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6
National Profile of
Local Health Departments
Acknowledgments
This is my fifth (and final) Profile survey, so I have been given the honor of conveying thanks to all of the people who
contribute to this unique study.
I continue to be amazed and humbled at the willingness of our members to contribute their time towards responding
to this survey and creating an accurate picture of local public health. Their willingness to do something for “the good
of the order” makes us the envy of many other associations.
The average response to a Web-based survey is 10–15%; response to the last five Profile surveys was 76–83%.
Our not-so-secret weapons are the many people outside of NACCHO who encourage local health departments
to complete the Profile survey, including State Association of County and City Health Officials (SACCHO) leaders,
state health department leaders, and current and past NACCHO Board members. Without them, we would be
unable to achieve the high response rates that make the Profile such a credible source of information.
People who are afraid of a little hard work cannot be part of the Profile staff team. Some aspects of the study are
decidedly not fun (cajoling members to complete their surveys and cleaning financial data come immediately to
mind). I am grateful for the Profile Team members who take meticulous care in their work and are always looking
for opportunities to improve.
Experts from local health departments, academia, and public health partners volunteer their time to help us ensure
that the Profile survey is both rigorous and relevant. Thank you to the members of the Profile Workgroup for their
contributions to the study.
Finally, a big thank you to our funders: the Centers for Disease Control and Prevention and the Robert Wood
Johnson Foundation. Without you, there would be no NACCHO Profile!
With gratitude,
Carolyn Leep
Senior Director, Research & Evaluation
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
2
The lifesaving work our national local health departments (LHDs) perform is guided by the most accurate and
up-to-date data available. We are pleased to provide the National Profile of Local Health Departments (Profile)
to LHDs, policymakers, public health researchers, and the public health community at large. The Profile is the
only survey of its kind that collects information on LHD infrastructure and practice at the national level.
Having these new data is especially critical now, as the nation is being led by a new Administration, and the funding
LHDs have depended upon may be at risk. The Profile 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. With this information, NACCHO’s Research and Evaluation
Team has given the public health community the data we need to more effectively advocate for our members and
the communities they serve as we continue in our work to reduce health inequities, combat disease, and improve
the quality and length of all lives.
Claude-Alix Jacob, MPH
NACCHO President
Cambridge Public Health Department (MA)
LaMar Hasbrouck, MD, MPH
Executive Director
NACCHO
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
3
The Centers for Disease Control and Prevention
(CDC) is pleased to support NACCHO and its work
on the National Profile of Local Health Departments.
This 2016 report is a valuable resource for all public
health professionals, policymakers, federal agencies,
researchers, and others to use in understanding our
nation’s current local public health infrastructure.
Our ability to be healthy and well is tied inextricably
to where we live. NACCHO and its partners are
dedicated to improving the health of our citizens
by supporting public health at its foundation—in
our communities.
The work of local health departments is critical in
protecting the health of communities. I commend
NACCHO and the local health departments for providing data and for their dedication and contributions
to public health.
By assessing health risks and behaviors, and by
developing improvement plans to enable local health
directors to develop their skills, NACCHO and its
partners are improving access to care, obesity reduction, promoting wellness and addressing the mental
health challenges that lead to substance use. We are
grateful for their unceasing devotion to this cause.
Thomas R. Frieden, MD, MPH
Director, CDC
Department of Health & Human Services
Risa Lavizzo-Mourey
President and CEO
Robert Wood Johnson Foundation
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
4
National Profile of Local Health Departments Workgroup Members
Betty Bekemeier, PhD, MPH, MSN, FAAN
University of Washington
Doug Mathis, MA
Henry County Health Department
Bonnie Brueshoff, RN, DNP, PHN
Dakota County Public Health Department
Carolyn Miller, MSHP, MA
Robert Wood Johnson Foundation
Glenn Czarnecki, MPA
Tennessee Department of Health, Southeast Region
Carol Moehrle, RN, BSN
Idaho Department of Health and Welfare, North Central District
Paul Erwin, MD, DrPH
University of Tennessee
Gulzar Shah, PhD, MStat, MS
Georgia Southern University
April Harris, MPH
Three Rivers District Health Department
Sergey Sotnikov, PhD
Centers for Disease Control and Prevention
Jenine Harris, PhD
Washington University in St. Louis
Patricia Sweeney, JD, MPH, RN
Mahoning County District Board of Health
Richard Ingram, DrPH
University of Kentucky
Lisa VanRaemdonck, MPH, MSW
Colorado Association of Local Public Health Officials
Nikki Lawhorn Rider, ScD, MPP
National Network of Public Health Institutes
Oktawia Wojcik, PhD
Robert Wood Johnson Foundation
Rivka Liss-Levinson, PhD
Association of State and Territorial Health Officials
Susan Zahner, DrPH, RN, FAAN
University of Wisconsin
Ruth Maiorana
Maryland Association of County Health Officers
Served as a workgroup member during 2015 or 2016.
NACCHO Profile Team
Carolyn Leep, MS, MPH
Senior Director of Research & Evaluation
Sarah Newman, MPH
Senior Research and Evaluation Analyst
Jiali Ye, PhD
Lead Research Scientist
Kari O’Donnell, MA
Research Specialist
Nathalie Robin, MPH
Senior Research Analyst
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
5
CONTENTS
1
2
3
4
5
6
7
8
9
10
11
12
Go directly to a chapter by clicking on the title.
Introduction. . ............................................................................................................................................................ 11
Jurisdiction and Governance..................................................................................................................... 22
Partnerships........................................................................................................................................................... 29
Leadership. . ............................................................................................................................................................. 37
Workforce................................................................................................................................................................. 47
Finance....................................................................................................................................................................... 64
Programs and Services.................................................................................................................................. 75
Emergency Preparedness and Response......................................................................................... 97
Assessment, Planning, and Accreditation...................................................................................... 106
Quality Improvement and Workforce Development................................................................. 118
Public Health Policy......................................................................................................................................... 127
Informatics............................................................................................................................................................. 140
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
6
FIG U R E S
Chapter 1 | Introduction
1.1
Questionnaire topics...................................................................................................................................................... 14
1.2
Number of LHDs in study population and number of respondents by state......................................................................................................................... 16
1.3
Number of LHDs in study population and number of respondents by size of population served.......................................................... 17
1.4
Size of population served by LHD jurisdiction....................................................................................................................... 19
1.5
Type of governance by LHD jurisdiction......................................................................................................................................................................................... 19
1.6
U.S. census region..............................................................................................................................................................................................................................20
1.7
Degree of urbanization by LHD jurisdiction........................................................................................................................... 20
Chapter 2 | Jurisdiction and Governance
2.1
Population sizes served by LHDs....................................................................................................................................... 23
2.2
Percent of U.S. population served by LHDs.......................................................................................................................... 24
2.3
Geographic jurisdictions served by LHDs............................................................................................................................ 25
2.4
Geographic jurisdictions served by LHDs by size of population served........................................................................................ 25
2.5
Governance of LHDs by state.......................................................................................................................................... 26
2.6
Percent of LHDs part of a combined Health and Human Services Agency (HHSA) by state............................................................. 27
2.7
Percent of LHDs with a local board of health by LHD characteristics.......................................................................................... 28
Chapter 3 | Partnerships
3.1
Cross-jurisdictional sharing of services by LHD characteristics................................................................................................. 30
3.2
Type of cross-jurisdictional sharing of services...................................................................................................................... 31
3.3
LHD partnerships and collaborations in the past year.............................................................................................................. 32
3.4
Formal LHD partnerships and collaborations over time............................................................................................................ 33
3.5
Engagement with academic institutions in the past year by size of population served...................................................................... 34
3.6
Engagement with academic institutions in the past year by urbanization....................................................................................... 35
3.7
Engagement with specific types of academic institutions in the past year..................................................................................... 36
Chapter 4 | Leadership
Go directly to a figure by clicking on the title.
4.1
Characteristics of top executives over time........................................................................................................................... 38
4.2
Age of top executives in 2016.......................................................................................................................................... 39
4.3
Age of top executives over time.......................................................................................................................................................................................................40
4.4
Top executive tenure over time.......................................................................................................................................... 41
4.5
Top executive average tenure over time by size of population served........................................................................................... 42
4.6
Positions held prior to current top executive position.............................................................................................................. 43
4.7
Highest degree obtained by top executive by LHD characteristics............................................................................................. 44
4.8
Specialized degrees obtained by top executive by LHD characteristics....................................................................................... 45
4.9
Characteristics of new versus experienced top executives....................................................................................................... 46
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
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FIG U R E S
Chapter 5 | Workforce
5.1
Number of Full-Time Equivalents (FTEs).............................................................................................................................. 48
5.2
Mean and median number of employees and Full-Time Equivalents (FTEs) by size of population served............................................... 49
5.3
Full-Time Equivalents (FTEs) per 10,000 people by size of population served................................................................................ 50
5.4
Estimated size of LHD workforce....................................................................................................................................... 51
5.5
Distribution of Full-Time Equivalents (FTEs) by urbanization...................................................................................................... 52
5.6
Estimated size of LHD workforce over time.......................................................................................................................... 53
5.7
Change in Full-Time Equivalents (FTEs) per 10,000 people over time by size of population served..................................................... 54
5.8
Percentage of total workforce retired over time..................................................................................................................... 55
5.9
Occupations employed at LHDs by size of population served................................................................................................... 56
5.10 Staffing patterns at LHDs by size of population served (in median Full-Time Equivalents (FTEs))........................................................ 57
5.11
Estimated numbers of LHD workers in select occupations....................................................................................................... 58
5.12 Workforce composition................................................................................................................................................... 59
5.13 Estimated size of select occupations over time. . .................................................................................................................... 60
5.14 Percent of LHDs reporting jobs lost due to layoffs and/or attrition in the past year by LHD characteristics............................................ 61
5.15 Percent of LHDs reporting jobs lost due to layoffs and/or attrition over time.................................................................................. 62
5.16 Number of jobs lost and added over time by size of population served........................................................................................ 63
Chapter 6 | Finance
6.1
Total annual expenditures................................................................................................................................................ 65
6.2
Mean and quartiles of total annual expenditures by size of population served................................................................................ 66
6.3
Median and mean annual per capita expenditures and revenues by LHD characteristics.................................................................. 67
6.4
Overall annual expenditures per capita by state..................................................................................................................... 68
6.5
Median and mean annual per capita expenditures over time...................................................................................................... 69
6.6
Revenue sources.......................................................................................................................................................... 70
6.7
Median and mean annual per capita revenue by selected sources and by LHD characteristics.......................................................... 71
6.8
Median and mean annual per capita revenue sources over time................................................................................................. 72
6.9
Budget changes over time............................................................................................................................................... 73
6.10 Percent of budget cut in the current fiscal year compared to the previous fiscal year....................................................................... 74
Chapter 7 | Programs and Services
Go directly to a figure by clicking on the title.
7.1
Clinical programs and services provided directly in the past year............................................................................................... 76
7.2
Population-based programs and services provided directly in the past year.................................................................................. 77
7.3
Adult and child immunization services provided directly in the past year by LHD characteristics......................................................... 78
7.4
Screening and treatment for diseases and conditions provided directly in the past year by LHD characteristics..................................... 79
7.5
Maternal and child health services provided directly in the past year by LHD characteristics............................................................. 80
7.6
Other clinical services provided directly in the past year by LHD characteristics............................................................................ 81
7.7
Epidemiology and surveillance services provided directly in the past year by LHD characteristics....................................................... 82
7.8
Population-based primary prevention services provided directly in the past year by LHD characteristics............................................... 83
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
8
FIG U R E S
7.9
Regulation, inspection, or licensing services provided directly in the past year by LHD characteristics................................................. 84
7.10
Environmental health services provided directly in the past year by LHD characteristics................................................................... 85
7.11
Other population-based services provided directly in the past year by LHD characteristics............................................................... 86
7.12
Number of services contracted out by LHDs by size of population served.................................................................................... 87
7.13
Programs and services provided most frequently via contracts.................................................................................................. 88
7.14
Provision of population-based primary prevention services over time by other organizations independent of LHD funding......................... 89
7.15
Programs and services more likely to be provided in rural jurisdictions......................................................................................... 90
7.16
Programs and services more likely to be provided in urban jurisdictions....................................................................................... 91
7.17
Programs and services provided by more LHDs since 2008..................................................................................................... 92
7.18
Programs and services provided by fewer LHDs since 2008.................................................................................................... 93
7.19
Changes in provision of services in the past year................................................................................................................... 94
7.20
Growing, stable, and shrinking services in the past year.......................................................................................................... 95
7.21
Changes in provision of services by changes in budgets in the past year..................................................................................... 96
Chapter 8 | Emergency Preparedness and Response
8.1
LHD budget changes for emergency preparedness activities by LHD characteristics...................................................................... 98
8.2
Response to any all-hazards event in past year by LHD characteristics........................................................................................ 99
8.3
Use of volunteers to respond to an all-hazards event in past year by LHD characteristics............................................................... 100
8.4
Participation in emergency preparedness exercises by size of population served.......................................................................... 101
8.5
Use of volunteers in any emergency preparedness exercises (tabletop, functional, or full-scale) in the past year
by size of population served and type of exercise. . ............................................................................................................... 102
8.6
Source of volunteers for emergency preparedness activities over time....................................................................................... 103
8.7
Involvement in planning for emergencies by LHD characteristics.............................................................................................. 104
8.8
Involvement in emergency preparedness training and education activities by LHD characteristics..................................................... 105
Chapter 9 | Assessment, Planning, and Accreditation
9.1
Participation over time in a community health assessment (CHA), community health improvement plan (CHIP),
and/or strategic plan (SP) within five years.......................................................................................................................... 107
9.2
2016 Participation in a community health assessment (CHA), community health improvement plan (CHIP),
and/or strategic plan (SP) within five years by size of population served.................................................................................... 108
9.3
Data included in most recent community health assessment (CHA) over time............................................................................. 109
9.4
Elements of most recent community health assessment (CHA)................................................................................................ 110
9.5
Actions taken in the past three years to implement or sustain a community health improvement plan (CHIP) over time............................ 111
9.6
Level of collaboration with non-profit hospitals on most recent community health needs assessment (CHNA)...................................... 112
9.7
Types of collaboration with non-profit hospitals on most recent community health needs assessment (CHNA)..................................... 113
9.8
Level of engagement with Public Health Accreditation Board (PHAB) accreditation in 2016............................................................ 114
9.9
Level of engagement with Public Health Accreditation Board (PHAB) accreditation over time.......................................................... 115
9.10 Formal engagement in Public Health Accreditation Board (PHAB) accreditation by LHD characteristics............................................. 116
9.11
Go directly to a figure by clicking on the title.
Reasons for not pursuing Public Health Accreditation Board (PHAB) accreditation over time........................................................... 117
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
9
FIG U R E S
Chapter 10 | Quality Improvement and Workforce Development
10.1 Level of quality improvement (QI) implementation over time..................................................................................................... 119
10.2 Level of quality improvement (QI) implementation by size of population served............................................................................ 120
10.3 Number of quality improvement (QI) projects implemented in the past year over time.................................................................... 121
10.4 Number of quality improvement (QI) projects implemented in the past year by level of QI implementation........................................... 122
10.5 Quality improvement (QI) elements used in QI efforts in the past year by size of population served................................................... 123
10.6 Elements of an agency-wide quality improvement (QI) program currently in place at LHD by level of QI implementation......................... 124
10.7 Any use of core competencies for public health professionals by size of population served............................................................. 125
10.8 Use of core competencies for public health professionals over time.......................................................................................... 126
Chapter 11 | Public Health Policy
11.1
Involvement in policy areas in the past two years by size of population served............................................................................. 128
11.2
Involvement in policy areas related to social determinants of health over time.............................................................................. 129
11.3
Involvement in policy areas related to tobacco, alcohol, or other drugs in the past two years by size of population served....................... 130
11.4
Involvement in policy areas related to obesity or chronic disease in the past two years by size of population served.............................. 131
11.5
Involvement over time in land use planning activities in the past year over time............................................................................. 132
11.6
Involvement in land use planning activities in the past year by size of population served................................................................. 133
11.7
Number of health impact assessments (HIAs) completed in the past two years over time and by size of population served..................... 134
11.8
Involvement in developing new or revising existing ordinances in the past two years by LHD characteristics....................................... 135
11.9
Topic areas of new or revised ordinances in the past two years............................................................................................... 136
11.10 Engagement in addressing health disparities in the past two years by size of population served........................................................ 137
11.11 Engagement in assuring access to health care services in the past year.................................................................................... 138
11.12 Engagement over time in assuring access to health care services in the past year........................................................................ 139
Chapter 12 | Informatics
12.1 Current level of activity in information technology systems...................................................................................................... 141
12.2 Current implementation in information technology systems by size of population served. . ............................................................... 142
12.3 Implementation of information technology systems over time................................................................................................... 143
12.4 Use of communication channels for routine or emergency response communications.................................................................... 144
12.5 Any use of communication channels by size of population served............................................................................................. 145
12.6 Any use of communication channels by type of governance.................................................................................................... 146
12.7
Any use of communication channels by urbanization............................................................................................................. 147
12.8 Use of communication channels over time.......................................................................................................................... 148
Go directly to a figure by clicking on the title.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
10
2
1
CHAPTE R
Jurisdiction
and Governance
Introduction
This chapter includes the following:
■■ Study
Population
background
sizes served
and methods.
by local health departments (LHDs).
■■ Questionnaire
Geographic jurisdictions
topics.
served by LHDs.
■■ Number
Governance
of local
of LHDs.
health departments (LHDs)
in study population.
■■ Combined Health and Human Services Agencies.
■■ Definitions of LHD jurisdiction size, type of governance,
■■ Local boards of health.
census regions, and degree of urbanization.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 1: Introduction
The National Association of County and City Health Officials (NACCHO) is the national non-profit membership
association representing the nation’s local health departments (LHDs). NACCHO’s mission is to be a leader, partner,
catalyst, and voice with LHDs. NACCHO conducted the first National Profile of Local Health Departments (Profile)
study from 1989 to 1990. This study helped to define an LHD and describe how funding, staffing, governance, and
activities of LHDs vary across the United States. Since then, NACCHO has conducted an additional seven Profile
studies, including in 2016. All Profile studies have been funded by the Centers for Disease Control and Prevention;
beginning in 2007, NACCHO also received funding from the Robert Wood Johnson Foundation.
Purpose
The purpose of the Profile study is to develop a comprehensive and accurate description of LHD infrastructure
and practice. Data from the Profile study are essential to painting a picture of the realities on the ground for LHDs
and are used by many people and organizations. For example, LHD staff use the data to compare their LHD or
those within their states to others nationwide. Data are used by policymakers at the local, state, and federal levels
to understand how LHDs improve and protect the health of local communities. Data are also used by universities to
educate future public health workforce members about LHDs and by researchers to address questions about public
health practice. Profile data also helps highlight the challenges faced by LHDs and differences between small,
medium, and large LHDs. NACCHO staff use Profile data to develop programs and resources that meet the needs
of LHDs and to advocate effectively for LHDs.
Study Methodology
Study population
Every Profile study has used the same definition of an LHD: 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. There are approximately 2,800 agencies or units that meet the Profile definition of an LHD. Some states have
a public health system structure that includes both regional and local offices of the state health agency. In those
states, the state health agency chooses to respond to the Profile survey at either the regional or local level, but not
at both levels.
NACCHO uses a database of LHDs based on previous Profile studies and consults with state health agencies and
state associations of local health officials to identify LHDs for inclusion in the study population. For the 2016 Profile
study, a total of 2,533 LHDs were included in the study population. Hawaii and Rhode Island were excluded from the
study because these state health departments operate on behalf of local public health and have no sub-state units.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
12
Chapter 1: Introduction
Sampling
All LHDs in the study population received the Core questionnaire. A randomly selected group of LHDs also received
one of the two sets of supplemental questions (or modules). LHDs were selected to receive the Core questionnaire
only or the Core plus one of the two modules using stratified random sampling (without replacement), with strata
defined by the size of the population served by the LHD. The module sampling process is designed to produce
national estimates but not to produce state-level estimates.
Questionnaire development
The NACCHO Profile team developed the 2016 questionnaire by first reviewing the previous Profile questionnaire
(2013) to determine how each question performed among respondents and what questions should be kept, modified, or deferred to a future Profile questionnaire. The team also reviewed questionnaires from previous years (2010,
2008, 2005) to identify whether any questions should be repeated in 2016. Lastly, the team explored developing
new questions based on current public health topics. An advisory group (comprised of LHD leaders, staff from affiliate organizations, and researchers) and other subject matter experts within NACCHO provided input and feedback
on new and revised survey questions. The Profile team piloted the questionnaire from October to November 2015
among 50 LHDs (29 completed the pilot for a response rate of 58%). NACCHO interviewed select LHDs to assess
whether certain sections and questions performed as expected. The Profile team revised the survey as needed and
finalized it for distribution. Refer to nacchoprofilestudy.org/data-requests for the final questionnaire.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
13
Chapter 1: Introduction
yy The 2016 Profile study questionnaire
FIG U R E 1.1
Questionnaire topics
Core
Module 1
Module 2
(Core only response rate = 74%)
(Core + Module 1 response rate = 80%)
(Core + Module 2 response rate = 77%)
Jurisdiction and governance
Community health assessment
and planning
Human resources issues
Programs and services
Quality improvement
Access to health care services
Finance
Health impact assessments
Health disparities
Changes in LHD budgets
Land use planning
Emergency preparedness
LHD top executive
Cross-jurisdictional sharing of services
Public health informatics
Workforce
Partnerships and collaboration
County health statistics
Staffing changes
Interaction with academic institutions
Evaluation of Profile
Guide to Community Preventive Services
Public health policy
Community health assessment
and planning
Accreditation
Communication among LHD leaders
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
included a set of questions (Core
questionnaire) sent to all LHDs in the
United States; additional supplemental questions were grouped into two
modules.
yy LHDs were randomly assigned to
receive only the Core questionnaire or
the Core plus one of the two modules.
yy Many questions in the Core and mod-
ules questionnaires have been used
in previous Profile studies and provide
an ongoing dataset for comparative
analysis; most new items were placed
in modules.
14
Chapter 1: Introduction
Questionnaire distribution
In December 2015, NACCHO sent an e-mail invitation from NACCHO’s President and Executive Director to all
LHDs in the study population. In the e-mail, LHDs were given the opportunity to designate another staff person as
the primary contact to complete the Profile questionnaire. NACCHO launched the final questionnaire from January
through April 2016 via an e-mail sent to a designated primary contact of every LHD in the study population. The
e-mail included a link to a Web-based questionnaire, individualized with preloaded identifying information specific to
the LHD. LHDs could print a hard copy version of their Profile questionnaire by using a link in the introduction to the
Web-based questionnaire or could request that NACCHO staff send a copy via e-mail or U.S. mail.
NACCHO sent all LHDs a postcard announcing the Profile launch and instructing them to contact NACCHO if they
had not received an e-mail with their survey link. In addition, NACCHO included promotional materials announcing the upcoming survey in NACCHO’s periodical publications (Public Health Dispatch, NACCHO Connect) from
October 2015 through March 2016.
The Profile team conducted extensive efforts to encourage participants to complete the questionnaire. NACCHO
staff and a nationwide group of Profile study advocates conducted follow-up with non-respondents using e-mail
messages and telephone calls. NACCHO also offered technical support to survey respondents through an e-mail
address and telephone hotline. For a select number of LHDs, NACCHO mailed a hard copy of their questionnaire
to their mailing address, encouraging them to complete the survey online or complete their hard copy and return via
e-mail, fax, or return mail.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
15
Chapter 1: Introduction
yy Overall, the 2016 Profile study had
FIG U R E 1.2
a response rate of 76%.
Number of LHDs in study population and number of respondents by state
State
Total
number
of LHDs
Number of
Response
respondents rate
All
2,533
1,930
Alabama
67
Alaska
yy With the exception of Massachusetts
State
Total
number
of LHDs
Number of
Response
respondents rate
76%
Missouri
115
93
81%
65
97%
Montana
51
35
69%
3
3
100%
Nebraska
20
18
90%
Arizona
15
15
100%
Nevada
4
4
100%
Arkansas
75
75
100%
California
61
41
67%
New
Hampshire
3
3
100%
Colorado
54
48
89%
New Jersey
101
73
72%
Connecticut
73
46
63%
New Mexico
6
6
100%
Delaware
2
2
100%
New York
58
48
83%
District of
Columbia
1
1
100%
North Carolina
85
76
89%
North Dakota
28
28
100%
Florida
67
65
97%
Ohio
121
90
74%
Georgia
18
14
78%
Oklahoma
70
60
86%
Idaho
7
7
100%
Oregon
34
29
85%
Illinois
96
74
77%
Pennsylvania
16
15
94%
Indiana
93
60
65%
South Carolina 4
4
100%
Iowa
101
65
64%
South Dakota
8
8
100%
Kansas
100
73
73%
Tennessee
95
93
98%
Kentucky
61
48
79%
Texas
67
48
72%
Louisiana
10
6
60%
Utah
13
10
77%
Maine
10
10
100%
Vermont
12
12
100%
Maryland
24
24
100%
Virginia
35
30
86%
Massachusetts 328
130
40%
Washington
35
33
94%
Michigan
45
35
78%
West Virginia
49
31
63%
Minnesota
74
63
85%
Wisconsin
86
85
99%
Mississippi
9
9
100%
Wyoming
23
19
83%
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
and Louisiana, all states had a
response rate of more than 60%.
yy A total of 15 states and the District
of Columbia had response rates
of 100%.
16
Chapter 1: Introduction
FIG U R E 1.3
Number of LHDs in study population and number of respondents by size of population served
Total
number
Size of population served of LHDs
Number of
Response
respondents rate
All
2,533
1,930
76%
<25,000
1,034
691
67%
25,000–49,999
527
418
79%
50,000–99,999
384
308
80%
100,000–249,999
304
262
86%
250,000–499,999
141
122
87%
500,000–999,999
96
86
90%
1,000,000+
47
43
91%
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
yy LHDs serving smaller populations had
lower response rates than did those
serving larger populations.
yy Because there are relatively few
LHDs serving large populations,
the higher response rates among
LHDs serving larger populations are
important to the analytic capacity of
the study data.
17
Chapter 1: Introduction
Survey Weights and National Estimates
Unless otherwise stated, national statistics presented were computed using appropriate estimation weights.
NACCHO developed estimation weights for the items from the Core questionnaire to account for dissimilar non-response by size of population served; estimation weights used to produce statistics from modules also accounted
for sampling. By using estimation weights, the Profile study provides national estimates for all LHDs in the United
States. Most statistics included in this report from previous Profile studies were also weighted for nonresponse, but
some statistics may differ from previous years due to a special weighting methodology. Special estimation weights
were developed for some finance and workforce variables because the rate of item non-response is much higher in
these two sections than in other sections of the Profile questionnaire.
Two weights were generated for the analysis: proportional weights and scale weights. Proportional weights for each
population category (see Figure 1.3) were calculated by dividing the proportion of LHDs in that population category
among the full study population by the proportion of LHDs in that population category among all survey respondents. Scale weights were generated by dividing the number of LHDs in a population category in the full study
population by the number of LHDs in that population category that responded to the survey. Scale weights are used
for estimating population totals. Either proportional weights or scale weights can be used for generating descriptive
statistics such as proportion, mean, and median.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
18
Chapter 1: Introduction
Subgroup Analysis
Throughout this report, data are analyzed by various LHD jurisdiction characteristics, namely size of population
served, type of governance, United States census region, and degree of urbanization. Definitions of the categories
are described in the sidebar to the right.
yy Size of population served: Statistics
FIG U R E 1.4
Size of population served by LHD jurisdiction
n <50,000
n 50,000–499,999
are compared across LHDs serving
different population sizes in the LHD
jurisdiction. LHDs are classified
as small if they serve fewer than
50,000 people, medium if they serve
populations between 50,000 and
500,000 people, and large if they
serve 500,000 or more people. For
certain statistics that are highly
dependent on size of population
served (e.g., finance and workforce
statistics), a larger number of
population subgroups are used.
n 500,000+
yy Type of governance: Statistics are
FIG U R E 1.5
compared across LHDs’ relationship
to their state health department.
Some LHDs are agencies of local
government (referred to as locally
governed); others are local or regional
units of the state health department
(referred to as state-governed). Some
are governed by both state and local
authorities (called shared governance).
Refer to Chapter 2 (Jurisdiction and
Governance) for more details.
Type of governance by LHD jurisdiction
n Local
n State
n Shared
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
19
Chapter 1: Introduction
yyCensus region: Statistics are also compared
FIG U R E 1.6
across United States census region. All
LHDs in each state are classified being in
the North, South, Midwest, or West, per the
U.S. Census Bureau (http://www.census.
gov/econ/census/help/geography/regions_
and_divisions.html).
U.S. census region
yy Degree of urbanization: Statistics are
n Northeast
n Midwest
n West
n South
FIG U R E 1.7
Degree of urbanization by LHD jurisdiction
n Urban
n Suburban
n Rural
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
compared across LHD jurisdiction by degree
of urbanization. Each LHD in the Profile
study population is assigned a Rural Urban
Commuting Area Codes (RUCA) designation
based on the zip code of their primary mailing
address, according to the U.S. Department
of Agriculture Economic Research Service
(http://depts.washington.edu/uwruca/
index.php). The RUCA method is a census
tract-based classification scheme that uses
the standard Bureau of Census urban area
and place definitions in combination with
community information to characterize all
of the nation’s census tracts regarding their
rural and urban status relationships. For this
study, NACCHO used these RUCA codes
to classify each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories.
Occasionally, suburban and rural statistics are
presented together; in these cases, groups
are labeled urban and non-urban. Each LHD
has a single classification based on the
zip code of the LHD mailing address, even
though some jurisdictions (especially those
that are geographically large) include census
tracts with differing degrees of urbanization.
20
Chapter 1: Introduction
Study Limitations
The Profile study is a unique and comprehensive source of information on LHD finances, infrastructure, workforce, activities, and other important characteristics. However, several limitations, should be considered when
using the results of this study. Because the questionnaire includes a large number of topics, Profile does not
provide in-depth information on these topics. For example, the Profile provides information about whether or not
an LHD provides a specific program or service but does not provide any information about the scope or scale of
that program or service. All data are self-reported by LHD staff and are not independently verified. LHDs may
have provided incomplete, imperfect, or inconsistent information for various reasons.
While the Profile questionnaire includes definitions for many items, not every item or term is defined. For example,
the questionnaire does not include definitions for each of the 85 programs and services included in the Profile
questionnaire. Consequently, respondents may have interpreted questions and items differently.
Responding to the Profile questionnaire is time-intensive; consequently, respondents may have skipped some questions because of time restrictions. In addition, responses to some questions may have been based on estimation to
reduce burden. In particular, questions on finance were difficult for LHDs to answer and yielded large amounts of
missing data; refer to the finance chapter for details.
Comparisons with data from prior Profile studies are provided for some statistics, but these comparisons should be
viewed with caution because both the study population and the respondents are different for each Profile study. In
addition, comparisons are not tested for significant differences.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
21
2
CHAPTE R
Jurisdiction
and Governance
This chapter includes the following:
■■ Population sizes served by local health departments (LHDs).
■■ Geographic jurisdictions served by LHDs.
■■ Governance of LHDs.
■■ Combined Health and Human Services Agencies.
■■ Local boards of health.
Chapter 2: Jurisdiction and Governance
FIG U R E 2.1
Population sizes served by LHDs
Size of population served
N
Percent
<10,000
439
17%
10,000–24,999
595
23%
25,000–49,999
527
21%
50,000–74,999
243
10%
75,000–99,999
141
6%
100,000–199,999
244
10%
200,000–499,999
201
8%
500,000–999,999
96
4%
1,000,000+
47
2%
Total
2,533
yy There are approximately 2,800 LHDs
in the United States, but not every unit
is included in the Profile study. LHDs
operating under a centralized governance structure may include multiple
levels (e.g., county units and multicounty regions or districts). The state
health agency selects one level for
inclusion in the Profile.
yy 2,533 LHDs were included in the
2016 Profile study population.
N=2,533
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
23
Chapter 2: Jurisdiction and Governance
yy LHDs serve different sized juris-
FIG U R E 2.2
Percent of U.S. population served by LHDs
■ Percent of all LHDs
62%
Small (<50,000)
10%
33%
Medium (50,000–499,999)
Large (500,000+)
■ Percent of population served by LHDs
39%
yy While only 6% of all LHDs are classi-
6%
N=2,533
dictions across the United States.
Throughout this report, small LHDs
are classified as those that serve populations of fewer than 50,000 people;
medium LHDs serve populations of
between 50,000 and 500,000 people;
and large LHDs serve populations of
500,000 or more people.
51%
fied as large, they serve about half of
the U.S. population (51%).
yy Most LHDs (62%) are small but serve
only 10% of the U.S. population.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
24
Chapter 2: Jurisdiction and Governance
yy Approximately two-thirds of LHDs
FIG U R E 2.3
(69%) are county-based and an
additional 8% serve multiple counties.
One-fifth of LHDs (20%) serve cities
or towns.
Geographic jurisdictions served by LHDs
yy Large LHDs are less likely to serve
cities or towns but are more likely
to serve multiple counties than
small LHDs.
n City or town
n County
n Multi-city
n Multi-county
FIG U R E 2.4
Geographic jurisdictions served by LHDs by size of population served
County*
All LHDs
Multicounty Other**
City or town
69%
20%
8% 3%
1%
<25,000
25,000–49,999
50,000–99,999
100,000–499,999
500,000+
68%
30%
72%
65%
69%
76%
*County includes city-counties.
**Other includes LHDs serving multiple cities or towns.
N=2,533
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
17%
6% 4%
17%
11%
8%
19%
6%
8%
4%
17%
1%
Technical note
Due to their small geographic size, many city and
town jurisdictions can only be seen in Figure 2.3
if the map is zoomed in significantly.
25
Chapter 2: Jurisdiction and Governance
yy Of the 2,533 LHDs included in the
FIG U R E 2.5
2016 Profile study population, 1,946
are locally governed, 396 are units
of the state health agency, and 191
have shared governance.
Governance of LHDs by state
n Local (all LHDs in state are units of local government)
n State (all LHDs in state are units of state government)
n Shared (all LHDs in state governed by both state and local authorities)
yy In 27 states, all LHDs are
n Mixed (LHDs in state have more than one governance type)
locally governed.
WA
MN
OR
ID
WI
SD
WY
UT
CA
AZ
CO
IL
KS
OK
NM
TX
HI
PA
OH
IN
MD
WV
MO
VA
KY
NC
TN
AR
SC
MS
AK
VT
NH
NY
MA
CT
MI
IA
NE
NV
Kentucky and most LHDs in Maryland
have shared governance.
ME
ND
MT
yy All LHDs in Florida, Georgia, and
AL
GA
NJ
DE
DC
yy All LHDs in Arkansas, Delaware,
RI
Mississippi, South Carolina, and
Vermont are units of the state
health agency, as are most LHDs
in Alabama, Louisiana, New Mexico,
Oklahoma, South Dakota, and Virginia.
yy In most states with mixed
governance, units of the state
health agency serve most parts of
the state, while a small number of
large metropolitan areas have locally
governed LHDs.
LA
RI and HI non-participants.
N=2,533
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
FL
Technical note
LHDs vary in their relationships with their state
health agency. Some LHDs are local or regional
units of the state health agency, others are
agencies of local government, and others are
governed by both state and local authorities
(called shared governance). Some states include
LHDs with more than one governance type
(shown as mixed on the map). States in which
all LHDs have state governance are referred to
as centralized, and those in which all LHDs are
locally governed are decentralized.
26
Chapter 2: Jurisdiction and Governance
yy Nineteen percent of all LHDs are cur-
FIG U R E 2.6
rently part of a combined HHSA.
Percent of LHDs part of a combined Health and Human Services Agency (HHSA) by state
yy More than half of LHDs in six states
Percentage of LHDs that are part of a combined HHSA:
are part of a combined HHSA; at least
one-third of LHDs in seven states
are a part of a combined HHSA; and
fewer than one-third of LHDs in the
remaining states are a part of combined HHSA.
n More than 50% n 33%–50% n Less than 33%
WA
ME
ND
MT*
MN
OR
ID
WI
SD
WY
UT
CA
AZ
CO
IL
KS
OK
NM
TX
HI
PA
OH
IN
MD
WV
MO*
VA
KY
AR
NJ
DE
DC
yy In Massachusetts, Missouri, Montana,
RI
and North Carolina, at least one-third
of LHDs that are part of a combined
HHSA were consolidated into that
HHSA within the past three years.
NC*
TN
SC
MS
AK
MI
IA
NE
NV
VT
NH
NY
MA*
CT
AL
GA
LA
FL
RI and HI non-participants.
*At least one-third of LHDs that are part of an HHSA were consolidated into the HHSA in past three years.
N=2,533
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
27
Chapter 2: Jurisdiction and Governance
yy Three-quarters (76%) of all LHDs
FIG U R E 2.7
have a local board of health.
Percent of LHDs with a local board of health by LHD characteristics
yy A larger proportion of small LHDs
76%
All LHDs
(83%) have local boards of health,
compared to large LHDs (52%).
Size of population served
83%
Small (<50,000)
66%
Medium (50,000–499,999)
52%
Large (500,000+)
Type of governance
State
likely to have a local board of health
(85%) compared to LHDs that are
units of their state health department
(41%) or LHDs that are governed by
both state and local authorities (57%).
41%
85%
Local
Shared
yy Locally governed LHDs are more
57%
N=2,533
Technical note
Refer to 2015 Local Board of Health Profile
for additional data on local boards of health
(available at http://nacchoprofilestudy.org/lboh).
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
28
3
CHAPTE R
Partnerships
This chapter includes the following:
■■ Cross-jurisdictional sharing of services.
■■ Local health department (LHD) partnerships
and collaborations.
■■ LHD engagement with academic institutions.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 3: Partnerships
yy More than half (56%) of LHDs share
FIG U R E 3.1
resources (such as funding, staff, or
equipment) with other LHDs on a
continuous, recurring, non-emergency
basis.
Cross-jurisdictional sharing of services by LHD characteristics
Percent of LHDs sharing services or resources with other LHD(s)
All LHDs
56%
yy Similar proportions of LHDs serving
small, medium, and large jurisdictions
share services.
Size of population served
54%
Small (<50,000)
yy A larger proportion of LHDs governed
by both state and local authorities
(shared governance) share resources
(75%) than locally governed LHDs
(50%).
59%
Medium (50,000–499,999)
53%
Large (500,000+)
Type of governance
67%
State
Local
50%
Shared
75%
n=493
Technical note
Cross-jurisdictional sharing of services is a term
used to refer to the various means by which
jurisdictions work together to provide public
health services. LHDs across the country are
looking to cross-jurisdictional sharing as a way to
help them more efficiently and effectively deliver
public health services. The information provided
in this section reflects sharing resources on a
continuous, recurring, non-emergency basis.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
30
Chapter 3: Partnerships
yyJust over one-third of LHDs (35%)
FIG U R E 3.2
Type of cross-jurisdictional sharing of services
Percent of LHDs sharing this type
of resource/service with other LHD(s)
35%
LHD receives functions/services from another LHD
35%
LHD provides functions/services for another LHD
31%
LHD shares a staff member with another LHD
LHD shares equipment with another LHD
receive functions or services from
another LHD or provide functions
or services for another LHD; 31%
share staff members with another
LHD and 25% share equipment
with another LHD.
25%
n=460–471
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
31
Chapter 3: Partnerships
yy LHDs work with a variety of partners
FIG U R E 3.3
LHD partnerships and collaborations in the past year
Percent of LHDs working with partner in any way (exchanging information, regularly scheduling meetings, with written agreements,
or sharing personnel/resources)
Percent of LHDs regularly scheduling meetings, with written agreements, or sharing personnel/resources with partner
Health care partners
71%
Emergency responders
95%
34%
89%
Community health centers
44%
Mental health/substance abuse providers
44%
Veterinarians
98%
65%
Hospitals
Physician practices/medical groups
88%
87%
17%
74%
29%
Health insurers
65%
Community-based partners (e.g., education, non-government)
59%
K–12 schools
Media
95%
51%
Community-based non-profits
87%
45%
86%
20%
84%
32%
Cooperative extensions
Libraries
92%
29%
Faith communities
Colleges or universities
Businesses
98%
18%
81%
17%
73%
Government agencies
29%
Criminal justice system
79%
35%
Local planning
78%
Parks and recreation
26%
76%
Economic and community development
26%
76%
Housing
20%
Tribal government
13%
yy Almost all LHDs work with some
partners, such as emergency
responders (98%), hospitals (95%),
K-12 schools (98%), and the media
(95%). Collaborations with other
partners are less common, including
tribal governments (41%) and health
insurers (65%).
yyOverall, LHDs are less likely to
collaborate in ways beyond only
exchanging information (i.e., regularly
scheduling meetings, establishing
written agreements, or sharing
personnel/resources). This difference
is particularly large for the media
(only 18% collaborate beyond
information exchange) and business
(only 20% collaborate beyond
information exchange).
68%
22%
Transportation
in their communities (including health
care partners, government agencies,
and community-based partners) in a
variety of ways, such as sharing information, regularly scheduling meetings,
establishing written agreements, and
sharing personnel/resources.
63%
41%
n=218–483 (among LHDs that reported presence of organization)
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
32
Chapter 3: Partnerships
FIG U R E 3.4
Formal* LHD partnerships and collaborations over time
Percent of LHDs that share personnel/resources and/or have written agreements
Health care partners
Community-based partners
Emergency
responders
61%
Hospitals
57%
K-12 schools
Colleges or
universities
38%
Physician practices/
medical groups
Health insurers
Government agencies
59%
45%
39%
Community
health centers
24%
35%
26%
Communitybased
non-profits
Cooperative
extensions
38%
34%
30%
28%
Local planning
26%
23%
21%
Faith
communities 19%
18%
13%
Media
11%
Libraries
18%
Criminal 19%
justice system
17%
Parks and recreation
14%
10%
8%
Businesses
7%
Economic and
community
development
11%
7%
5%
2008
2016
n=414–447
n=218–483
2008
2016
10%
9%
Transportation
2008
2016
*Share personnel/resources and/or have written agreements.
yy Across all types of partnerships, the percentage of
LHDs reporting formal collaborations (i.e., sharing
personnel/resources and/or have written agreements)
was lower in 2016 compared to 2008.
yy Between 2008 and 2016, the proportion of LHDs
reporting formal collaborations with emergency responders, hospitals, and K-12 schools decreased by 23, 22,
and 21 percentage points, respectively.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
yy LHDs are also generally less likely to have formal
partnerships with government agencies than with either
health care or other community-based partners but the
decreases since 2016 are generally smaller with the
exception of local planning.
33
Chapter 3: Partnerships
FIG U R E 3.5
Engagement with academic institutions in the past year by size of population served
Size of population served
Medium
(50,000–
499,999)
Large
(500,000+)
yy Three-quarters of LHDs (76%) accept
students from academic institutions
(as trainees, interns, or volunteers)
but fewer actively recruit graduates
from institutions (25%).
All LHDs
Small
(<50,000)
LHD accepts students from academic institutions as trainees, interns,
or volunteers
76%
66%
92%
92%
LHD staff serve as faculty in academic institutions
30%
17%
45%
79%
LHD staff serve on an academic institution advisory group
25%
16%
35%
65%
staff that serve as faculty (30%)
and one-quarter have staff who
serve on an academic institution
advisory group (25%).
LHD has formal relationship with academic institutions to provide training
or professional development for LHD staff
25%
19%
31%
45%
yy Medium and large LHDs are more
LHD actively recruits graduates from academic institutions
25%
12%
41%
65%
Faculty/staff from academic institutions have served in a consulting role for LHD
24%
11%
40%
55%
Academic institutions have agreements or policies on providing LHD with access
to scientific and professional journals
11%
7%
14%
34%
Did not engage academic institutions in any of the ways above
16%
25%
2%
3%
n=484
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
yy Fewer than one-third of LHDs have
likely to engage in these partnerships
with academic institutions than small
LHDs (25% do not engage in any
of these ways). Notably, almost all
medium and large LHDs (92%)
accept students from academic
intuitions and 79% of large LHDs
have staff who serve as faculty.
34
Chapter 3: Partnerships
yy LHDs in urban areas are more likely
FIG U R E 3.6
Engagement with academic institutions in the past year by urbanization
Degree of urbanization
All LHDs
Urban
Suburban
Rural
LHD accepts students from academic institutions as trainees, interns,
or volunteers
76%
83%
76%
63%
LHD staff serve as faculty in academic institutions
30%
45%
21%
19%
LHD staff serve on an academic institution advisory group
25%
35%
24%
8%
LHD has formal relationship with academic institutions to provide training
or professional development for LHD staff
25%
28%
24%
20%
LHD actively recruits graduates from academic institutions
25%
35%
24%
6%
Faculty/staff from academic institutions have served in a consulting role for LHD
24%
38%
15%
12%
Academic institutions have agreements or policies on providing LHD with access
to scientific and professional journals
11%
16%
7%
8%
Did not engage academic institutions in any of the ways above
16%
12%
13%
33%
to engage with academic institutions.
For example, 35% actively recruit
graduates from academic institutions,
compared to only 6% of LHDs in rural
areas. Similarly, 35% of urban LHD
staff serve on an academic institution
advisory group, compared to only 8%
of rural LHD staff.
yy Almost two-thirds of rural LHDs
(63%) accept students as trainees,
interns, or volunteers. Less than 20%
of rural LHDs report any of the other
kinds of engagement with academic
institutions.
n=484
Technical note
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
35
Chapter 3: Partnerships
yy LHDs are more likely to be engaged
FIG U R E 3.7
with schools of nursing than other
kinds of academic institutions, usually
through formal agreements.
Engagement with specific types of academic institutions in the past year
Percent of LHDs
■ Any engagement
n=416
■ Formal engagement*
yy Sixty-three percent of LHDs partner
n=457
83%
Schools of nursing
60%
74%
Four-year colleges
or universities**
Accredited schools or
programs of public health
Community colleges
(two-year)**
or interact with accredited schools
or programs of public health in some
way, while almost one third of LHDs
(31%) have a formal agreement.
41%
63%
31%
53%
30%
*Formal Memorandum of Understanding or similar written agreement.
**In schools or programs other than nursing or public health.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
36
4
CHAPTE R
Leadership
This chapter includes the following:
■■ Characteristics of local health department (LHD) top
executives, including age, tenure, positions held prior
to top executive position, and degrees.
■■ Characteristics of new versus experienced LHD
top executives.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 4: Leadership
yy More than half of top executives are
FIG U R E 4.1
Characteristics of top executives over time
Female
56%
58%
60%
62%
female; since 2008, the percentage of
female top executives has increased
steadily, from 56% in 2008 to 62%
in 2016.
yy Few top executives are Hispanic/
Latino or a race other than white and
these percentages have remained low
since 2008.
yy The percentage of top executive posi-
tions that are part-time has decreased
by half since 2008, from 14% to 7%
in 2016.
Part time position
Race other than white
Hispanic/Latino
14%
7%
2%
2008
9%
6%
2%
2010
n=2,229–2,298 n=2,036–2,087
10%
7%
2%
2013
n=1,946–1,966
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
8%
7%
2%
2016
n=1,843–1,868
38
Chapter 4: Leadership
yy Almost two-thirds of top executives
FIG U R E 4.2
(65%) are 50 or older including
one-quarter (26%) who are 60 or
older. Twelve percent are younger
than 40.
Age of top executives in 2016
Less than 40
12%
40-49
24%
50-59
39%
60-69
70 or older
24%
2%
n=1,757
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
39
Chapter 4: Leadership
yy Since 2008, the percentage of top
FIG U R E 4.3
executives in their fifties has declined,
while the percentages of both older
(60–69) and younger (less than 40)
top executives have grown.
Age of top executives over time
50-59
46%
45%
42%
39%
40-49
60-69
Less than 40
70 or older
25%
23%
23%
17%
21%
9%
9%
9%
3%
2%
2%
2008
2010
n=2,188 n=2,005
2013
n=1,877
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
24%
12%
2%
2016
n=1,757
40
Chapter 4: Leadership
yy Compared to 2013, top executives
FIG U R E 4.4
Top executive
tenure over time
Percentage of top executives
Less than 2 years
2013
n=1,930
2016
n=1,759
20%
2-5 years
6-10 years
27%
28%
11 or more years
23%
29%
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
30%
18%
24%
have been in their positions for fewer
years. Since 2013, the percentage
of top executives who have been in
their positions less than five years has
increased, while the percentage of
top executives who have been in their
positions for six or more years has
decreased.
41
Chapter 4: Leadership
FIG U R E 4.5
Top executive average tenure over time by size of population served
Mean number of years
8.9
8.7
9.3
9.2
8.8
8.4
8.7
8.1
8.0
7.5
6.9
6.9
4.9
2008
decreased from 8.7 years to 7.5 years
since 2013; this trend is consistent
among LHDs serving different population sizes.
yy Top executives at large LHDs remain
Small (<50,000)
All LHDs
Medium (50,000–499,999)
in their positions for fewer years on
average (4.9) than top executives at
medium (6.9) or small (8.0) LHDs.
6.4
6.3
n=2,207
yy The average tenure for top executives
2010
n=2,033
2013
n=1,930
Large (500,000+)
2016
n=1,759
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
42
Chapter 4: Leadership
yy Prior to their current positions, top
FIG U R E 4.6
Positions held prior to current top executive position
Same LHD
Position at LHD
37%
Other public health position
19%
Non-public health position
Top executive position is vacant
Another LHD
11%
17%
6%
11%
Top executive
59%
executives are most likely to come
from LHDs—either from another
position in their current LHD (37%) or
from another LHD (22%). Only 11%
of top executives were top executives
at another LHD prior to their current
position.
yy Only 17% of top executives come
from positions in fields other than
public health.
n=1,815
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
43
Chapter 4: Leadership
yy The highest degree held by top exec-
FIG U R E 4.7
Highest degree obtained
by top executive by LHD characteristics
Percent of top executives with highest degree obtained
Associate's
All LHDs
8%
Bachelor's
Master's
Doctoral
30%
46%
16%
yy Top executives at large LHDs are
Size of population served
Small (<50,000)
21%
60%
17%
1%
Degree of urbanization
Rural
Suburban
Urban 3%
21%
12%
48%
32%
8%
8%
31%
42%
18%
52%
much more likely to have graduate
degrees (91%) than top executives at
small LHDs (48%).
yy Similarly, top executives at LHDs serv-
49%
42%
8%
9%
39%
39%
12%
Medium (50,000–499,999) 2%
Large (500,000+)
utives is most often a Master’s degree
(46%), followed by a Bachelor’s
degree (30%); fewer hold Associate’s
(8%) or Doctoral degrees (16%).
ing urban areas are much more likely
to have graduate degrees (75%) than
top executives at LHDs serving rural
areas (39%).
23%
n=1,807
Technical note
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
44
Chapter 4: Leadership
yy Slightly less than one-third of top
FIG U R E 4.8
executives hold nursing degrees
(31%), one-quarter hold public health
degrees (25%), and 12% hold medical
degrees.
Specialized degrees obtained by top executive by LHD characteristics
Nursing
All LHDs
Public health
Medical
12%
25%
31%
yy Top executives at large LHDs are
Size of population served
Small (<50,000)
Medium (50,000–499,999)
6%
18%
40%
35%
20%
Large (500,000+) 9%
16%
40%
41%
Degree of urbanization
Rural
52%
Suburban
Urban
36%
16%
6%
16%
9%
21%
35%
18%
more likely to have public health
degrees (41%) and medical degrees
(40%) than nursing degrees (9%). On
the other hand, top executives at small
LHDs are more likely to have nursing
degrees (40%) than public health
degrees (18%) or medical degrees
(6%).
yy Top executives at LHDs serving rural
areas are more likely to have nursing
degrees (52%) than top executives at
LHDs serving urban areas (16%).
n=1,807
Technical note
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
45
Chapter 4: Leadership
yy In some ways, new top executives
FIG U R E 4.9
(i.e., top executives who have been
in their positions for less than three
years) are different than experienced
top executives. For example, new top
executives are less likely to come from
another local or state agency prior to
holding their current position and are
four times more likely to be less than
40 years old than experienced top
executives.
Characteristics of new versus experienced top executives
Percent of top executives
■ New: Top executive for less than three years
■ Experienced: Top executive for three or more years
New top executives are less likely to come from a local
or state agency
New top executives are more likely to be less than
40 years old
59%
25%
69%
New top executives have very similar race and ethnicity
8%
3%
8%
2%
6%
yy On the other hand, new top exec-
utives are typically of similar race
and ethnicity as experienced top
executives (mostly white and mostly
non-Hispanic).
New top executives are slighly more likely to be female
Race other than white
Hispanic
68%
62%
New top executives are slightly more likely to have
a graduate degree
yy New top executives are also slightly
more likely to be female, slightly more
likely to have a graduate degree, and
slightly less likely to have a nursing
degree than their more experienced
counterparts.
New top executives are slightly less likely to have
a nursing degree
64%
61%
29%
33%
n=1,757–1,868
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
46
5
CHAPTE R
Workforce
This chapter includes the following:
■■ Current numbers of local health department (LHD) staff
(employees and Full-Time Equivalents (FTEs)).
■■ Annual LHD job losses and gains.
■■ Changes in numbers of LHD staff (2008 to 2016).
■■ Employees retiring from LHD workforce.
■■ Occupations employed by LHDs.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 5: Workforce
yy Eighty percent of LHDs employ fewer
FIG U R E 5.1
than 50 FTEs: 37% employ fewer
than 10 FTEs and 42% employ
between 10 and 50 FTEs.
Number of Full-Time Equivalents (FTEs)
Percent of LHDs
16%
<5
28%
10–24.9
15%
25–49.9
10%
50–99.9
200+
or more FTEs.
21%
5–9.9
100–199.9
yy Ten percent of LHDs employ 100
5%
5%
n=1,743
Technical note
In order to minimize data loss, special statistical weights were developed to calculate some workforce statistics. Statistics were
calculated using all valid data available, regardless of missing information in other occupations, total employees, and total FTEs.
A note below each figure in this chapter indicates whether special weights were used to calculate the statistics presented.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
48
Chapter 5: Workforce
FIG U R E 5.2
Mean and median number of employees and Full-Time Equivalents (FTEs)
by size of population served
Number of employees
Number of FTEs
Size of population served
Mean
Median
Mean
Median
All LHDs
57
18
50
15
<10,000
8
6
6
4
10,000–24,999
14
10
11
8
25,000–49,999
22
17
19
14
50,000–99,999
41
32
36
27
100,000–249,999
71
63
64
58
250,000–499,999
164
134
159
124
500,000–999,999
294
261
259
230
1,000,000+
736
478
694
486
n(employees)=1,828
yy On average, LHDs employ 57 employees or 50 FTEs; however, these vary
greatly by the size of population
served by the LHD. While LHDs that
serve fewer than 10,000 people
employ eight employees or six FTEs
on average, LHDs that serve over one
million people employ 736 employees
or 694 FTEs on average.
yy Half of LHDs employ fewer than
18 employees.
n(FTEs)=1,743
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
49
Chapter 5: Workforce
FIG U R E 5.3
Full-Time Equivalents (FTEs) per 10,000 people by size of population served
Size of population served
2016
All LHDs
4.2
<10,000
10.2
10,000–24,999
7.2
25,000–49,999
5.2
50,000–99,999
5.1
100,000–199,999
4.5
200,000–499,999
4.3
500,000–999,999
3.7
1,000,000+
3.4
yy Among all LHDs, the overall work-
force capacity is 4.2 FTEs per 10,000
people.
yy LHDs that serve smaller populations
employ a greater number of FTEs per
10,000 people than LHDs that serve
larger populations.
n=1,743
Technical notes
The number of LHD staff per 10,000 people
served by the LHD is a useful way to measure
overall workforce capacity and facilitates
comparisons across LHDs serving different
jurisdiction sizes. These statistics are computed
by summing the FTE staff (for all LHDs or for
LHDs in specific jurisdiction size categories),
dividing by the total population of those
jurisdictions, and multiplying by 10,000.
Special weighting methodology applied
to account for item non-response.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
50
Chapter 5: Workforce
yy Approximately 147,000 employees or
FIG U R E 5.4
133,000 FTEs are employed by LHDs.
Estimated size of LHD workforce
Estimated size
Total employees
n=1,828
Total FTEs
n=1,743
95% Confidence intervals
147,000
126,000
168,000
yy The confidence intervals reflect the
uncertainty of this estimate (because
of incomplete data and great variability in numbers of LHD staff).
133,000
112,000
153,000
Technical note
Special weighting methodology applied
to account for item non-response.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
51
Chapter 5: Workforce
FIG U R E 5.5
Distribution of Full-Time Equivalents (FTEs) by urbanization
Rural
5%
yy Almost three-quarters of LHD FTEs
(73%, or 97,400 FTEs) are employed
by LHDs that serve urban areas. Only
5% of LHD FTEs (6,700 FTEs) are
employed by LHDs that serve rural
populations.
Suburban
22%
Urban
73%
n=1,743
Technical notes
Special weighting methodology applied
to account for item non-response.
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
52
Chapter 5: Workforce
yy Since 2008, the estimated number of
FIG U R E 5.6
LHD employees has decreased from
190,000 in 2008 to 147,000 in 2016,
a decrease of 23%.
Estimated size of LHD workforce over time
Total employees
Total Full-Time Equivalents (FTEs)
190,000
184,000
162,000
166,000
147,000
160,000
146,000
2008
2010
n=2,205–2,234 n=1,971–2,033
2013
n=1,922–1,942
133,000
yy Similarly, the estimated number
of FTEs employed by LHDs has
decreased from 166,000 in 2008 to
133,000 in 2016, a decrease of 20%.
2016
n=1,743–1,828
Technical notes
Special weighting methodology applied
to account for item non-response.
Estimates for 2008 workforce are different
from 2008 National Profile of Local Health
Departments Report due to new weighting
methodology
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
53
Chapter 5: Workforce
FIG U R E 5.7
Change in Full-Time Equivalents (FTEs) per 10,000 people over time
by size of population served
FTEs per 10,000 people
6.9
6.2
4.5
4.2
3.6
2008
2010
n=2,205 n=1,971
2013
n=1,922
workforce capacity since 2008. While
5.3 FTEs per 10,000 people were
employed at LHDs in 2008, only
4.2 FTEs per 10,000 people were
employed in 2016.
yy Large LHDs have experienced a
Small (<50,000)
5.3
5.2
4.9
yy Overall, LHDs lost 21% of their
greater loss in workforce capacity
since 2008 than medium or small
LHDs.
Medium (50,000–499,999)
All LHDs
Large (500,000+)
2016
n=1,743
Technical notes
This figure shows changes in overall LHDs
workforce capacity (measured in FTEs per 10,000
people) between 2008 and 2016. See notes on
Figure 5.3 for more information on how these
statistics are computed.
Special weighting methodology applied
to account for item non-response.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
54
Chapter 5: Workforce
yy Less than 3% of the total LHD work-
FIG U R E 5.8
force retired in calendar year 2015.
Percentage of total workforce retired over time
2.1%
2.4%
2008
2010
n=428
n=392
2.7%
2.7%
2013
2016
n=462
yy LHDs reported similar percentages
of the LHD workforce retiring in the
2013 and 2016 Profiles; the percentage has increased only slightly since
2008.
n=414
Based on numbers of employees who retired in the previous year.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
55
Chapter 5: Workforce
yy Almost all LHDs employ registered
FIG U R E 5.9
Occupations employed at LHDs by size of population served
Size of population served
All LHDs
<25,000
25,000–
49,999
50,000–
99,999
100,000–
249,999
250,000–
499,999
500,000–
999,999
1,000,000+
Agency leadership
76%
66%
75%
84%
88%
93%
95%
88%
Animal control worker
10%
7%
8%
16%
10%
13%
18%
24%
Behavioral health staff
13%
6%
9%
18%
18%
32%
45%
36%
Business operations staff
50%
33%
48%
61%
69%
82%
83%
86%
Community health worker
29%
17%
26%
29%
44%
62%
71%
69%
Environmental health worker
76%
62%
79%
86%
92%
90%
86%
79%
Epidemiologist/statistician
26%
8%
14%
28%
54%
79%
92%
95%
Health educator
55%
34%
56%
67%
78%
90%
89%
83%
Information systems specialist 18%
5%
10%
18%
35%
57%
66%
76%
Laboratory worker
15%
4%
8%
19%
27%
40%
54%
79%
Licensed practical or
vocational nurse
32%
24%
27%
36%
41%
54%
54%
69%
Nursing aide and home
health aide
24%
26%
21%
23%
19%
29%
25%
21%
Nutritionist
50%
31%
47%
65%
71%
80%
77%
86%
Office support staff
91%
87%
92%
95%
95%
97%
96%
93%
Oral health care professional
18%
7%
13%
23%
31%
37%
51%
52%
Preparedness staff
59%
39%
56%
69%
84%
94%
93%
88%
Public health physician
31%
15%
27%
35%
50%
69%
69%
93%
Public information
professional
20%
6%
13%
21%
38%
59%
72%
76%
Registered nurse
94%
90%
97%
97%
97%
97%
95%
100%
nurses (94%) and office and administrative support staff (91%). Fewer
LHDs employ animal control workers
(10%), behavioral health staff (13%),
or laboratory workers (15%).
yy LHDs serving larger populations are
much more likely than small LHDs to
employ epidemiologist/statisticians,
information systems specialists,
public information professionals, and
public health physicians. LHDs of all
jurisdiction sizes are approximately
equally as likely to employ office
and administrative support staff and
nursing or home health aides.
n=1,865
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
56
Chapter 5: Workforce
FIG U R E 5.10
Staffing patterns at LHDs by size of population served (in median Full-Time Equivalents (FTEs))
<10,000
10,000–24,999
25,000–49,999
50,000–99,999
4 Total FTEs
8 Total FTEs
14 Total FTEs
27 Total FTEs
1 Registered nurse
1 Office support staff
0.5 Agency leadership
100,000–249,999
2 Registered nurses
2 Office support staff
1 Agency leadership
1 Environmental health worker
3 Registered nurses
3 Office support staff
1 Agency leadership
1 Environmental health worker
0.4 Health educators
0.2 Preparedness staff
250,000–499,999
500,000–999,999
6 Registered nurses
5 Office support staff
1 Agency leadership
3 Environmental health workers
1 Health educator
0.9 Preparedness staff
1 Nutritionist
1 Business operations staff
1,000,000+
58 Total FTEs
124 Total FTEs
230 Total FTEs
486 Total FTEs
9 Registered nurses
8.5 Office support staff
3 Agency leadership
7 Environmental health workers
2 Health educators
1 Preparedness staff
2 Nutritionists
1.5 Business operations staff
17 Registered nurses
20 Office support staff
5 Agency leadership
15 Environmental health workers
3 Health educators
2 Preparedness staff
4 Nutritionists
4 Business operations staff
1 Community health worker
1 Epidemiologist/statistician
1 Information systems specialist
1 Public health physician
1 Public information professional
29.3 Registered nurses
30.5 Office support staff
6 Agency leadership
20.5 Environmental health workers
6 Health educators
3 Preparedness staff
6 Nutritionists
5.8 Business operations staff
4 Community health workers
2.9 Epidemiologist/statisticians
1 Information systems specialist
1 Public health physician
1 Public information professional
54.2 Registered nurses
76.7 Office support staff
7 Agency leadership
37 Environmental health workers
14 Health educators
4.8 Preparedness staff
15 Nutritionists
20.4 Business operations staff
4 Community health workers
6 Epidemiologist/statisticians
3.5 Information systems specialists
2 Public health physicians
1 Public information professional
6 Laboratory workers
2.5 Licensed practical or vocational nurses
n=1,611–1,817
yy LHDs serving the smallest jurisdictions typically employ yy LHDs serving medium-sized jurisdictions typically also
registered nurses, office support staff, a top executive,
and environmental health workers.
employ some additional occupations, including health
educators, preparedness staff, nutritionists, and business and financial operations staff.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
yy LHDs serving jurisdictions over one million people typ-
ically employ nearly 500 FTE staff including more than
50 registered nurses, more than 75 office support staff,
and employees in many specialized occupations such as
community health workers, epidemiologists, information
systems specialists, and public information professionals.
57
Chapter 5: Workforce
FIG U R E 5.11
Estimated numbers of LHD workers in select occupations
Number of FTEs for select occupations
Total
95% Confidence intervals
Agency leadership
7,000
4,900
9,100
Animal control worker
910
650
1,200
Behavioral health staff
3,200
2,000
4,400
Business operations staff
6,000
4,400
7,700
Community health worker
5,200
4,000
6,500
Environmental health worker
13,000
10,200
15,900
Epidemiologist/statistician
1,600
1,200
2,000
Health educator
5,700
3,900
7,400
Information systems specialist
1,700
780
2,700
Laboratory worker
1,600
1,000
2,200
Licensed practical or vocational nurse
2,400
1,800
2,900
Nursing aide and home health aide
3,200
2,300
4,100
Nutritionist
4,900
4,100
5,700
Office support staff
23,700
19,900
27,500
Oral health care professional
1,800
1,400
2,300
Preparedness staff
2,100
1,900
2,400
Public health physician
1,400
890
1,800
Public information professional
540
450
630
Registered nurse
23,600
19,700
27,500
yy Approximately 23,700 FTEs are office
and administrative support staff and
23,600 FTEs are registered nurses.
yy Only 910 FTEs are animal control
workers and 540 FTEs are public
information professionals.
n=1,611–1,828
Technical note
Special weighting methodology applied
to account for item non-response.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
58
Chapter 5: Workforce
yy More than one-third of the LHD
FIG U R E 5.12
workforce is composed of registered
nurses (18%) or office and administrative support staff (18%).
Workforce composition
Agency leadership
(5%)
Environmental health workers
(10%)
Business operations staff
(5%)
Preparedness staff
(2%)
Licensed practical
or vocational nurse
(2%)
Nursing or
home health aide
(2%)
Behavioral health staff
(2%)
yy Ten percent of the LHD workforce is
environmental health workers.
yy A total of less than 10% of the LHD
Nutritionists
(4%)
Community
health workers
(4%)
Health educators
(4%)
workforce comprises oral health
care professionals, information
systems specialists, epidemiologists/
statisticians, public health physicians,
laboratory workers, and animal control
workers.
Oral health
care
(1%)
Physicians
(1%)
Epi/stats
(1%)
Info
systems
(1%)
Office support staff
(18%)
Registered nurses
(18%)
Lab
workers
(1%)
Animal
control
(1%)
Estimates shown (detail lost due to rounding). Public information professional (0.4%) not shown.
n=1,611–1,828
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Other occupations
not in Profile
(18%)
Technical notes
This diagram depicts the overall composition of
the LHD workforce across the United States. The
area of each box corresponds to the fraction of
the LHD workforce comprised by that occupation.
Special weighting methodology applied
to account for item non-response.
59
Chapter 5: Workforce
yy The estimated number of registered
FIG U R E 5.13
nurses decreased by 28% from 2008
to 2016 and the estimated number of
behavioral staff decreased by more
than half.
Estimated size of select occupations over time
Number of Full-Time Equivalents (FTEs)
Registered nurses
Environmental health workers
32,900
27,900
yy On the other hand, the estimated
27,700
23,600
15,300
13,800
2008
n=1,992
2010
n=1,855
2013
n=1,704
2016
n=1,611
2008
n=1,831
2010
n=1,802
5,600
2010
n=1,766
2013
13,000
2016
n=1,573
n=1,645
5,100
5,700
Health educators
Behavioral health staff
7,400
2008
n=1,925
13,300
number of health educators and nutritionists increased by 30% and 18%
respectively from 2008 to 2016.
4,000
2013
n=1,388
3,200
2016
n=1,804
4,400
2008
n=1,899
4,900
2010
n=1,754
2013
n=1,441
2016
n=1,652
Nutritionists
Technical notes
4,200
4,600
2008
2010
n=1,863
n=1,733
5,000
4,900
2013
2016
n=1,443
n=1,700
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Special weighting methodology applied
to account for item non-response.
Estimates for 2008 workforce are different from
2008 National Profile of Local Health Departments
Report due to new weighting methodology.
60
Chapter 5: Workforce
FIG U R E 5.14
Percent of LHDs reporting jobs lost due to layoffs and/or attrition in the past year
by LHD characteristics
Percent of LHDs reporting jobs lost due to layoffs and/or attrition
All LHDs
medium LHDs, those serving populations of 50,000 or more people,
reported having lost at least one job
compared to small LHDs.
21%
36%
Medium (50,000–499,999)
yy Similarly, LHDs with shared
41%
Large (500,000+)
Type of governance
State
Local
Shared
reported at least one job lost during
calendar year 2015 due to layoffs
and/or attrition.
yy A larger proportion of large and
27%
Size of population served
Small (<50,000)
yy Twenty-seven percent of LHDs
24%
governance (governed by both state
and local authorities) were more likely
to report having lost at least one job
compared to state-governed or locally
governed LHDs.
27%
42%
n=1,780–1,778
Technical note
The 2016 Profile included questions about
loss of LHD staff (by layoffs or attrition) during
calendar year 2015. Similar questions have
been included in nine other NACCHO surveys
administered periodically since the beginning of
the Great Recession. Figures 5.14 through 5.16
present findings based on those data.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
61
Chapter 5: Workforce
yy Since 2011, the percentage of LHDs
FIG U R E 5.15
Percent of LHDs reporting jobs lost due to layoffs and/or attrition over time
44%
36%
38%
34%
27%
2011
n=432–437
2013
n=1,895–1,938
2014
n=620–631
2015
n=646–664
reporting at least one job lost due to
layoffs and/or attrition has decreased.
While 44% of LHDs reported having
lost at least one job during the 2010
calendar year, 27% of LHDs reported
having lost at least one job during the
2015 calendar year.
2016
n=1,780–1,778
Technical note
N’s vary because questions regarding layoffs
and attrition were asked in separate questions
with different numbers of observations across
survey years.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
62
Chapter 5: Workforce
FIG U R E 5.16
Number of jobs lost and added over time by size of population served
Number of
positions eliminated
Number of
positions added
All LHDs
Net Change
2011
9,970
3,700
-6,270
2012
4,090
3,680
-410
2015
2,720
3,570
850
Small LHDs (<50,000)
2011
2,200
600
-1,600
2012
820
620
-200
2015
620
720
100
Medium (50,000–499,999)
2011
4,500
1,350
-3150
2012
2,030
1,650
-380
2015
1,460
1,640
180
Large (500,000+)
2011
3,270
1,740
-1,530
2012
1,240
1,400
160
2015
640
1,210
570
n(Jun 2011)=604 n(Jan 2012)=617 n(2012)=1,775 n(2015)=1,261
yy Among all LHDs, there was a net loss
of 6,270 jobs in the 2011 calendar
year; the net job loss decreased to
410 jobs in 2012. In 2015, the number
of jobs added exceeded the number
of jobs eliminated, for a net increase
of 850 jobs across all LHDs.
yy The number of jobs added was similar
in all three time periods (between
3,500 and 3,700). The decreasing
number of jobs lost accounts for the
differences in the net job change
during these three years.
yy LHDs in all jurisdiction size cate-
gories showed net losses of staff
during 2011 and net gains of staff
during 2015. LHDs serving small
and medium jurisdictions showed
net losses of staff during 2012, while
LHDs serving large jurisdictions
showed a net gain during 2012.
Technical notes
This figure summarizes data on numbers of LHD
positions added and eliminated during three
calendar years. The net change is the number of
positions added minus the number of positions
eliminated. Net loss figures are shown in orange
and net gain figures in green.
Only LHDs that reported values for all job cuts
and added variables are included in the analysis.
NACCHO estimated 2011 statistics using data
from two surveys in which LHDs reported jobs
lost and added: in January through June 2011
(labeled as Jun 2011) and July through December
(labeled as Jan 2012).
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
63
6
CHAPTE R
Finance
This chapter includes the following:
■■ Total annual local health department (LHD) expenditures.
■■ Annual per capita LHD expenditures and revenues including
expenditures over time.
■■ LHD revenue sources.
■■ Annual per capita LHD revenue sources including revenue
over time.
■■ Changes in LHD budgets over time.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 6: Finance
yy Total annual LHD expenditures range
FIG U R E 6.1
from less than $250,000 to more than
$25 million.
Total annual expenditures
Percent of LHDs
<$250,000
9%
$500,000–$749,999
7%
9%
$5,000,000–$9,999,999
Not reported
(34%) did not report their annual
expenditures.
14%
$2,500,000–$4,999,999
$25,000,000+
yy More than one-third of LHDs
5%
$1,000,000–$2,499,999
$10,000,000–$24,999,999
annual expenditures of less than
$1 million; 3% of LHDs report expenditures of $25 million or more.
7%
$250,000–$499,999
$750,000–$999,999
yy Twenty-eight percent of LHDs report
7%
5%
3%
34%
n=1,929
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
65
Chapter 6: Finance
FIG U R E 6.2
Mean and quartiles of total annual expenditures by size of population served
Size of population served
Mean
25th percentile
50th percentile
(Median)
75th percentile
All LHDs
$6,400,000
$500,000
$1,280,000
$4,000,000
<25,000
$760,000
$250,000
$480,000
$890,000
25,000–49,999
$1,640,000
$600,000
$1,140,000
$2,100,000
50,000–99,999
$3,280,000
$1,440,000
$2,640,000
$4,290,000
100,000–249,999
$6,220,000
$3,220,000
$5,100,000
$7,650,000
250,000–499,999
$16,500,000
$6,920,000
$10,100,000
$19,800,000
500,000–999,999
$32,900,000
$15,200,000
$24,400,000
$42,200,000
1,000,000+
$126,000,000
$34,300,000
$56,400,000
$94,200,000
yy On average, LHDs spend $6.4 million
per year. Half of LHDs spend less
than $1.3 million per year.
yy Comparing the 25th and 75th per-
centiles for each population category
illustrates the great diversity in funding
levels among LHDs serving jurisdictions of similar sizes.
n=1,286
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
66
Chapter 6: Finance
FIG U R E 6.3
Median and mean annual per capita expenditures and revenues by LHD characteristics
Expenditures
Revenue
Median
Mean
Median
Mean
All LHDs
$39
$55
$41
$54
Size of population served
<25,000
$49
$68
$51
$65
25,000–49,999
$32
$46
$37
$50
50,000–99,999
$39
$48
$40
$48
100,000–249,999
$33
$40
$33
$40
250,000–499,999
$32
$46
$31
$44
500,000–999,999
$37
$48
$36
$50
1,000,000+
$31
$44
$33
$43
Type of governance
State
$35
$40
$38
$45
Local
$38
$53
$38
$51
Shared
$58
$78
$69
$86
n(expenditures)=1,286
yy Median and mean annual per capita
expenditures were similar to annual
per capita revenues across LHDs.
yy On average, LHDs serving the smallest populations (fewer than 25,000
people) have higher per capita revenues and expenditures than LHDs
serving larger populations.
yy LHDs with a shared governance
structure receive and spend more on
average than LHDs with exclusively
local or state governance.
n(revenue)=1,166
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
67
Chapter 6: Finance
yy Overall annual LHD expenditures per
FIG U R E 6.4
capita vary greatly by state, with LHDs
in Delaware spending less than $6
per person and LHDs in Alaska and
New York spending more than $100
per person.
Overall annual expenditures per capita by state
n <$30 n $30–$49.99 n $50–$69.99 n $70+
WA
MT
ME
ND
MN
OR
ID
WI
SD
WY
UT
CA
AZ
CO
IL
KS
OK
NM
TX
HI
PA
OH
IN
MD
WV
MO
VA
KY
AR
RI
were less than $30 in 10 states, $30
to $49 in 15 states, $50 to $69 in
10 states, and more than $70 in four
states.
NJ
DE
DC
NC
TN
SC
MS
AK
MI
IA
NE
NV
VT
NH
NY
MA
CT
yy Annual LHD expenditures per capita
AL
GA
LA
The following states have insufficient expenditure data: AR, LA, ME, NM, NV, OK, PA, SD, VT.
FL
Technical notes
Statistics presented in this map are computed
by summing the expenditures reported by LHDs
in each state and dividing by the total population
of the reporting jurisdictions. This reflects the
overall level of LHD expenditures in the state and
is a weighted average that takes into account the
population of each jurisdiction.
State estimates were not computed using
weights to account for non-response.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
68
Chapter 6: Finance
yy Over time, average LHD expenditures
FIG U R E 6.5
per capita have decreased 25%, from
$63 in 2008 to $48 in 2016.
Median and mean annual per capita expenditures over time
Mean
Median
$63
$55
$36
2008
n=2,096
$40
2010
n=1,709
yy On the other hand, median per capita
$51
$35
2013
n=1,516
$48
expenditures increased between
2008 and 2010 (from $36 to $40),
but then decreased 15% between
2010 and 2016 (from $40 to $34).
$34
2016
n=1,286
The statistics for 2010, 2013, and 2016 have been adjusted to reflect inflation rates based on the Bureau of Labor Statistics’ Consumer Price Index.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
69
Chapter 6: Finance
yy LHDs receive funding from a variety
FIG U R E 6.6
of sources, including local, state, federal, and clinical sources.
Revenue sources
yy Just under one-third (30%) of LHD
revenues come from local sources
and 21% come from state sources.
Local
(30%)
State
(21%)
yy Fifteen percent of LHD revenues
are payments for clinical services
(Medicare, Medicaid, private insurers,
or patient personal fees).
Medicare and Medicaid
(12%)
Non-clinical fees and fines
(7%)
Federal direct
(7%)
Federal pass-through
(17%)
Estimates shown (detail lost due to rounding).
n=920–1482
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Other
(3%)
Private
Private
foundation insurers
(1%)
(1%)
Patient
fee
(1%)
Technical note
This diagram depicts the overall composition
of LHD revenue sources. The area of each box
corresponds to the fraction of all revenues that
source provides.
70
Chapter 6: Finance
FIG U R E 6.7
Median and mean annual per capita revenue by selected sources and by LHD characteristics
Local
State
Federal direct
and pass-through
Clinical*
Median
Mean
Median
Mean
Median
Mean
Median
Mean
All LHDs
$10
$15
$6
$10
$8
$11
$4
$12
Small (<50,000)
$11
$16
$6
$11
$8
$12
$4
$14
Medium (50,000–499,999)
$8
$12
$5
$9
$7
$9
$3
$9
Large (500,000+)
$7
$15
$6
$9
$10
$13
$2
$7
State
$2
$5
$11
$13
$8
$11
$6
$14
Local
$12
$16
$4
$8
$7
$10
$2
$10
Shared
$11
$14
$15
$21
$15
$20
$12
$23
Urban
$9
$14
$2
$6
$5
$7
$1
$5
Suburban
$10
$12
$7
$12
$9
$12
$6
$15
Rural
$15
$20
$9
$14
$12
$17
$9
$20
Northeast
$10
$14
$0
$5
$0.04
$2
$0
$2
Midwest
$12
$16
$4
$7
$8
$10
$3
$12
South
$4
$12
$11
$15
$9
$14
$9
$18
West
$10
$16
$6
$13
$13
$17
$3
$11
Size of population served
Type of governance
Degree of urbanization
Region
*Includes Medicaid/Medicare, private health insurance, and patient personal fees.
n=981–1,251
yy On average, small LHDs receive more
per capita from local, state, and clinical
sources than medium and large LHDs.
yy LHDs with shared governance receive
more per capita from state, federal,
and clinical sources than LHDs with
exclusively local or state governance.
Locally governed LHDs receive more
per capita from local sources than
state-governed LHDs or LHDs with
shared governance.
yy Rural LHDs receive more per capita
from all sources than urban or suburban LHDs. The difference in clinical
revenues among rural and urban
LHDs is particularly striking (mean
of $20 per capita for rural jurisdictions versus $5 per capita for urban
jurisdictions).
yy LHDs in the Northeast and Midwest
receive more per capita from local
sources than LHDs in the South or
West; LHDs in the South receive more
per capita from state sources than
LHDs in other regions; and LHDs in
the West receive more per capita from
federal sources than LHDs in other
regions.
Technical note
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
71
Chapter 6: Finance
yy Since 2008, average per capita
FIG U R E 6.8
revenues from local, state, and clinical
sources have decreased. Notably,
LHD mean per capita revenues from
clinical sources decreased by onethird since 2008.
Median and mean annual per capita revenue sources over time
State
Local
Mean
$15
$12
$13
$13
Mean
Median
$7
2008
n=1,623
$8
2010
n=1,439
$9
$7
2013
n=1,549
Median
2016
$11
$6
2008
n=1,251
n=1,665
$11
$9
$6
$5
2010
2016
n=1,533
yy Mean and median revenue per capita
from federal sources (direct and
passed through from state agencies)
has remained relatively consistent
since 2008.
n=1,140
Clinical*
Federal direct and pass-through
$18
Mean
Median
$9
$6
2008
n=1,569
$10
$10
$7
$7
2010
n=1,387
Mean
Median
2016
n=1,021
$14
$13
$10
$4
$5
$4
2008
2010
2013
n=1,626
n=1,408
n=1,364
$3
2016
n=981
Statistics for 2010, 2013, and 2016 were adjusted for inflation.
*Includes Medicaid/Medicare, private health insurance, and patient personal fees.
Technical notes
The statistics of revenues from local, state and
federal direct and pass-through in 2010, 2013,
and 2016 have been adjusted to reflect inflation
rates based on the Bureau of Labor Statistics’
Consumer Price Index.
The statistics of clinical revenue in 2010, 2013,
and 2016 have been adjusted to reflect inflation
rates based on the Bureau of Labor Statistics’
Consumer Price Index and medical cost inflation.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
72
Chapter 6: Finance
yy From 2009 to 2012, between 38%
FIG U R E 6.9
and 45% of LHDs reported lower
budgets compared to the previous fiscal year. In recent years, fewer LHDs
have reported budget cuts; 23% of
LHDs reported having a lower budget
in both 2015 and 2016.
Budget changes over time
Percent of LHDs reporting a lower budget in the current fiscal year
Percent of LHDs reporting a higher budget in the current fiscal year
45%
44%
45%
41%
38%
27%
yy On the other hand, the percent of
27%
29%
28%
23%
26%
23%
25%
25%
19%
16%
Dec
2008
July
2009
Jan
2010
Nov
2010
11%
11%
July
2011
Jan
2012
21%
23%
LHDs reporting a higher budget compared to the previous fiscal year has
slowly started to increase over time.
While only 11% reported a higher budget in 2011 and 2012, 29% of LHDs
reported a higher budget in 2016.
yy For the first time since NACCHO
Jan
2013
Jan
2014
Jan
2015
Jan
2016
started collecting these data, more
LHDs reported higher budgets
than lower budgets; in all previous
NACCHO surveys, more LHDs have
reported lower than higher budgets.
Technical note
The 2016 Profile included questions about
budget changes relative to the previous fiscal
year. Similar questions have been included
in nine other NACCHO surveys administered
periodically since the beginning of the Great
Recession. Figures 6.9 and 6.10 present findings
based on those data.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
73
Chapter 6: Finance
FIG U R E 6.10
Percent of budget cut in the current fiscal year compared to the previous fiscal year
Percent of LHDs
77%
No budget cut
1–2.9%
7%
3–4.9%
5%
5–9.9%
5%
10% or more
5%
yy While most LHDs (77%) did not
report a lower budget compared to
the previous fiscal year, five percent of
LHDs reported a budget cut of 10%
or more.
n=1,665
Technical notes
The data reported in this chapter should be interpreted with some caution. Collecting error-free data on LHD financing across the United
States remains challenging. Large amounts of missing data from the 2016 Profile study led to a greater degree of approximation than
was necessary for other chapters of this report. Special weights were generated for all funding measures to minimize the effect of low
responses to those questions.
None of the LHDs in Vermont can provide any financial data, nor can state health agency units Oklahoma and South Dakota. In some
other states (Arkansas, Louisiana, Maine, New Mexico, Nevada, and Pennsylvania) data are very incomplete, so reliable state-level
estimates cannot be developed for per capita expenditures. Data for the District of Columbia were not included in the analysis of total
expenditures, total revenues, and revenues from various sources because its status as both a local and state health department results in
extreme values relative to other LHDs.
Comparisons with statistics from past Profile studies should be made with caution, especially for subgroups (e.g., state-governed LHDs,
LHDs from certain states, or LHDs serving large jurisdictions). Some of the observed differences from year to year result from a large
difference in the group of LHDs that provided financial data in each Profile year.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
74
7
CHAPTE R
Programs
and Services
This chapter includes the following:
■■ Clinical and population-based programs and services provided
directly in the past year.
■■ Programs and services provided most frequently via contracts.
■■ Differences in programs and services provided in rural and
urban jurisdictions.
■■ Programs and services provided by more or fewer local health
departments (LHDs) compared with 2008.
■■ Change in level of service provision in the past year.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 7: Programs and Services
yy LHDs provide many different types of
FIG U R E 7.1
Clinical programs and services provided directly in the past year
Program/service
% LHDs
Program/service
Immunization
Adult immunizations
Childhood immunizations
% LHDs
Program/service
% LHDs
Treatment for communicable diseases
Other clinical services
90%
Tuberculosis
79%
Laboratory services
38%
88%
Other STDs
63%
School-based clinics
34%
Screening for diseases/conditions
HIV/AIDS
35%
Oral health
28%
Tuberculosis
84%
Maternal and child health services
Other STDs
65%
22%
HIV/AIDS
62%
Women, Infants,
and Children (WIC)
66%
Asthma prevention
and/or management
Home health care
20%
Blood lead
61%
Home visits
60%
Correctional health
13%
High blood pressure
54%
Family planning
53%
Substance abuse
11%
Body Mass Index (BMI)
53%
Comprehensive primary care
11%
Diabetes
34%
Behavioral/mental health
10%
Cancer
32%
Emergency medical services
4%
Cardiovascular disease
25%
Early and periodic screening,
diagnosis, and treatment
38%
Well child clinic
29%
Prenatal care
27%
Obstetrical care
8%
n=1,461–1,899
clinical programs and services directly,
including adult and child immunizations, screening and treatment for
chronic and communicable diseases
or conditions, and maternal and child
health services.
yy Adult and child immunizations are
the clinical services most often
provided by LHDs (90% and 88%,
respectively).
yy Almost two-thirds (66%) of LHDs
provide Women, Infants, and Children
(WIC) services.
yy The proportion of LHDs providing
other clinical services varies greatly;
only 4% provide emergency medical
services while 84% provide tubercu
losis screening.
Technical note
LHD laboratories may test clinical or
environmental specimens; the Profile
questionnaire includes a single item
intended to include both types.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
76
Chapter 7: Programs and Services
yy LHDs provide many different types of
FIG U R E 7.2
Population-based programs and services provided directly in the past year
Program/service
% LHDs
Epidemiology and surveillance
Program/service
% LHDs
Other environmental health services
Food service establishments
79%
Food safety education
77%
Schools/daycare
74%
Nuisance abatement
76%
Vector control
53%
Groundwater protection
44%
Surface water protection
35%
Indoor air quality
35%
Hazmat response
21%
Radiation control
21%
Air pollution
20%
Land use planning
19%
Hazardous waste disposal
18%
Noise pollution
16%
93%
Environmental health
85%
Maternal and child health
69%
Recreational water
(e.g., pools, lakes, beaches)
68%
Syndromic surveillance
61%
Septic systems
67%
Chronic disease
49%
Smoke-free ordinances
65%
Behavioral risk factors
45%
Injury
32%
Body art
(e.g., tattoos, piercings)
60%
Private drinking water
60%
Children’s camps
59%
Hotels/motels
58%
Lead inspection
53%
Campgrounds & RVs
46%
Tobacco retailers
38%
Health-related facilities
38%
Public drinking water
37%
Food processing
36%
Mobile homes
32%
Housing (inspections)
Nutrition
74%
Tobacco
74%
Physical activity
60%
Chronic disease programs
57%
Unintended pregnancy
51%
Injury
42%
Substance abuse
34%
Violence
22%
Mental illness
17%
% LHDs
Regulation, inspection, and/or licensing
Communicable/infectious
disease
Population-based primary prevention
Program/service
population-based programs and services directly, including epidemiology
and surveillance; primary prevention;
regulation, inspection, or licensing; and
environmental health services.
yy The most common population-based
programs and services provided
across LHDs include communicable/
infectious disease surveillance (93%),
environmental health surveillance
(85%), regulation of food service
establishments (79%), food safety
education (77%), and public health
nuisance abatement (76%).
Other population-based services
Vital records
62%
Outreach and enrollment
for medical insurance
44%
School health
41%
31%
Collection of unused
pharmaceuticals
18%
Solid waste haulers
31%
Animal control
18%
Solid waste disposal sites
30%
Milk processing
18%
Occupational safety
and health
15%
n=1,461–1,899
Technical note
School health programs may include both clinical
services and populated-based prevention programs.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
77
Chapter 7: Programs and Services
FIG U R E 7.3
Adult and child immunization services provided directly in the past year by LHD characteristics
Size of population served
Degree of urbanization
All LHDs
Small
(<50,000)
Medium
(50,000–
499,999)
Large
(500,000+)
Urban
Suburban
Rural
Adult immunizations
90%
87%
93%
94%
83%
93%
94%
Childhood immunizations
88%
86%
91%
94%
77%
95%
95%
yy Most LHDs provide adult (90%)
and child (88%) immunizations,
regardless of jurisdiction size or
degree of jurisdiction urbanization.
n=1,876–1,892
Technical notes
Omitting Massachusetts LHDs increases the
percentages of urban jurisdictions directly
providing these services by an average of 6
percentage points.
Technical note
Massachusetts LHDs skew the statistics among urban LHDs because there are a large number of Massachusetts LHDs and they are
typically quite different from other urban LHDs across the United States. If excluding Massachusetts LHDs changes the urban percentage
presented in Figures 7.3 through 7.11 by an average of more or less than 2%, this will be indicated in a technical note for that figure.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
78
Chapter 7: Programs and Services
FIG U R E 7.4
Screening and treatment for diseases and conditions provided directly in the past year
by LHD characteristics
All LHDs
Size of population served
Degree of urbanization
Small
(<50,000)
Medium
(50,000–
499,999)
Large
(500,000+)
Urban
Suburban
Rural
Screening for diseases/conditions
Tuberculosis
84%
81%
89%
94%
76%
90%
86%
Other STDs
65%
57%
75%
92%
59%
71%
64%
HIV/AIDS
62%
53%
74%
93%
58%
69%
57%
Blood lead
61%
60%
63%
56%
49%
66%
72%
High blood pressure
54%
56%
51%
51%
51%
53%
62%
Body Mass Index (BMI)
53%
53%
53%
57%
43%
57%
65%
Diabetes
34%
33%
35%
43%
32%
34%
37%
Cancer
32%
28%
38%
41%
30%
35%
29%
Cardiovascular disease
25%
23%
28%
34%
26%
23%
28%
yy LHDs are more likely to provide
screening for chronic and communicable diseases/conditions than
treatment.
yy With the exception of screening for
high blood pressure and blood lead,
medium and large LHDs are more
likely to provide the services presented in this table.
Treatment for communicable diseases
Tuberculosis
79%
75%
85%
87%
72%
86%
79%
Other STDs
63%
56%
73%
89%
57%
70%
63%
HIV/AIDS
35%
32%
39%
48%
30%
40%
34%
n=1,777–1,898
Technical notes
Omitting Massachusetts LHDs increases the
percentages of urban jurisdictions directly
providing these services by an average of 5
percentage points.
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
79
Chapter 7: Programs and Services
FIG U R E 7.5
Maternal and child health services provided directly in the past year by LHD characteristics
Size of population served
Degree of urbanization
All LHDs
Small
(<50,000)
Medium
(50,000–
499,999)
Large
(500,000+)
Urban
Suburban
Rural
Women, Infants, and Children (WIC)
66%
61%
72%
79%
53%
75%
72%
Home visits
60%
55%
67%
72%
51%
66%
64%
Family planning
53%
50%
57%
58%
42%
62%
56%
Early and periodic screening,
diagnosis, and treatment
38%
38%
39%
36%
27%
47%
42%
Well child clinic
29%
29%
30%
27%
24%
31%
35%
Prenatal care
27%
23%
33%
30%
23%
31%
25%
Obstetrical care
8%
6%
11%
17%
8%
9%
6%
yy Many LHDs provide services to
support the health of mothers and
children, including Women, Infants,
and Children (WIC) services (66%),
home visits (60%), and family planning (53%).
yy Few LHDs provide other direct clinical
services to mothers and children, such
as obstetrical care (8%), prenatal care
(27%), and well child clinics (29%).
n=1,700–1,899
Technical notes
Omitting Massachusetts LHDs increases the
percentages of urban jurisdictions directly
providing these services by an average of 5
percentage points.
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
80
Chapter 7: Programs and Services
yy Few LHDs provide other clinical
FIG U R E 7.6
Other clinical services provided directly in the past year by LHD characteristics
Size of population served
Medium
(50,000–
499,999)
Large
(500,000+)
Degree of urbanization
All LHDs
Small
(<50,000)
Urban
Suburban
Rural
Laboratory services
38%
33%
43%
70%
36%
40%
40%
School-based clinics
34%
39%
27%
24%
24%
35%
50%
Oral health
28%
22%
35%
52%
30%
27%
27%
Asthma prevention and/or management
22%
16%
30%
45%
29%
19%
17%
Home health care
20%
24%
14%
3%
11%
23%
32%
Correctional health
13%
12%
14%
17%
12%
14%
14%
Substance abuse
11%
9%
13%
25%
14%
10%
7%
Comprehensive primary care
11%
8%
15%
17%
10%
12%
11%
Behavioral/mental health
10%
7%
13%
26%
12%
10%
7%
Emergency medical services
4%
2%
5%
15%
6%
2%
2%
services, such as behavioral/mental
health services (10%), substance
abuse services (11%), or comprehensive primary care (11%).
yy With the exception of home health
care, large LHDs are more likely to
provide the services presented in this
table than small or medium LHDs.
yy 38% of LHDs (and 70% of large
LHDs) provide laboratory services.
n=1,847–1,896
Technical notes
LHD laboratories may test clinical or
environmental specimens; the Profile
questionnaire includes a single item
intended to include both types.
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
81
Chapter 7: Programs and Services
FIG U R E 7.7
Epidemiology and surveillance services provided directly in the past year by LHD characteristics
Size of population served
Medium
(50,000–
499,999)
Large
(500,000+)
Degree of urbanization
All LHDs
Small
(<50,000)
Urban
Suburban
Rural
Communicable/infectious disease
93%
90%
96%
97%
90%
94%
94%
Environmental health
85%
82%
89%
88%
88%
85%
79%
Maternal and child health
69%
64%
75%
82%
59%
74%
76%
Syndromic surveillance
61%
56%
66%
84%
61%
61%
60%
Chronic disease
49%
44%
56%
65%
51%
49%
47%
Behavioral risk factors
45%
39%
53%
59%
44%
46%
45%
Injury
32%
25%
40%
54%
34%
31%
29%
yy Almost all LHDs provide communi-
cable/infectious disease surveillance
(93%); most provide environmental
health surveillance (85%) and maternal child health surveillance (69%).
yy Large LHDs are more likely to provide
the services presented in this table
than small or medium LHDs.
n=1,622–1,898
Technical notes
Omitting Massachusetts LHDs increases the
percentages of urban jurisdictions directly
providing these services by an average of 5
percentage points.
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
82
Chapter 7: Programs and Services
FIG U R E 7.8
Population-based primary prevention services provided directly in the past year
by LHD characteristics
Size of population served
Degree of urbanization
All LHDs
Small
(<50,000)
Medium
(50,000–
499,999)
Nutrition
74%
70%
81%
85%
69%
79%
75%
Tobacco
74%
72%
77%
86%
70%
76%
79%
Physical activity
60%
55%
68%
73%
59%
61%
61%
Chronic disease programs
57%
50%
65%
79%
59%
57%
52%
Unintended pregnancy
51%
46%
56%
66%
42%
58%
51%
Injury
42%
38%
49%
51%
39%
45%
45%
Substance abuse
34%
31%
36%
43%
33%
33%
35%
Violence
22%
19%
25%
36%
21%
24%
19%
Mental illness
17%
15%
19%
31%
19%
16%
16%
Large
(500,000+)
Urban
Suburban
Rural
yy Most LHDs provide population-based
primary prevention services focused
on nutrition (74%), tobacco use (74%),
and physical activity (60%).
yy Large LHDs are more likely to provide
these services than small or medium
LHDs.
n=1,672–1,886
Technical notes
Omitting Massachusetts LHDs increases the
percentages of urban jurisdictions directly
providing these services by an average of 4
percentage points.
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
83
Chapter 7: Programs and Services
yy LHDs are most likely to provide regu-
FIG U R E 7.9
Regulation, inspection, or licensing services provided directly in the past year
by LHD characteristics
Size of population served
Degree of urbanization
Medium
(50,000–
499,999)
Large
(500,000+)
Urban
Suburban
Rural
All LHDs
Small
(<50,000)
Food service establishments
79%
75%
87%
77%
89%
78%
61%
Schools/daycare
74%
71%
81%
75%
81%
75%
59%
Recreational water
(e.g., pools, lakes, beaches)
68%
63%
76%
74%
82%
65%
45%
Septic systems
67%
64%
74%
65%
75%
65%
55%
Smoke-free ordinances
65%
63%
70%
73%
73%
63%
55%
Body art (e.g., tattoos, piercings)
60%
55%
70%
58%
66%
63%
44%
Private drinking water
60%
58%
63%
62%
62%
61%
54%
Children’s camps
59%
53%
69%
61%
70%
58%
40%
Hotels/motels
58%
56%
63%
46%
59%
61%
50%
Lead inspection
53%
48%
59%
67%
63%
49%
40%
Campgrounds & RVs
46%
41%
55%
47%
48%
47%
39%
Tobacco retailers
38%
39%
38%
29%
47%
33%
30%
Health-related facilities
38%
36%
40%
41%
44%
36%
28%
Public drinking water
37%
33%
42%
42%
41%
37%
28%
Food processing
36%
36%
35%
33%
42%
33%
29%
Mobile homes
32%
29%
37%
37%
36%
33%
23%
Housing (inspections)
31%
32%
28%
29%
45%
23%
15%
Solid waste haulers
31%
30%
31%
33%
39%
26%
21%
Solid waste disposal sites
30%
29%
32%
38%
38%
27%
22%
Milk processing
18%
19%
16%
18%
20%
15%
18%
lation, inspection, or licensing services
of food service establishments (79%),
schools/daycares (74%), and recreational water (68%).
yy With the exception of hotels/motels,
LHDs serving urban jurisdictions
are more likely to provide regulation, inspection, and/or licensing
than LHDs serving suburban or rural
jurisdictions.
n=1,521–1,864
Technical note
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
84
Chapter 7: Programs and Services
FIG U R E 7.10
Environmental health services provided directly in the past year by LHD characteristics
Size of population served
Medium
(50,000–
499,999)
Large
(500,000+)
Degree of urbanization
All LHDs
Small
(<50,000)
Urban
Suburban
Rural
Food safety education
77%
72%
84%
80%
81%
78%
67%
Public health nuisance abatement
76%
74%
79%
71%
84%
72%
66%
Vector control
53%
50%
55%
60%
59%
51%
42%
Groundwater protection
44%
40%
48%
62%
53%
39%
36%
Surface water protection
35%
31%
40%
45%
44%
30%
28%
Indoor air quality
35%
32%
38%
46%
44%
31%
23%
Hazmat response
21%
20%
22%
31%
27%
18%
16%
Radiation control
21%
20%
21%
27%
22%
18%
23%
Air pollution
20%
18%
20%
31%
30%
12%
10%
Land use planning
19%
15%
23%
28%
26%
16%
9%
Hazardous waste disposal
18%
18%
16%
30%
25%
13%
15%
Noise pollution
16%
17%
15%
20%
31%
5%
6%
yy More than three-quarters of LHDs
provide food safety education (77%)
and public health nuisance abatement
(76%). Few provide noise pollution
control (16%) or hazardous waste
disposal (18%).
yy With the exception of radiation control,
LHDs serving urban jurisdictions are
more likely to provide these environmental health services than LHDs
serving suburban or rural jurisdictions.
n=1,461–1,865
Technical note
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
85
Chapter 7: Programs and Services
FIG U R E 7.11
Other population-based services provided directly in the past year by LHD characteristics
Size of population served
Degree of urbanization
Medium
(50,000–
499,999)
Large
(500,000+)
Urban
Suburban
Rural
All LHDs
Small
(<50,000)
Vital records
62%
57%
68%
70%
62%
62%
61%
Outreach and enrollment
for medical insurance
44%
40%
49%
56%
41%
46%
45%
School health
41%
41%
39%
44%
36%
41%
49%
Collection of unused pharmaceuticals
18%
18%
18%
23%
22%
16%
16%
Animal control
18%
16%
19%
23%
24%
14%
12%
Occupational safety and health
15%
15%
14%
19%
18%
12%
13%
yy More than half of LHDs provide vital
records services (62%); LHDs serving
urban, suburban, or rural jurisdictions
are equally likely to provide these
services.
yy Eighteen percent of LHDs provide
animal control services; large LHDs
are slightly more likely to provide
these services than small or medium
LHDs.
n=1,674–1,897
Technical notes
School health programs may include both
clinical services and populated-based
prevention programs.
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
86
Chapter 7: Programs and Services
yy Over half of all LHDs (and three-quar-
FIG U R E 7.12
ters of large LHDs) contract out for
at least one service (i.e., pay another
organization to perform this service on
behalf of the LHD).
Number of services contracted out by LHDs by size of population served
Percent of LHDs
All LHDs
1 service
2 to 5 services
More than
5 services
No services
15%
22%
16%
47%
yy Only 16% of all LHDs and 37% of
large LHDs contract out for more than
five services.
Size of population served
Small (<50,000)
15%
Medium (50,000–499,999)
15%
Large (500,000+)
17%
19%
27%
15%
51%
15%
21%
43%
37%
25%
n=1,915
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
87
Chapter 7: Programs and Services
FIG U R E 7.13
Programs and services provided most frequently via contracts
Percent of LHDs
contracting service
Laboratory services
14%
HIV/AIDS treatment
9%
HIV/AIDS screening
8%
STD screening
8%
Lead inspection
7%
Tuberculosis treatment
7%
Population-based tobacco prevention services
7%
STD treatment
7%
Women, Infants, and Children (WIC)
6%
Family planning
6%
Cancer screening
6%
Prenatal care
6%
Tuberculosis screening
6%
Population-based nutrition services
6%
Oral health
6%
yy LHDs are most likely to contract out
their laboratory services.
yy Six of these services (laboratory
services, HIV/AIDS treatment, STD
screening, population-based tobacco
prevention services, STD treatment,
and cancer screening) have been
among the top 10 services to be
consistently contracted out since
2005 (not shown).
n=1,461–1,899
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
88
Chapter 7: Programs and Services
FIG U R E 7.14
Provision of population-based primary prevention services over time by other organizations
independent of LHD funding
Percent of LHDs reporting service provided by other organizations
2013 2016
84% 93%
Mental illness
79%
Substance abuse
Tobacco
52%
65%
79%
66%
83%
60%
79%
72%
Violence
Injury
81%
59%
Chronic disease
Unintended pregnancy
of LHDs reporting that primary
prevention services are provided by
other organizations independent of
LHD funding increased for every
activity, from eight percentage
points for mental illness prevention
to 21 percentage points for injury
prevention.
69%
Physical activity
Nutrition
89%
yy Since 2013, the percentages
60%
89%
82%
n=1,672–1,857
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
89
Chapter 7: Programs and Services
yy This figure includes 12 services that
FIG U R E 7.15
rural LHDs provide more frequently
than urban LHDs (with differences of
more than 10 percentage points).
Programs and services more likely to be provided in rural jurisdictions
Percent of LHDs providing service directly
Urban
Childhood immunizations
77%
Maternal and child health surveillance
59%
Women, Infants, and Children (WIC)
53%
Blood lead screening
51%
High blood pressure screening
51%
42%
School-based clinics
24%
36%
27%
11%
more likely to provide certain clinical services, including school-based
clinics, blood lead screening, BMI
screening, home health care, and WIC.
64%
62%
56%
50%
School health
Early and periodic screening,
diagnosis, and treatment
yy LHDs serving rural jurisdictions are
65%
43%
Family planning
95%
72%
Maternal and child health home visits
Home health care
72%
49%
Body Mass Index (BMI) screening
76%
Rural
49%
42%
32%
n=1,461–1,899
Technical notes
Massachusetts LHDs skew the statistics among
urban LHDs because there are a large number
of Massachusetts LHDs and they are typically
quite different from other urban LHDs across the
United States. See notes in Figures 7.3 through
7.8 for more information.
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
90
Chapter 7: Programs and Services
yy The following figure shows the 11
FIG U R E 7.16
Programs and services more likely to be provided in urban jurisdictions
Percent of LHDs providing service directly
Rural
Regulation of food service establishments
61%
Regulation of recreational water
82%
59%
Regulation of septic systems
81%
44%
Lead inspection
40%
Housing inspections
10%
63%
44%
23%
6%
66%
45%
15%
Indoor air quality control
are more likely to provide certain
regulation, inspection, licensing, and
environmental health services.
70%
40%
Regulation of body art retailers
yy LHDs serving urban jurisdictions
75%
55%
Regulation of children’s camps
Air pollution control
89%
45%
Regulation of schools/daycare
Noise pollution control
Urban
services that urban LHDs provide
more frequently than rural LHDs (with
differences of more than 20 percentage points).
31%
30%
Regulation includes inspections and/or licensing.
n=1,461–1,899
Technical notes
Massachusetts LHDs skew the statistics among
urban LHDs because there are a large number
of Massachusetts LHDs and they are typically
quite different from other urban LHDs across the
United States. See notes in Figures 7.3 through
7.8 for more information.
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
91
Chapter 7: Programs and Services
yy The following table shows the 12
FIG U R E 7.17
Programs and services provided by more LHDs since 2008
Change
since 2008
2008
2010
2013
2016
Syndromic surveillance
22%
40%
45%
47%
61%
HIV/AIDS treatment
15%
20%
21%
24%
35%
Laboratory services
13%
25%
30%
27%
38%
Behavioral risk factors surveillance
12%
33%
36%
36%
45%
Vital records
12%
50%
54%
54%
62%
Regulation of tobacco retailers
11%
27%
27%
25%
38%
Regulation of children’s camps
11%
48%
54%
48%
59%
Chronic disease surveillance
10%
39%
41%
44%
49%
Regulation of body art retailers
10%
50%
55%
55%
60%
Radiation control
10%
11%
13%
13%
21%
Environmental health surveillance
10%
75%
77%
78%
85%
Population-based substance abuse prevention
10%
24%
27%
24%
34%
n=2,230–2,316
n=1,987–2,091
n=1,904–1,975 n=1,461–1,899
services for which the percentage of
LHDs providing that service directly
increased the most since 2008.
yy Ten of these 12 programs and ser-
vices are population-based, one is
clinical (HIV/AIDS treatment), and
one can include both environmental and clinical activities (laboratory
services).
Regulation includes inspections and/or licensing.
Technical note
The Profile questionnaire includes two sections
on LHD programs and services. One section asks
LHDs to indicate whether or not they provide
that service (regardless of scope) and a second
asks LHDs to indicate how 11 service areas
have changed during calendar year 2015 (i.e.,
increased, reduced, did not change). Figures
7.17 and 7.18 show the change in the overall
percentage of LHDs that indicated they provided
that service (regardless of scale or scope) over
time by comparing results from the 2016 Profile
to previous Profiles. Figures 7.19, 7.20, and 7.21
show the percentage of LHDs that reported how
service areas have changed in scale or scope
during 2015.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
92
Chapter 7: Programs and Services
yy The following table shows the 10
FIG U R E 7.18
Programs and services provided by fewer LHDs since 2008
Change
since 2008
2008
2010
2013
2016
High blood pressure screening
-14%
68%
67%
57%
54%
Well child clinic
-11%
41%
36%
32%
29%
Diabetes screening
-11%
45%
44%
36%
34%
Cardiovascular disease screening
-10%
35%
33%
27%
25%
Cancer screening
-10%
42%
39%
36%
32%
Prenatal care
-7%
33%
30%
27%
27%
Outreach and enrollment for medical insurance
-6%
50%
49%
42%
44%
Early and periodic screening, diagnosis,
and treatment
-6%
44%
40%
36%
38%
Home health care
-5%
25%
25%
21%
20%
Asthma prevention and/or management
-4%
26%
23%
19%
22%
n=2,230–2,316
n=1,987–2,091
n=1,904–1,975 n=1,461–1,899
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
services for which the percentage of
LHDs providing that service directly
decreased the most since 2008.
yy All of these 10 programs and services
are clinically oriented.
93
Chapter 7: Programs and Services
yy A larger proportion of LHDs expanded
FIG U R E 7.19
than reduced both clinical and
population-based services in the past
year compared to the previous year.
Changes in provision of services in the past year
Percent of LHDs that
reduced services
Clinical services
Percent of LHDs that
expanded services
11%
High blood pressure screening
10%
15%
Diabetes screening
9%
Blood lead screening
6%
Communicable disease screening or treatment
5%
proportions of LHDs expanding
versus reducing clinical services is
smaller than the difference between
LHDs expanding versus reducing
population-based services.
12%
Maternal and child health services
11%
yy The difference between the
18%
Immunization
16%
6%
yy In particular, 25% expanded their
10%
Population-based services
24%
Tobacco, alcohol, or other drug prevention
8%
25%
Obesity prevention
6%
17%
Emergency preparedness
5%
4%
3%
14%
Environmental health, including food safety
Epidemiology and surveillance
n=776–1,806
obesity prevention services and 24%
expanded their tobacco, alcohol,
and other drug prevention services,
compared to only 6% and 8% of
LHDs that reduced these services
respectively.
11%
Technical note
The Profile questionnaire includes two sections
on LHD programs and services. One section asks
LHDs to indicate whether or not they provide
that service (regardless of scope) and a second
asks LHDs to indicate how 11 service areas
have changed during calendar year 2015 (i.e.,
increased, reduced, did not change). Figures
7.17 and 7.18 show the change in the overall
percentage of LHDs that indicated they provided
that service (regardless of scale or scope) over
time by comparing results from the 2016 Profile
to previous Profiles. Figures 7.19, 7.20, and 7.21
show the percentage of LHDs that reported how
service areas have changed in scale or scope
during 2015.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
94
Chapter 7: Programs and Services
FIG U R E 7.20
Growing, stable, and shrinking services in the past year
Clinical service
30%
Population-based service
Average percent reduced (7%)
Growing
services
Mixed
trend
Obesity
prevention
25%
yy Programs in the lower left quadrant are
Percent of LHDs expanding service
Tobacco, alcohol,
other drugs
stable services—those that few LHDs
are expanding or reducing. These include
communicable disease screening or treatment, epidemiology and surveillance, and
environmental health.
20%
yy Programs in the upper left quadrant are
Immunization
Emergency
preparedness
15%
Diabetes screening
Average percent expanded (15%)
Environmental
health
Epidemiology
and surveillance
10%
shrinking services—those that relatively
more LHDs are reducing and few are
expanding. These include maternal and
child health services and high blood pressure screening.
High blood pressure screening
yy Programs in the upper right quadrant are
Blood lead
screening
Stable
services
0%
0%
Shrinking
services
5%
growing services—those that relatively few
LHDs are reducing and more are expanding. These include obesity prevention and
emergency preparedness.
yy Programs in the lower right quadrant are
Maternal and child health services
Communicable
disease screening
or treatment
5%
This diagram illustrates how LHDs are
changing their levels of service provision in 11
programmatic areas. The horizontal and vertical lines represent the average percentages of
LHDs expanding and reducing services across
these 11 programmatic areas. The direction
and distance from the average lines illustrate
whether programs are being expanded and
reduced more or less than average.
10%
15%
20%
Percent of LHDs reducing service
25%
services where the trends are mixed—those
that relatively high percentages of LHDs
are expanding and reducing. These include
immunization and diabetes screening.
Population-based services are more likely to
be stable or growing than clinical services.
30%
n=776–1,806
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
95
Chapter 7: Programs and Services
FIG U R E 7.21
Changes in provision of services by changes in budgets in the past year
Percent of LHDs reducing service
■ Immunization ■ High blood pressure screening ■ Maternal and child health services
23%
Lower budget
18%
20%
to the previous fiscal year are more
likely to expand and less likely to
reduce services than LHDs with lower
or unchanging budgets.
8%
9%
yy Similarly, LHDs with lower budgets
11%
Higher budget
most likely to expand or reduce are
the same in LHDs with varying budget
situations. However, the degree to
which LHDs are expanding or reducing the programs varies by budget
situation.
yy LHDs with higher budgets compared
13%
Same budget
yy In general, the services that LHDs are
6%
than the previous fiscal year are
more likely to reduce and less likely
to expand services than LHDs with
higher or unchanging budgets.
8%
Percent of LHDs expanding service
■ Immunization ■ Obesity prevention ■ Tobacco, alcohol, and other drug prevention
17%
Lower budget
22%
18%
16%
Same budget
25%
21%
22%
Higher budget
31%
35%
n=1,083–1,561
Technical note
This figure shows the three programmatic areas
LHDs were most likely to report reducing and
expanding. Note that immunization appears in
both categories.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
96
8
CHAPTE R
Emergency
Preparedness
and Response
This chapter includes the following:
■■ Local health department (LHD) budget changes for
emergency preparedness activities.
■■ Response to all-hazards events.
■■ Emergency preparedness planning, exercises, and training.
■■ Use of volunteers for emergency preparedness and response.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 8: Emergency Preparedness and Response
yy Approximately one-fifth of LHDs
FIG U R E 8.1
LHD budget changes for emergency preparedness activities by LHD characteristics
Percent of LHDs reporting change in budget in current fiscal year compared to previous year
Lower budget
Approximately the same budget
Higher
budget
Don't
know
19%
60%
11%
10%
All LHDs
70%
10%
27%
Midwest
South
11%
65%
5%
15%
54%
15%
9%
29%
West
14%
6%
54%
12%
yy LHDs in the West and Midwest were
more likely than LHDs in South and
Northeast to report a lower budget for
emergency preparedness.
Census region
Northeast
(19%) report a lower budget for emergency preparedness in the current
fiscal year compared to the previous
fiscal year, while 11% report a higher
budget.
yy The proportion of LHDs reporting a
change in emergency preparedness
budgets was similar among LHDs
serving populations of different sizes.
6%
Size of population served
Small (<50,000)
19%
Medium
(50,000–499,999)
20%
Large (500,000+)
19%
60%
61%
59%
10%
12%
18%
11%
8%
5%
n=474
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
98
Chapter 8: Emergency Preparedness and Response
yy Almost half (45%) of LHDs report
FIG U R E 8.2
having responded to an all-hazards
event in the past year.
Response to any all-hazards event in past year by LHD characteristics
Percent of LHDs that responded to at least
one all-hazards event in the past year
yy Large LHDs were more than twice
as likely as small LHDs to have
responded to an all-hazards event in
the past year.
45%
All LHDs
yy Similarly, LHDs in urban areas were
Size of population served
more likely to have responded to an
all-hazards event (61%) than LHDs in
suburban (40%) or rural areas (24%).
32%
Small (<50,000)
64%
Medium (50,000–499,999)
76%
Large (500,000+)
Degree of urbanization
Rural
Suburban
24%
40%
Urban
61%
n=465
Technical note
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
99
Chapter 8: Emergency Preparedness and Response
FIG U R E 8.3
Use of volunteers to respond to an all-hazards event in past year by LHD characteristics*
Percent of LHDs that used volunteers
to respond to an all-hazards event
All LHDs
Size of population served
26%
Medium (50,000–499,999)
LHDs that responded to an allhazards event reported using
volunteers to help with the response.
yy Similar percentages of small and
medium LHDs use volunteers to help
with responding to an all-hazards
event (26% and 25% respectively),
but large LHDs were more likely to
use volunteers (42%).
27%
Small (<50,000)
yy More than one-quarter (27%) of
yy LHDs that used volunteers in an exer-
25%
Large (500,000+)
42%
cise in the past year were more than
twice as likely to use volunteers during
an event.
Use of volunteers in exercises
Used volunteers in exercises
Did not use volunteers in exercises
36%
14%
*Among LHDs that responded to an event.
n=230
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
100
Chapter 8: Emergency Preparedness and Response
yy Nearly all LHDs (90%) participated in
FIG U R E 8.4
Participation in emergency preparedness exercises by size of population served
Percent of LHDs
All LHDs
Small (<50,000)
Full-scale exercises
38%
33%
95%
43%
yy Small LHDs are less likely to participate in all three types of exercises
than medium or large LHDs.
82%
78%
55%
64%
Functional exercises
97%
90%
72%
80%
Tabletop exercises
Large (500,000+)
97%
85%
90%
Any type of exercise
Medium
(50,000–499,999)
some kind of exercise in the past year;
80% participated in tabletop exercises, 64% participated in functional
exercises, and 38% participated in
full-scale exercises.
61%
n=464
Technical note
A Tabletop Exercise is a scenario-based
discussion that permits evaluation of all or
portions of the Emergency Operations Plan,
through oral interaction and application of
plan guidance.
A Functional Exercise is a scenario-based
execution of selected tasks or activities
within a functional area of the Emergency
Operations Plan.
A Full-Scale Exercise is a scenario-based
exercise that includes all or most of the functions
and complex activities of the Emergency
Operations Plan and is intended to replicate
real-world response situations.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
101
Chapter 8: Emergency Preparedness and Response
FIG U R E 8.5
Use of volunteers in any emergency preparedness exercises (tabletop, functional,
or full-scale) in the past year by size of population served and type of exercise*
Percent of LHDs that use volunteers in exercises
volunteers in at least one exercise in
the past year.
yy Volunteers were included less often
in tabletop exercises (42%) than in
functional or full-scale exercises.
67%
All LHDs
yy Two-thirds of LHDs (67%) included
yy Small LHDs were less likely to use
volunteers for any exercises (63%)
than large LHDs (84%).
Size of population served
Small (<50,000)
63%
Medium (50,000–499,999)
71%
Large (500,000+)
84%
Type of exercise
Tabletop and/or full scale
or functional exercises
Tabletop exercises only
73%
42%
*Among LHDs that indicated they participated in exercises.
n=420
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
102
Chapter 8: Emergency Preparedness and Response
yy LHDs are most likely to engage volun-
FIG U R E 8.6
Source of volunteers for emergency preparedness activities over time
65%
Percent of LHDs engaging volunteers from this
source for emergency preparedness activities
Medical Reserve Corps
49%
Community Emegency Response Team (34%)
Other groups (34%)
ARC
47% CERT
36%
American Red Cross (33%)
Independent individuals
48%
Other
29%
25%
15%
Do not engage volunteers
teers from the Medical Reserve Corps
(MRC) for emergency preparedness
activities; the percentage of LHDs
that engaged volunteers from the
MRC increased from 49% in 2010 to
65% in 2016.
yy A similar proportion of LHDs engage
volunteers from the Community
Emergency Response Team (47%)
and the American Red Cross (48%).
yy LHDs are less likely to engage
independent individuals (i.e., volunteers who are not affiliated with any
volunteer organization) than volunteer
organizations (25% in 2010 and 29%
in 2016).
7%
2010
2016
n=516
n=426
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
103
Chapter 8: Emergency Preparedness and Response
yy Almost all LHDs developed or
FIG U R E 8.7
Involvement in planning for emergencies by LHD characteristics
Size of population served
Type of governance
All LHDs
Small
(<50,000)
Medium
(50,000–
499,999)
Large
(500,000+)
State
Local
Shared
Developed or updated a written
emergency plan
87%
85%
89%
95%
75%
90%
93%
Planned for emergencies through
participation in a health care coalition
69%
63%
75%
89%
45%
74%
83%
Developed or updated plans to ensure
the inclusion of vulnerable populations
58%
54%
65%
71%
42%
62%
66%
Reviewed relevant legal authorities
44%
36%
57%
61%
21%
51%
50%
Developed or updated a written
recovery plan
41%
37%
46%
51%
40%
39%
64%
Developed or updated expedited
administrative processes*
34%
29%
41%
34%
25%
36%
34%
*For example, government funding, procurement, contracting, and hiring for use during emergencies
updated a written emergency plan
(87%); more than two-thirds of LHDs
participated in health care coalitions
(69%).
yy With the exception of developing or
updating expedited administrative
processes, large LHDs are more likely
than medium or small LHDs to participate in these planning activities.
yy With the exception of developing
or updating a written recovery plan,
LHDs governed by state authorities
are less likely than LHDs governed
by local authorities or LHDs governed
by both state and local authorities to
participate in these planning activities.
n=464
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
104
Chapter 8: Emergency Preparedness and Response
yy LHDs are more likely to provide staff
FIG U R E 8.8
with emergency preparedness training
(81%) than to assess staff emergency
preparedness competencies (61%).
Involvement in emergency preparedness training and education activities
by LHD characteristics
Size of population served
Type of governance
All LHDs
Small
(<50,000)
Medium
(50,000–
499,999)
Provided emergency preparedness
training to staff
81%
77%
86%
95%
74%
81%
98%
Assessed emergency preparedness
competencies of staff
61%
59%
64%
62%
53%
61%
78%
Educated community members on
emergency preparedness
62%
57%
70%
80%
46%
66%
74%
n=464
Large
(500,000+)
State
Local
Shared
yy Over half of LHDs (62%) educated
community members on emergency
preparedness.
yy Large LHDs are more likely to train
staff and educate community members than small LHDs. However, there
is little variation by size of population
served in the percentage of LHDs that
assess staff competencies.
yy LHDs governed by state authorities
are less likely to participate in these
training/education activities than
LHDs governed by local authorities
or LHDs governed by both state and
local authorities.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
105
9
CHAPTE R
Assessment, Planning,
and Accreditation
This chapter includes the following:
■■ Community health assessment (CHA).
■■ Community health improvement planning (CHIP).
■■ Strategic planning (SP).
■■ Collaboration with non-profit hospitals on community health
needs assessments (CHNA).
■■ Public Health Accreditation Board (PHAB) engagement.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 9: Assessment, Planning, and Accreditation
yy Participation by LHDs in a CHA, CHIP,
FIG U R E 9.1
and SP within the past five years has
increased since 2010.
Participation over time in a community health assessment (CHA), community health
improvement plan (CHIP), and/or strategic plan (SP) within five years
78%
Percent of LHD participation
70%
CHA
CHIP
SP
All three
(CHA, CHIP, & SP)
60%
51%
55%
67%
53%
43%
44%
31%
30%
yy In 2016, more than three-quarters of
LHDs had completed a CHA (78%),
two-thirds had completed a CHIP
(67%), and approximately half had
completed a SP (53%) within the past
five years.
yy Just under half (44%) had completed
all three processes within the past
five years, a requirement for PHAB
accreditation.
20%
2010
n=519–2,091
2013
n=1,939–1,964
2016
n=1,853–1,885
Technical note
In 2010, the strategic planning question was
included in a module, resulting in a lower number
of respondents.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
107
Chapter 9: Assessment, Planning, and Accreditation
yy Almost three-quarters of small LHDs
FIG U R E 9.2
have completed a CHA within the past
five years.
2016 Participation in a community health assessment (CHA), community health
improvement plan (CHIP), and/or strategic plan (SP) within five years by size
of population served
yy Over half of medium LHDs have
completed all three accreditation
prerequisites.
Percent of LHD participation
All LHDs
All three
(CHA, CHIP, SP)
Small (<50,000)
CHA
CHIP
SP
67%
53%
85%
74%
78%
75%
62%
46%
63%
Large (500,000+)
69%
54%
36%
44%
Medium
(50,000–499,999)
87%
yy Over 80% of large LHDs have com-
pleted each of the three accreditation
prerequisites, and almost 70% have
completed all three.
83%
80%
n=1,853–1,885
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
108
Chapter 9: Assessment, Planning, and Accreditation
FIG U R E 9.3
Data included in most recent community health assessment (CHA) over time*
■ 2016
n=392
■ 2008
n=328–333
93%
Socioeconomic characteristics
89%
83%
Social and mental health
61%
81%
Community perceptions of health
80%
Environmental health indicators
63%
their CHAs, including data on socioeconomic characteristics (93%), social
and mental health (83%), community
perceptions of health (81%), and environmental health indicators (80%).
yy LHDs are less likely to use data on
the built environment factors that
impact health (52%) or data on policies that impact health (41%).
yy Compared to 2008, larger percent-
ages of LHDs are using data on
socioeconomic characteristics, social
and mental health, environmental
health indicators, and quality of life
indicators.
74%
Quality of life indicators
53%
67%
Community attitudes about health
promotion/improvement
52%
Built environment factors
that impact health
Policies that impact health
yy LHDs use a variety of data sources in
41%
*Among LHDs that completed a CHA.
Technical note
Certain items were not inlcuded in the
2008 Profile.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
109
Chapter 9: Assessment, Planning, and Accreditation
yy Almost all LHDs that completed a
FIG U R E 9.4
Elements of most recent community health assessment (CHA)*
Percent of LHDs with elements among LHDs that completed CHA
Representatives from a variety of sectors of
the local community participated in the CHA
88%
Local community was given opportunity to
review and contribute to the assessment
CHA report is readily available to the public
75%
68%
CHA report includes information on
community assets to address health issues
65%
CHA report includes specific descriptions of
health issues for populations with health inequities
65%
CHA report that representatives
from a variety of sectors of their local
community participated in their CHA
(88%) and three-quarters (75%) gave
their community the opportunity to
review and contribute to their CHA.
yy Approximately two-thirds of LHDs
made their CHA report available to the
public (68%) and included information on community assets to address
health issues (65%) and specific
descriptions of health issues for populations with health inequities (65%).
*Among LHDs that completed a CHA.
n=393
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
110
Chapter 9: Assessment, Planning, and Accreditation
FIG U R E 9.5
Actions taken in the past three years to implement or sustain a community health
improvement plan (CHIP) over time*
Percent of LHDs taking action among LHDs that completed CHIP
2008
n=315-335
Developed or strengthened relationships
with community partners
80%
Participated in a coalition(s) to address
one or more priorities
84%
61%
Advocated for other community partners to establish
or increase activities to support priorities
75%
58%
69%
Set or revisited goals for LHD performance
45%
67%
Set or revisited goals for community health outcomes
45%
66%
Worked with community partners to advance
policy changes related to priorities
yy Compared to 2008, larger proportions
of LHDs have taken these actions;
notably, two-thirds of LHDs set or
revisited goals for LHD performance
(67%) and community health
outcomes (66%) in 2016 compared
to less than half (45%) in 2008.
58%
Developed performance measures to monitor
implementation of the plan
Measured progress to Healthy People goals
implement or sustain their CHIPs,
including developing or strengthening
relationships with community partners
(91%), participating in a coalition
to address one or more priorities
(84%), and establishing or reaffirming
priorities for LHDs (75%).
60%
Reported on progress toward implementation
of the plan
Increased LHD funding for one or more priorities
91%
73%
Established or reaffirmed priorities for LHD
2016
n=311
yy LHDs take a variety of actions to
53%
21%
28%
39%
31%
*Among LHDs that completed a CHIP.
Technical note
Certain items were not inlcuded
in the 2008 Profile.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
111
Chapter 9: Assessment, Planning, and Accreditation
FIG U R E 9.6
Level of collaboration with non-profit hospitals on most recent community health needs
assessment (CHNA)
No non-profit hospitals
serving jurisdiction
Discussing future
collaboration
collaborated or are currently collaborating with a non-profit hospital on
a CHNA; 6% are discussing future
collaboration; 10% are neither collaborating nor discussing collaboration.
yy Twenty percent of LHDs report there
20%
Not engaged
in discussion
or collaboration
yy Just under two-thirds of LHDs (64%)
is no non-profit hospital serving their
jurisdiction.
10%
6%
64%
Has collaborated
or is currently
collaborating
n=1,693
Technical note
The Patient Protection and Affordable Care Act
(ACA) includes a requirement that non-profit
hospitals must conduct a community health
needs assessment (CHNA) at least once
every three years. The CHNA must take into
account input from persons who represent the
broad interests of the community served by the
hospital, including those with special knowledge
of or expertise in public health.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
112
Chapter 9: Assessment, Planning, and Accreditation
FIG U R E 9.7
Types of collaboration with non-profit hospitals on most recent community health needs
assessment (CHNA)
Among
all LHDs
Among LHDs
collaborating
on a CHNA
LHD shared local data resources on health status and/or social determinants of health
37%
62%
LHD provided input on strategies to improve community health
37%
60%
LHD and non-profit hospital jointly conducted an assessment that serves as both the LHD’s
Community Health Assessment and the hospital’s CHNA
35%
58%
LHD assisted in engaging community organizations and residents in CHNA process
32%
53%
LHD provided technical assistance on data collection, analysis, synthesis, or interpretation
17%
28%
LHD coordinated joint efforts by multiple hospitals to pool resources and information for a CHNA
15%
24%
LHD provided technical assistance to hospital on how to design and implement a CHNA
12%
19%
LHD served as a neutral facilitator to ensure a collaborative CHNA process
10%
17%
Not sure
1%
2%
None of the above
1%
1%
n=452
n=296
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
yy Among LHDs that are collaborating
with a non-profit hospital on a CHNA,
more than half share local data
resources on health status and/or
social determinants of health (62%),
provide input on strategies to improve
community health (60%), and jointly
conduct an assessment that serves
as both the LHD’s CHA and hospital’s
CHNA (58%).
yy Approximately one-third of all LHDs
collaborate with non-profit hospitals in
each of these ways.
113
Chapter 9: Assessment, Planning, and Accreditation
FIG U R E 9.8
Level of engagement with Public Health Accreditation Board (PHAB) accreditation in 2016
Percent of LHDs
Accredited by PHAB
Submitted application
4% 3%
yy Thirty-one percent of LHDs are
undecided about PHAB accreditation
and 20% decided not to apply.
1%
31%
Undecided
20%
Decided not to apply
Do not know
they plan to apply for accreditation but
have not yet registered in e-PHAB.
17%
Plans to apply, not yet registered in e-PHAB*
by PHAB, and an additional 3% are
part of a PHAB-accredited state
integrated system.
yy Eighteen percent of LHDs report that
As part of a state
integrated system
5%
Registered in e-PHAB* 3%
yy Four percent of LHDs are accredited
5%
*PHAB’s online information system.
n=1,930
Technical note
All LHDs in Florida are accredited as part of
a state integrated system. As of early 2016,
no other states were actively engaged in this
option. Responses of LHDs in states other than
Florida that erroneously reported accreditation
activities as part of a state integrated system
were removed, and special estimation weights
were used to account for the special status
of Florida LHDs.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
114
Chapter 9: Assessment, Planning, and Accreditation
FIG U R E 9.9
Level of engagement with Public Health Accreditation Board (PHAB) accreditation over time
56%
Percent of LHDs
favorably inclined
to engage in
accreditation
53%
42%
yy The percentage of LHDs favorably
inclined to engage in PHAB
accreditation has decreased from
56% in 2013 to 42% in 2016.
yy However, the percentage of LHDs
formally engaged in PHAB
accreditation has increased from
6% in 2013 to 21% in 2016.
21%
Percent of LHDs
formally engaged 6%
in PHAB accreditation
2013
13%
2014
n=448–449 n=609
2016
n=1,710
Level of engagement
in PHAB accreditation
Formally engaged in PHAB accreditation:
LHDs that are accredited, have submitted
application or registered in e-PHAB, or are part
of a state integrated system that is accredited
or registered in e-PHAB.
Favorably inclined to engage in PHAB
accreditation: LHDs that are formally engaged
in PHAB accreditation or plan to apply either
individually or as part of a state integrated system
(all LHDs except those that are undecided or
decided not to apply for PHAB accreditation).
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
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Chapter 9: Assessment, Planning, and Accreditation
FIG U R E 9.10
Formal engagement in Public Health Accreditation Board (PHAB) accreditation
by LHD characteristics
Percent of LHDs formally engaged in PHAB accreditation
21%
All LHDs
Size of population served
Small (<50,000)
yy A larger proportion of large LHDs are
formally engaged in PHAB accreditation than small and medium LHDs.
yy Locally governed LHDs are less likely
to be formally engaged in PHAB
accreditation than state governed
LHDs or LHDs governed by both
state and local authorities.
12%
33%
Medium (50,000–499,999)
58%
Large (500,000+)
Type of governance
35%
State
Local
Shared
15%
57%
n=1,710
Level of engagement
in PHAB accreditation
Formally engaged in PHAB accreditation:
LHDs that are accredited, have submitted
application or registered in e-PHAB, or are part
of a state integrated system that is accredited or
registered in e-PHAB.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
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Chapter 9: Assessment, Planning, and Accreditation
FIG U R E 9.11
Reasons for not pursuing Public Health Accreditation Board (PHAB) accreditation over time
Time/effort exceeds benefit
73%
67%
Standards exceed capacity
Fees are too high
66%
63%
54%
45%
41%
48%
34%
2013
2014
2016
2014
2016
Governing body said no
Standards are not appropriate
27%
2013
2014
2014
20%
18%
19%
19%
2016
2013
2014
2016
8%
2013
to report the reason they are not
applying for PHAB accreditation
is that the time/effort required for
PHAB accreditation exceeds its perceived benefit. This percentage has
decreased slightly since 2013.
yy The percent of LHDs reporting that
2016
fees are too high for accreditation has
increased from 48% in 2014 to 63%
in 2016.
yy The percent of LHDs reporting that
Other reasons
15%
2013
2013
yy Since 2013, LHDs are most likely
PHAB accreditation standards exceed
their LHD’s capacity increased from
34% in 2014 to 45% in 2016.
20%
18%
2014
2016
n(2013)=61 (Profile module)
n(2014)=103 (Forces of Change survey)
n(2016)=371 (Profile core)
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
117
10
CHAPTE R
Quality Improvement
and Workforce
Development
This chapter includes the following:
■■ Level of quality improvement implementation at local health
departments (LHDs).
■■ Number of quality improvement projects.
■■ Elements used in quality improvement efforts.
■■ Use of core competencies for public health workers.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 10: Quality Improvement and Workforce Development
yy In 2016, 54% of LHDs were engaged
FIG U R E 10.1
in formal QI; half of them report formal
agency-wide QI programs.
Level of quality improvement (QI) implementation over time
Percent of LHDs
2010
n=519
2013
n=477
2016
n=483
yy Since 2010, the percentages of LHDs
Formal
agency-wide QI
Formal QI in specific
programmatic areas
Informal or ad hoc QI
No QI
15%
30%
39%
16%
23%
27%
33%
27%
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
32%
35%
13%
11%
reporting informal or no QI have
decreased, while the percentage of
LHDs reporting formal QI programs
has increased.
yy Between 2013 and 2016, the per-
centage of LHDs engaged in formal
QI (either agency-wide or in specific
programmatic areas) did not change
significantly. However, a larger proportion of LHDs participated in
agency-wide QI in 2016 than in 2013.
119
Chapter 10: Quality Improvement and Workforce Development
yy Large LHDs are more likely to be
FIG U R E 10.2
involved in formal QI (agency-wide
as well as in specific programmatic
areas) than small or medium LHDs.
Level of quality improvement (QI) implementation by size of population served
Percent of LHDs
Small (<50,000)
Medium (50,000–499,999)
Large (500,000+)
Formal
agency-wide QI
Formal QI in specific
programmatic areas
Informal or ad hoc QI
No QI
20%
22%
42%
16%
37%
34%
45%
n=483
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
26%
41%
yy Sixteen percent of small LHDs are not
involved in any QI at their agency—
formal or informal.
4%
13%
2%
120
Chapter 10: Quality Improvement and Workforce Development
FIG U R E 10.3
Number of quality improvement (QI) projects implemented in the past year over time
Percent of LHDs engaged in QI
2013
n=425
2016
n=445
More than
3 projects
1–3 projects
No projects
14%
63%
23%
21%
61%
18%
yy Among LHDs involved in QI, most
reported having implemented one to
three formal QI processes in the past
year, both in 2013 and 2016.
yy The proportion of LHDs reporting
more than three formal QI projects in
the past year increased from 14% in
2013 to 21% in 2016.
Excludes LHDs not invovled in QI activities.
Technical note
A systematic quality improvement initiative
that includes an aim statement; a work plan
with tasks, responsibilities, and timelines;
intervention strategy/strategies; and measures
for tracking change.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
121
Chapter 10: Quality Improvement and Workforce Development
yy LHDs involved in formal QI are more
FIG U R E 10.4
Number of quality improvement (QI) projects implemented in the past year by level
of QI implementation
Percent of LHDs engaged in any QI
More than 3 projects
1–3 projects
29%
65%
Formal QI
Informal QI
9%
55%
No projects
likely to have implemented one or
more formal QI projects and more
than three times as likely to have
implemented more than three formal
QI projects as LHDs involved in only
informal QI at their agency.
6%
36%
Excludes LHDs not invovled in QI activities.
n=445
Technical note
A systematic quality improvement initiative
that includes an aim statement; a work plan
with tasks, responsibilities, and timelines;
intervention strategy/strategies; and measures
for tracking change.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
122
Chapter 10: Quality Improvement and Workforce Development
yy Most LHDs involved in QI set mea-
FIG U R E 10.5
surable objectives (73%) or obtain
baseline data (69%) as a part of their
QI efforts.
Quality improvement (QI) elements used in QI efforts in the past year by size
of population served
Size of population served
Among LHDs
involved in any QI
at their agency
Small
(<50,000)
Medium
(50,000–499,999)
Large
(500,000+)
Setting measurable objectives
73%
67%
81%
89%
Obtaining baseline data
69%
60%
82%
82%
Identifying root causes
54%
48%
58%
77%
Mapping a process
45%
37%
53%
77%
Analyzing results of the test
37%
27%
50%
62%
Testing effects of intervention
36%
28%
45%
62%
Formally adopting a tested intervention
28%
19%
39%
50%
None of the above
12%
15%
8%
5%
yy However, only 37% analyze results
of a test, 36% test effects of an
intervention, and 28% formally adopt
a tested intervention.
yy Small LHDs are less likely to use any
of these QI elements than medium
and large LHDs.
Excludes LHDs not invovled in QI activities.
n=444
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
123
Chapter 10: Quality Improvement and Workforce Development
FIG U R E 10.6
Elements of an agency-wide quality improvement (QI) program currently in place at LHD
by level of QI Implementation
Level of QI
implementation
All LHDs
involved
in QI
Formal QI
Informal QI
Leadership dedicates resources for QI
44%
60%
18%
QI resources and training offered on ongoing basis
43%
54%
26%
Use performance data to drive improvement efforts
40%
54%
17%
Staff member with dedicated time
35%
50%
14%
QI Council
33%
50%
9%
Agency-wide QI plan
30%
46%
7%
QI incorporated into performance appraisals
28%
37%
13%
QI incorporated into job descriptions
26%
34%
14%
None of the above
18%
5%
39%
yyMore than two in five LHDs have
leadership that dedicates resources
for QI (44%) and have QI resources
and trainings offered on an ongoing
basis at their agency (43%). Fewer
LHDs have QI incorporated into
performance appraisals (28%) or job
descriptions (26%).
yy Few LHDs reporting informal QI have
these elements in place at their LHD.
Offering QI resources and training
is the only element reported by more
than 25% of LHDs with informal
QI programs.
n=443
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
124
Chapter 10: Quality Improvement and Workforce Development
FIG U R E 10.7
Any use of core competencies for public health professionals by size of population served
Percent of LHDs using core competencies
All LHDs
yy Almost half (45%) of LHDs have
used the core competencies in their
workforce development programs.
yy Medium and large LHDs are
more likely to have used the core
competencies than small LHDs.
45%
Size of population served
Small (<50,000)
38%
Medium (50,000–499,999)
Large (500,000+)
56%
54%
n=462
Technical note
The Core Competencies for Public Health
Professionals (developed by the Council
on Linkages between Academia and Public
Health Practice) are a consensus set of skills
for the broad practice of public health. The
Core Competencies can provide a framework
for workforce development planning and
action. More information is available at
www.phf.org/link/corecompetencies.htm.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
125
Chapter 10: Quality Improvement and Workforce Development
yy After several years of declining use,
FIG U R E 10.8
Use of core competencies for public health professionals over time
Developing staff training plans
Any use
Assessing staff training needs
45%
37%
26%
34%
28%
19%
28%
26%
yy In particular, the percent of LHDs
20%
18%
16%
2008
2010
n=450–472 n=499
2013
n=470
2016
n=462
Writing position descriptions
2008
more LHDs reported using the core
competencies in some way to support
their workforce development effort.
The percentage of LHDs using the
core competencies in some way
increased from 26% in 2013 to
45% in 2016 (a 73% increase).
2010
developing staff training plans and
writing position descriptions doubled
in 2016 compared to 2013.
14%
2013
2016
Conducting staff performance evaluations
26%
23%
17%
15%
2008
16%
13%
2010
2013
2016
2008
2010
14%
2013
2016
Technical note
Core Competencies for Public Health Professionals
developed by the Council on Linkages
(www.phf.org/link/corecompetencies.htm).
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
126
11
CHAPTE R
Public Health Policy
This chapter includes the following:
■■ Local health department (LHD) policy development, including
social determinants of health; tobacco, alcohol, or other drugs;
and obesity or chronic disease.
■■ Land use planning.
■■ Health impact assessments.
■■ Public health ordinances and regulations.
■■ Addressing health disparities.
■■ Access to health care services.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 11: Public Health Policy
FIG U R E 11.1
Involvement in policy areas in the past two years by size of population served
Size of population served
Medium
(50,000–
499,999)
Large
(500,000+)
All LHDs
Small
(<50,000)
Tobacco, alcohol, or other drugs
74%
72%
78%
81%
Emergency preparedness and response
72%
73%
70%
75%
Infectious disease (e.g., vaccination)
68%
66%
68%
79%
Food safety
57%
53%
62%
67%
Obesity/chronic disease
55%
48%
62%
82%
Waste, water, or sanitation
43%
40%
47%
46%
Animal control or rabies
41%
38%
45%
49%
Education
34%
33%
35%
40%
Oral health
31%
27%
35%
44%
Injury or violence prevention
29%
26%
32%
51%
Mental health
27%
22%
36%
40%
Funding for access to health care
27%
21%
36%
44%
Safe and healthy housing
23%
19%
28%
40%
Body art
18%
15%
23%
23%
Land use
17%
12%
21%
33%
Affordable housing
11%
8%
13%
21%
Occupational health and safety
10%
9%
10%
15%
Criminal justice system
9%
5%
14%
20%
Labor
2%
2%
2%
9%
None
7%
8%
6%
3%
yy Over 90% of LHDs report involvement
in at least one policy area during the
past two years.
yy LHDs most often report involvement
in policies related to tobacco, alcohol,
or other drugs (74%), emergency
preparedness and response (72%),
and infectious disease (68%).
yy Large LHDs are more likely to be
involved in all policy areas than small
LHDs and this difference is greater
for areas that relate to the social
determinants of health than for other
health-related areas. For example,
large LHDs are more than twice as
likely as small LHDs to be involved in
policy activities related to affordable
housing, access to health care, and
safe and healthy housing.
n=1,872
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
128
Chapter 11: Public Health Policy
FIG U R E 11.2
Involvement in policy areas related to social determinants of health over time
Percent of LHDs involved in policy area
34%
23%
Education
Safe and healthy housing
19%
17%
Land use
yy Since 2013, a larger proportion of
LHDs have been involved in policy
areas related to the social determinants of health. LHDs reporting
involvement in policy activities related
to education and safe and healthy
housing increased by 15 and 8 percentage points, respectively.
yy LHD involvement in land use and
labor policy areas has also increased
among LHDs since 2013 but only by
a few percentage points.
15%
11%
6%
5%
1%
2013
n=1,936
9%
2%
Affordable housing
Criminal justice system
Labor
2016
n=1,872
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
129
Chapter 11: Public Health Policy
FIG U R E 11.3
Involvement in policy areas related to tobacco, alcohol, or other drugs in the past two years
by size of population served
Size of population served
All LHDs
Small
(<50,000)
Medium
(50,000–
499,999)
Smoke-free indoor air (e.g., workplace, multi-unit residential)
57%
52%
61%
76%
Smoke-free outdoor air (e.g., parks, beaches, playgrounds, sporting events)
44%
41%
49%
57%
Reducing sale of tobacco to minors
42%
39%
43%
59%
Regulating e-cigarettes or other electronic smoking devices
38%
34%
43%
52%
Reducing exposure to alcohol or tobacco advertising
25%
24%
25%
35%
Increasing use of medications to prevent drug overdose (e.g., Naloxone)
22%
15%
32%
42%
Reducing alcohol or drug impaired driving
16%
15%
16%
18%
Raising cigarette taxes
12%
9%
13%
24%
Increasing access to clean syringes
9%
5%
12%
26%
Diverting certain drug offenders into treatment rather than incarceration
8%
5%
11%
22%
Raising alcohol taxes
2%
2%
2%
4%
Large
(500,000+)
yy Over one-third of all LHDs (38%)
and over half of large LHDs (52%)
were involved in policies related to
e-cigarette use in the past two years.
yy More than one-fifth (22%) of all
LHDs (and 42% of large LHDs) were
involved in policies to increase use of
medications to prevent drug overdose,
such as Naloxone.
yy Large LHDs are more likely to be
involved in these policy areas than
small LHDs, especially areas related
to drug abuse. For example, large
LHDs are almost three times as likely
as small LHDs to be involved in policy
activities related to increasing access
to clean syringes and diverting certain
drug offenders into treatment rather
than incarceration.
n=1,827
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
130
Chapter 11: Public Health Policy
FIG U R E 11.4
Involvement in policy areas related to obesity or chronic disease in the past two years
by size of population served
Size of population served
All LHDs
Small
(<50,000)
Medium
(50,000–
499,999)
Large
(500,000+)
Policies to promote breastfeeding
39%
32%
47%
67%
School or child care policies that encourage physical activity
35%
29%
42%
61%
School or child care policies that reduce availability of unhealthy foods
32%
25%
40%
60%
Increasing retail availability of fruits and vegetables
28%
19%
39%
57%
Community level urban design and land use policies to encourage physical activity
26%
17%
37%
58%
Expanding access to recreational facilities
25%
20%
31%
47%
Active transportation options
18%
11%
26%
46%
Nutritional labeling
9%
7%
10%
23%
Fiscal policies to decrease consumption of unhealthy foods or beverages
6%
4%
8%
20%
Limiting fast food outlets
1%
1%
2%
4%
yy More than one-third of LHDs are
involved in policies to promote breastfeeding (39%) and school or child
care policies that encourage physical
activity (35%).
yy Few LHDs are involved in fiscal
policies to decrease consumption
of unhealthy foods or beverages
(6%) or efforts to limit fast food
outlets (1%).
yy Large LHDs are more than twice as
likely as small LHDs to be involved
in each of these policy areas.
n=1,810
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
131
Chapter 11: Public Health Policy
FIG U R E 11.5
Involvement over time in land use planning activities in the past year over time
2008
2016
Healthy eating, active living
Access to healthy food resources
35%
45%
Safe, convenient walking or biking access
31%
41%
Safe routes to school
20%
25%
School locations encourage walking and biking
12%
10%
Connecting safe walking and biking routes with mass transit options
12%
17%
Road designs that support and encourage walking and biking
12%
14%
Access to or protection of recreation areas
25%
Zoning
Use of school grounds for other community activities
22%
20%
Discourage the location of alcohol sales within neighborhoods
9%
6%
Neighborhoods that meet life needs without car use
7%
5%
Ecological
Ecological waste management
11%
8%
Green building, ecological sustainability
10%
6%
Protection of productive agricultural land
7%
3%
Urban remediation
3%
3%
None of the above
38%
30%
n=431–433
n=486
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
yy Many LHDs are involved in increasing
access to healthy food resources
(45%) and ensuring safe, convenient
walking or biking access (41%). The
percentage of LHDs involved in these
activities increased by 10 percentage
points between 2008 and 2016.
yy Few LHDs are involved in land use
planning activities that focus on
ecology, such as urban remediation
(3%) or protecting productive agricultural land (3%). The percentages of
LHDs involved in these activities were
unchanged or declined between 2008
and 2016.
132
Chapter 11: Public Health Policy
FIG U R E 11.6
Involvement in land use planning activities in the past year by size of population served
Size of population served
All LHDs
Small
(<50,000)
Medium
(50,000–
499,999)
Large
(500,000+)
Healthy eating, active living
Access to healthy food resources
45%
35%
57%
78%
Safe, convenient walking or biking access
41%
34%
49%
64%
Access to or protection of recreation areas
25%
20%
31%
53%
Safe routes to school
25%
18%
33%
58%
Connecting safe walking and biking routes with mass transit options
17%
11%
22%
49%
Road designs that support and encourage walking and biking
14%
7%
20%
48%
School locations encourage walking and biking
10%
7%
15%
24%
Zoning
Use of school grounds for other community activities
20%
19%
19%
45%
Discourage the location of alcohol sales within neighborhoods
6%
4%
8%
9%
Neighborhoods that meet life needs without car use
5%
3%
6%
24%
Ecological
Ecological waste management
8%
5%
11%
19%
Green building, ecological sustainability
6%
3%
10%
22%
Protection of productive agricultural land
3%
3%
2%
8%
Urban remediation
3%
2%
4%
13%
None of the above
30%
37%
21%
9%
yy Large LHDs are more likely to be
involved in land use planning activities than small LHDs. Over 20% of
large LHDs are involved in promoting
green buildings and neighborhoods
that meet life needs without car use,
compared with 3% of small LHDs.
yy Over half of large LHDs are involved
in activities focused on increasing
access to healthy food resources
(78%), walking or biking routes (64%),
and recreation areas (53%).
n=486
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
133
Chapter 11: Public Health Policy
FIG U R E 11.7
Number of health impact assessments (HIAs) completed in the past two years over time
and by size of population served
■ Percent of LHDs with one HIA ■ Percent of LHDs with two or more HIAs
All LHDs
2010
n=365
4%
1%
2016
12%
n=478
yy Nearly one in five LHDs were
involved in at least one HIA in
the past two years.
yy Half of large LHDs were involved in
at least one HIA in the past two years,
compared to 22% of medium LHDs
and 15% of small LHDs.
yy A larger proportion of LHDs
completed at least one HIA in
the past two years in 2016 (19%)
than in 2010 (5%).
7%
Small (<50,000)
2010 2% 0%
2016
9%
6%
Medium (50,000–499,999)
2010
6%
2%
2016
17%
5%
Large (500,000+)
2010
2016
13%
13%
21%
31%
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
134
Chapter 11: Public Health Policy
FIG U R E 11.8
Involvement in developing new or revising existing ordinances in the past two years
by LHD characteristics
Percent of LHDs
All LHDs
involved in new or revised ordinances
or regulations (64%) than medium
(51%) or small (36%) LHDs.
Size of population served
36%
Medium (50,000–499,999)
51%
Large (500,000+)
64%
Type of governance
State
25%
Local
48%
Shared
37%
Northeast
65%
38%
South
31%
West
Suburban
are less likely to be involved in new
or revised ordinances or regulations
(25%) than LHDs governed by local
authorities (48%) or LHDs with
shared governance (37%).
West (53%) are more likely to be
involved in new or revised ordinances
or regulations than LHDs in the
Midwest (38%) or South (31%).
yy LHDs in urban areas (59%) are more
53%
likely to be involved in new or revised
ordinances than LHDs in suburban
(36%) or rural (24%) areas.
Degree of urbanization
Rural
yy LHDs governed by state authorities
yy LHDs in the Northeast (65%) and
Census region
Midwest
involved in developing a new or revising an existing public health ordinance
or regulation in their jurisdiction during
the past two years.
yy Large LHDs are more likely to be
42%
Small (<50,000)
yy Forty-two percent of LHDs were
24%
36%
Urban
59%
n=1,869
Technical note
NACCHO classified each LHD into urban (1–3),
suburban (4–7), or rural (8–10) categories based
on U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
135
Chapter 11: Public Health Policy
yy One-quarter (25%) of LHDs
FIG U R E 11.9
Topic areas of new or revised ordinances in the past two years
Percent of LHDs invovled in developing new or revising existing ordinances
25%
Tobacco, alcohol, or other drugs
21%
Environment
Infectious disease (e.g., vaccination)
3%
Obesity/chronic disease
3%
Emergency preparedness and response
3%
Safe and healthy housing
2%
Injury prevention
2%
Funding for access to health care
2%
Violence prevention
1%
Oral health
1%
Mental health
1%
Occupational health and safety
report new or substantially revised
ordinances or regulations related to
tobacco, alcohol, or other drugs and
one fifth (21%) LHDs report new or
substantially revised ordinances or
regulations related to the environment
in the past two years.
yy Few LHDs (3% or less) report
new or substantially revised
ordinances or regulations related
to other topic areas.
0.4%
None
59%
n=1,864
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
136
Chapter 11: Public Health Policy
yy Almost two-thirds of LHDs (63%) and
FIG U R E 11.10
almost all large LHDs (90%) are supporting community efforts to change
the causes of health disparities.
Engagement in addressing health disparities in the past two years by size
of population served
Size of population served
All LHDs
Small
(<50,000)
Medium
(50,000–
499,999)
Supporting community efforts to change the causes of health disparities
63%
55%
74%
90%
Describing health disparities in their jurisdiction using data
61%
50%
75%
89%
Educating elected or appointed officials about health disparities and their causes
52%
46%
58%
76%
Training their workforce on health disparities and their causes
51%
42%
62%
82%
Offering staff training in cultural/linguistic competency
49%
41%
57%
75%
Prioritizing resources and programs specifically for the reduction in health disparities
39%
32%
48%
62%
Recruiting workforce from communities adversely impacted by health disparities
24%
16%
33%
53%
Taking public policy positions on health disparities (through testimony, written
statements, media, etc.)
16%
12%
20%
39%
Conducting original research that links health disparities to differences in social
or environmental conditions
12%
8%
17%
25%
Large
(500,000+)
yy Similarly, 61% of all LHDs and
89% of large LHDs are describing
health disparities in their jurisdictions
using data.
yy Large LHDs are more likely to be
involved in these activities related
to health disparities than medium
or small LHDs.
n=470
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
137
Chapter 11: Public Health Policy
yy LHDs are more likely to be engaged
FIG U R E 11.11
Engagement in assuring access to health care services in the past year
Percent of LHDs
■ Medical services
■ Dental services
■ Behavioral services
64%
Assessed the gaps in access to services
50%
50%
58%
Implemented strategies to target health
care needs of underserved populations
57%
assuring access through direct
provision of clinical services.
37%
38%
52%
Evaluated strategies to target health care
needs of underserved populations
Addressed gaps through direct
provision of clinical services
yy LHDs were least likely to report
32%
30%
Implemented strategies to increase
accessibility of existing services
(e.g., referrals)
in assuring access to medical services
than dental and behavioral services.
For example, 58% of LHDs implemented strategies to target medical
health care needs of underserved
populations, while 32% implemented
strategies to target dental health care
needs and 30% to target behavioral
health care needs.
29%
29%
41%
24%
17%
n=452–458
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
138
Chapter 11: Public Health Policy
FIG U R E 11.12
Engagement over time in assuring access to health care services in the past year
Percent of LHDs engaged in assurance activities*
Medical
Dental
Behavioral
71%
73%
77%
yy The proportion of LHDs engaged in
assuring access to behavioral health
care services increased from 40% in
2010 to 56% in 2016, more than the
increases seen in either medical or
dental health care services.
57%
55%
51%
56%
47%
40%
2010
n=512
2013
n=485
2016
n=468
*Percent of LHDs reporting providing at least one of the activities listed in Figure 11.11.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
139
12
CHAPTE R
Informatics
This chapter includes the following:
■■ Level of implementation in information technology systems
at local health departments (LHDs).
■■ Use of communication channels for routine or emergency
response communications.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
Chapter 12: Informatics
yy Most LHDs use immunization regis-
FIG U R E 12.1
Current level of activity in information technology systems
Percent of LHDs
Implemented
Implementation in process
Immunization registries
Electronic disease reporting systems
3%
79%
Electronic lab reporting
49%
Electronic health records
Health information exchanges
3%
85%
yy Relatively large proportions of LHDs
are in the process of implementing
electronic health records (24%) and
health information exchanges (19%).
24%
37%
17%
8%
tries and electronic disease reporting
systems; LHDs are less likely to use
electronic lab reporting, electronic
health records, and health information
exchanges.
19%
n=459
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
141
Chapter 12: Informatics
FIG U R E 12.2
Current implementation in information technology systems by size of population served
Percent of LHDs that have implemented technology
Immunization
registries
All LHDs
85%
Electronic disease
reporting systems
79%
Electronic lab
reporting
49%
Electronic health
records
37%
Health information
exchanges
17%
Size of population served
Small (<50,000)
84%
78%
Medium (50,000–499,999)
85%
81%
Large (500,000+)
93%
86%
45%
55%
64%
33%
42%
59%
16%
yy With the exception of health informa-
tion exchanges, large LHDs are more
likely to have implemented most of
these technology systems than LHDs
serving smaller populations.
yy The difference in implementation
between LHDs serving small and
large jurisdictions are greatest for
electronic health records and electronic lab reporting.
20%
17%
n=459
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
142
Chapter 12: Informatics
FIG U R E 12.3
Implementation of information technology systems over time
Percent of LHDs that have implemented technology
85%
75%
85% Immunization registries
79%
Electronic disease reporting systems
74%
48%
19%
8%
6%
2008
n=460–464
tems has increased since 2008,
although some have increased more
than others. For example, use of
electronic health records increased by
14 percentage points between 2013
and 2016, while use of immunization
registries and electronic lab reporting
showed very little change during that
time period.
49% Electronic lab reporting
37%
19%
yy Use of information technology sys-
Electronic health records
23%
17%
Health information exchanges
14%
2010
2013
2016
n=518
n=505
n=459
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
143
Chapter 12: Informatics
FIG U R E 12.4
Use of communication channels for routine or emergency response communications
Any use
Routine use
Use for
emergency
response
Print media
91%
87%
49%
LHD website
78%
76%
49%
Broadcast media
69%
61%
49%
Facebook
65%
63%
39%
E-mail
64%
60%
35%
Fax broadcast/fax blast
44%
30%
32%
Text messaging
42%
34%
15%
Automated phone calling
40%
16%
29%
Twitter
28%
27%
16%
Hotline or call center
19%
6%
16%
Video sharing sites
10%
9%
1%
LinkedIn
6%
6%
1%
Blogs
6%
5%
1%
Photo sharing sites
4%
4%
1%
None
2%
3%
19%
yy LHDs most often use print media
and websites and use them more
often for routine than emergency
communications.
yy LHDs are more likely to use auto-
mated phone calling and a hotline or
call center for emergency communications than for routine communications.
yy Few LHDs use LinkedIn (6%), blogs
(6%), and photo sharing sites (4%) for
any use.
n=454–466
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
144
Chapter 12: Informatics
FIG U R E 12.5
Any use of communication channels by size of population served
Size of population served
Medium
(50,000–
499,999)
Large
(500,000+)
All LHDs
Small
(<50,000)
Print media
91%
89%
94%
91%
LHD website
78%
72%
87%
91%
Broadcast media
69%
64%
78%
85%
Facebook
65%
62%
69%
76%
E-mail
64%
57%
75%
75%
Fax broadcast/fax blast
44%
33%
61%
63%
Text messaging
42%
38%
46%
53%
Automated phone calling
40%
36%
48%
33%
Twitter
28%
17%
40%
74%
Hotline or call center
19%
10%
30%
66%
Video sharing sites
10%
3%
18%
41%
LinkedIn
6%
5%
8%
10%
Blogs
6%
4%
6%
16%
Photo sharing sites
4%
1%
9%
13%
None
2%
2%
1%
2%
yy With the exception of automated
phone calling, large LHDs are more
likely to use these communication
channels than small LHDs.
yy In particular, a much greater propor-
tion of large LHDs use a hotline or call
center, Twitter, and video sharing sites
(such as YouTube) to communicate
with the public. Differences in use of
print media and LinkedIn by small and
large LHDs are much smaller.
n=466
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
145
Chapter 12: Informatics
FIG U R E 12.6
Any use of communication channels by type of governance
Type of governance
All LHDs
State
Local
Shared
Print media
91%
86%
92%
97%
LHD website
78%
46%
86%
85%
Broadcast media
69%
53%
73%
77%
Facebook
65%
44%
72%
58%
E-mail
64%
43%
69%
70%
Fax broadcast/fax blast
44%
25%
47%
62%
Text messaging
42%
30%
45%
39%
Automated phone calling
40%
35%
41%
40%
Twitter
28%
13%
32%
23%
Hotline or call center
19%
10%
21%
28%
Video sharing sites
10%
4%
11%
13%
LinkedIn
6%
4%
7%
3%
Blogs
6%
0%
7%
4%
Photo sharing sites
4%
1%
5%
4%
None
2%
4%
1%
0%
yy State-governed LHDs are less likely
to use nearly all of these communication channels than LHDs with local or
shared governance.
yy Locally governed LHDs are more
likely to use Facebook and Twitter
than LHDs with state or shared
governance.
yy LHDs governed by both state and
local authorities (shared governance)
are more likely to use fax broadcasts
and print and broadcast media than
LHDs with state or local governance.
n=466
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
146
Chapter 12: Informatics
FIG U R E 12.7
Any use of communication channels by urbanization
Degree of urbanization
All LHDs
Urban
Non-urban
Print media
91%
87%
93%
LHD website
78%
84%
74%
Broadcast media
69%
70%
69%
Facebook
65%
65%
65%
E-mail
64%
74%
57%
Fax broadcast/fax blast
44%
50%
40%
Text messaging
42%
39%
43%
Automated phone calling
40%
51%
33%
Twitter
28%
43%
18%
Hotline or call center
19%
35%
10%
Video sharing sites
10%
18%
5%
LinkedIn
6%
7%
5%
Blogs
6%
12%
2%
Photo sharing sites
4%
10%
1%
None
2%
2%
1%
yy LHDs in urban areas are more likely
to use some of these communication
channels. For example, half of LHDs
(51%) in urban areas use automated
phone calling while only one-third
(33%) of LHDs in non-urban areas
use this communication channel.
yy Similar percentages of LHDs in urban
and non-urban areas use broadcast
media, Facebook, and text messaging.
n=466
Technical note
NACCHO classified each LHD into urban (1–3)
or non-urban (4–10) categories based on
U.S. Department of Agriculture Rural Urban
Commuting Area codes.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
147
Chapter 12: Informatics
yy LHD use of newer technology to
FIG U R E 12.8
Use of communication channels over time
Percent of LHDs using channel to communicate to the public
65% Facebook
E-mail
64%
communicate with the public has
increased since 2010. For instance,
use of Facebook increased dramatically from 28% of LHDs in 2010 to
65% in 2016.
yy Use of video sharing sites (such as
43%
42%
Text messaging
YouTube) increased from 6% in 2010
to 10% in 2013, but has not increased
since.
35%
28%
28%
26%
13%
17%
10%
10%
Twitter
Video sharing sites
6%
2010
n=511
2013
n=475
2016
n=466
Technical note
2010 Profile did not include questions about
e-mail and text messaging.
NACCHO 2016 NATIONAL PROFILE OF LOCAL HEALTH DEPARTMENTS
148
The mission of the National Association of County and City Health Officials (NACCHO) is to be a leader,
partner, catalyst, and voice with local health departments. Funding for this project was provided by the
Centers for Disease Control and Prevention (under cooperative agreement 1U38OT000172-04) and the
Robert Wood Johnson Foundation® in Princeton, New Jersey. The contents of this document are solely the
responsibility of NACCHO and do not necessarily represent the official views of the sponsors.
1100 17th St, NW, 7th Floor
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