. Research questions focused on preparation for heat waves, communication among state and local health departments, climate change perceptions of health officials, and finally, the influence of grant funding on preparedness efforts. This study was constructed using an interpretive paradigm to guide a comparative case study framework for comparing heat wave preparedness of three Midwestern States. Using document analysis and semi-structured interviews, I was able to discuss the concept of preparedness with public health officials including emergency preparedness coordinators, environmental health directors, and emergency managers. In Chapters Four and Five, I developed the uniqueness of each case, and then built a broader story by examining findings across the cases. I met with 22 individuals representing fourteen local health departments, two state health departments, one city health department, two emergency management agencies, and one state climatologist office. Analysis was threaded into both Chapters Four and Five by exploring within (locality, misconception, and camaraderie) and cross (passive leadership, transitions, expectations, reputation, and strategies) case themes. In Chapter Six, I discuss the study findings by incorporating the social ecological model as well as cited literature. Finally, Chapter Seven revisits the study significance and implications for best possible practices in health and public health education. Climate change is one of the greatest threats to public health, and heat waves are only one anticipated threat from enhanced warming. This study sheds light on the importance of climate literacy and preparedness for all-hazards approaches in public health planning.

archives@tulane.edu / Public health finance is still a relatively young field and, as such, many questions have yet to be asked—and answered. To date, few have examine how specific revenue streams—alone or in combination—shape local health departments’ (LHD) resources and capacity to accomplish their public health missions. Given ongoing policy conversations about financing for public health, it’s important for researchers to rigorously examine the and the potential costs and benefits associated with different revenue sources. Introduction Chapter: The central thesis for the body of work encapsulated by this dissertation is simple: where money comes from matters. This chapter critically examines published evidence and theory linking public health financing mechanisms and their interactions to LHD operations, outputs, and even outcomes. The chapter also introduces situates the specific research questions addressed in this dissertation within a broader conceptual framework. Paper 1: The first paper examines the relationship between revenue diversification and revenue volatility among Washington State LHDs. Using fixed effects linear regression models and revenue data reported during 1998-2014 by all LHDs operating in Washington State, the paper finds little evidence to suggest revenue diversification is significantly associated with revenue volatility. Paper 2: The second paper evaluates whether available revenue sources differentially effected the scope of programs provided by Washington State LHDs between 2000 and 2011. Using two measures of program scope and both linear and non-linear fixed effects panel regression models, the paper finds that only funding received from federal Medicaid was consistently and significantly associated with both measures of program scope. Paper 3: The third paper examines changes in total LHD expenditures in Washington State between 2006 and 2013 following introduction of a new state funding program to support core public health services and infrastructure. Using a pre-post design regression model to evaluate changes in LHD expenditures, the paper finds overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program. However, those increases were not sustained over the longer term Conclusion Chapter: The final chapter reviews findings from the three papers and discusses their implications for public health policy, practice, finance, and research. / 1 / Abigail Hope Viall

Introduction: The appropriate role of local health departments (LHDs) as a clinical service provider remains a salient issue. This study examines differences in clinical service provision among rural/urban LHDs for early periodic screening, diagnosis, and treatment (EPSDT) and prenatal care services. Methods: Data collected from the 2013 National Association of County and City Health Officials Profile of Local Health Departments Survey was used to conduct a cross-sectional analysis of rural/urban differences in clinical service provision by LHDs. Profile data were linked with the 2013 Area Health Resource File to derive other county-level measures. Data analysis was conducted in 2015. Results: Approximately 35% of LHDs in the analysis provided EPSDT services directly and 26% provided prenatal care. LHDs reporting no others providing these services in the community were four times more likely to report providing EPSDT services directly and six times more likely to provide prenatal care services directly. Rural LHDs were more likely to provide EPSDT (OR=1.46, 95% CI=1.07, 2.00) and prenatal care (OR=2.43, 95% CI=1.70, 3.47) services than urban LHDs. The presence of a Federally Qualified Health Center in the county was associated with reduced clinical service provision by LHDs for EPSDT and prenatal care. Conclusions: Findings suggest that many LHDs in rural communities remain a clinical service provider and a critical component of the healthcare safety net. The unique position of rural LHDs should be considered in national policy discussions around the organization and delivery of public health services, particularly as they relate to clinical services.

Background: The Healthy People 2020 goal for the public health system is “to ensure that Federal, State, Tribal, and local health agencies have the necessary infrastructure to effectively provide essential public health services.” To address this goal, Missouri established the first statewide, voluntary accreditation program of local health departments (LHDs) and began accrediting the LHDs in 2003. The purpose of this study was to identify organizational, structural, and workforce factors related to accreditation status of LHDs in Missouri. Methods: Using data from the National Association of County & City Health Officials (2010) and the Missouri Department of Health & Senior Services (2012), binary logistic regression analysis was performed to predict accreditation status of LHDs. Likelihood ratio tests were used to examine whether the addition of each predictor added significantly to the model compared with a model including total revenues alone. Adjusted odds ratios (aORs), 95% confidence intervals, the significance level of the likelihood ratio test, and the overall Nagelkerke pseudo-R2 for each model are reported. Results: Having a community health improvement plan (aOR = 6.2), a strategic plan (aOR = 7.9), evaluating programs (aOR = 3.6), being in a region with a high proportion of accredited LHDs (aOR = 5.5), and participating in multijurisdictional collaborations (aOR = 6.4) all increased the likelihood of accreditation. Barriers of time (aOR = 0.1) and cost (aOR = 0.3) were negatively associated with accreditation. Conclusions: Accredited LHDs were more likely to have completed the prerequisites for accreditation and collaborate with other LHDs. These activities help LHDs meet the accreditation standards. In addition, with shrinking budgets, LHDs will need additional financial and technical support to achieve accreditation. Assisting LHDs to find ways to increase the staff is important. Through collaborations with other LHDs, regional or multicounty positions can be created. Also collaborations with universities, specifically colleges or schools of public health, can provide opportunities for internships at LHDs giving practical experience while providing important assistance to LHDs.

Local Health Departments (LHD) that aim to address the public health needs of growing populations require qualified professionals with management competencies. In Arizona, the majority of public health services are delivered by the county health departments, which are charged with assisting community members and monitoring and improving community health. These activities are funded with federal, state and local money, which varies across counties. This study provides a comprehensive understanding of the local public health system in Arizona, the distribution of public health services across counties and examines the association between health outcomes data and funding patterns for each county. National Association of City and County Health Officials (NACCHO) data from their 2008 survey was used to examine the activities performed at the local level. The majority of the activities in which the LHDs focus fall within the assurance function of public health. Interviews with all Arizona county health department directors (N=15) were conducted. Discussion focused on LHD activities, county and state political/policy climate and partnerships that contribute to LHDs activities. Responses varied significantly across the state due to differences in demographic and financial characteristics of the counties. Many political, socioeconomic and environmental barriers to provision of services were identified as well as the need for developing a stronger public health infrastructure.Finally, associations between several health outcomes and funding, workforce and demographic data of the 15 local health departments in Arizona were examined by conducting correlation analysis and linear regressions. This study found strong positive associations between LHD revenues, LHD expenditures, population size and number of LHD employees and HIV/AIDS incidence, low birth weight births and infant mortality rate. Positive associations were also found between revenues and number of women who received prenatal care and HIV/AIDS mortality rate as well as between number of LHD employees and diabetes mortality rate. This study represents a small step in better understanding the local public health system in Arizona, the distribution of public health services across counties and the political, financial and policy constraints faced by county health department directors.

This research examined if there is a relationship between engagement in quality improvement (QI) and health information technology (HIT) for local health departments (LHDs) controlling for workforce, finance, population, and governance structure. This was a cross-sectional study that analyzed data obtained from the Core questions and Module 1 in the NACCHO 2010 Profile of LHDs. Descriptive statistics, bivariate analyses, and logistic regression analyses were conducted. Findings suggest that LHD engagement in QI has a relationship with utilization of HIT including electronic health records, practice management systems, and electronic syndromic surveillance systems. This study provides baseline information about the HIT use of LHDs. LHDs and their system partners (hospitals, federally qualified health centers, and primary care providers) that utilize HIT as part of their QI decision making may have an easier time of using data to support evidence-based decision making and implementing the provisions of the Patient Protection and Affordable Care Act of 2010 in order to achieve population health for all.

Purpose: Access to the full range of contraceptive options is essential to providing patient-centered reproductive health care. Women living in rural areas often experience more barriers to contraceptive care than women living in urban areas. Therefore, federally funded family planning clinics are important for ensuring women have access to contraceptive care, especially in rural areas. This study examines contraceptive provision, factors supporting contraceptive provision, and contraceptive utilization among federally funded family planning clinics in 2 Southern states. Methods: All health department and Federally Qualified Health Center clinics in Alabama and South Carolina that offer contraceptive services were surveyed in 2017-2018. Based on these surveys, we examined differences between rural and urban clinics in the following areas: clinic characteristics, services offered, staffing, staff training, policies, patient characteristics, contraceptive provision, and contraceptive utilization. Differences were assessed using Chi-square tests of independence for categorical variables and independent t-tests for continuous variables. Findings: Urban clinics had more staff on average than rural clinics, but rural clinics reported greater ease in recruiting and retaining family planning providers. Patient characteristics did not significantly vary between rural and urban clinics. While no significant differences were observed in the provision of long-acting reversible contraceptives (LARCs) overall, a greater proportion of patients in urban clinics utilized LARCs. Conclusions: While provision of most contraceptives is similar between rural and urban federally funded family planning clinics, important differences in other factors continue to result in women who receive care in rural clinics being less likely to choose LARC methods.

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.

Objective: Health department accreditation is a crucial strategy for strengthening public health infrastructure. The purpose of this study was to investigate local health department (LHD) characteristics that are associated with accreditation-seeking behavior. This study sought to ascertain the effects of rurality on the likelihood of seeking accreditation through the Public Health Accreditation Board (PHAB). Design: Cross-sectional study using secondary data from the 2013 National Association of County & City Health Officials (NACCHO) National Profile of Local Health Departments Study (Profile Study). Setting: United States. Participants: LHDs (n = 490) that responded to the 2013 NACCHO Profile Survey. Main Outcome Measures: LHDs decision to seek PHAB accreditation. Results: Significantly more accreditation-seeking LHDs were located in urban areas (87.0%) than in micropolition (8.9%) or rural areas (4.1%) (P < .001). LHDs residing in urban communities were 16.6 times (95% confidence interval [CI], 5.3-52.3) and micropolitan LHDs were 3.4 times (95% CI, 1.1-11.3) more likely to seek PHAB accreditation than rural LHDs (RLHDs). LHDs that had completed an agency-wide strategic plan were 8.5 times (95% CI, 4.0-17.9), LHDs with a local board of health were 3.3 times (95% CI, 1.5-7.0), and LHDs governed by their state health department were 12.9 times (95% CI, 3.3-50.0) more likely to seek accreditation. The most commonly cited barrier was time and effort required for accreditation application exceeded benefits (73.5%). Conclusion: The strongest predictor for seeking PHAB accreditation was serving an urban jurisdiction. Micropolitan LHDs were more likely to seek accreditation than smaller RLHDs, which are typically understaffed and underfunded. Major barriers identified by the RLHDs included fees being too high and the time and effort needed for accreditation exceeded their perceived benefits. RLHDs will need additional financial and technical support to achieve accreditation. Even with additional funds, clear messaging of the benefits of accreditation tailored to RLHDs will be needed.

Context: Accreditation of local health departments has been identified as a crucial strategy for strengthening the public health infrastructure. Rural local health departments (RLHDs) face many challenges including lower levels of staffing and funding than local health departments serving metropolitan or urban areas; simultaneously their populations experience health disparities related to risky health behaviors, health outcomes, and access to medical care. Through accreditation, rural local health departments can become better equipped to meet the needs of their communities. Objective: To better understand the needs of communities by assessing barriers and incentives to state-level accreditation in Missouri from the RLHD perspective. Design: Qualitative analysis of semistructured key informant interviews with Missouri local health departments serving rural communities. Participants: Eleven administrators of RLHDs, 7 from accredited and 4 from unaccredited departments, were interviewed. Population size served ranged from 6400 to 52 000 for accredited RLHDs and from 7200 to 73 000 for unaccredited RLHDs. Results: Unaccredited RLHDs identified more barriers to accreditation than accredited RLHDs. Time was a major barrier to seeking accreditation. Unaccredited RLHDs overall did not see accreditation as a priority for their agency and failed to the see value of accreditation. Accredited RLHDs listed more incentives than their unaccredited counterparts. Unaccredited RLHDs identified accountability, becoming more effective and efficient, staff development, and eventual funding as incentives to accreditation. Conclusions: There is a need for better documentation of measurable benefits in order for an RLHD to pursue voluntary accreditation. Those who pursue accreditation are likely to see benefits after the fact, but those who do not pursue do not see the immediate and direct benefits of voluntary accreditation. The finding from this study of state-level accreditation in Missouri provides insight that can be translated to national accreditation.