Health Objectives for the Nation Selected Characteristics of Local Health Departments -- United States, 1992-1993

A year 2000 national health objective is to increase to at least 90% the proportion of persons who are served by a local health department (LHD) that is effectively performing the core functions of public health (objective 8.14) (1). A framework for examining essential roles and services of LHDs is critical to developing a surveillance system to monitor progress toward this goal (2-4). To characterize the activities, staff, expenditures, and jurisdictions of LHDs in the United States, during 1992-1993 the National Association of County and City Health Officials (NACCHO), in collaboration with CDC, surveyed all LHDs. This report summarizes the services provided by LHDs by population of the jurisdiction, the expenditures and staff to support these services, and type of jurisdiction.

For this survey, an LHD was defined as "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." LHDs were identified from the 1990 NACCHO Profile database (5) through a review of NACCHO member mailing lists and inquiries to selected state health agencies. The questionnaire was mailed in November 1992 to LHDs in 49 states and the District of Columbia (Rhode Island had no LHDs meeting the study definition). Three follow-up mailings and telephone calls were made to nonrespondents. Data collection ended in December 1993.

Overall, 2079 (72%) of the LHDs that met the study definition (n=2888) returned completed questionnaires. The estimated total population served by the responding LHDs was approximately 85% of the 1990 U.S. total (249 million); 1710 (82%) respondents served jurisdictions with populations less than 100,000, and 369 (18%) served jurisdictions with 100,000 or more.

Surveillance data. Data maintained by LHDs for surveillance activities included communicable diseases (82%), vital records (53%), drinking water supply (49%), chronic diseases (42%), recreational water quality (30%), behavioral risk factors (20%), injury (19%), and air quality (14%).

Program planning. Resources used by LHDs to guide program planning included Healthy People 2000 by 70%, Healthy Communities 2000 Model Standards by 47%, the Assessment Protocol for Excellence in Public Health by 32%, and the Planned Approach to Community Health by 12%.

Agency services. The percentage of LHDs reporting activity in specific services generally increased in relation to the size of population served by the LHD. In addition to community prevention services Table_1, substantial numbers of LHDs provided clinical prevention and health-care services Table_2. Overall, 57% of LHDs reported they had conducted evaluations to determine whether a gap existed between available clinical prevention services and a need for these services in their jurisdictions. Of these LHDs, 83% reported the provision of clinical prevention service programs to address the gaps.

Personnel and budget. In general, LHD staff and annual expenditures increased in relation to the population served: for the 82% of LHDs serving less than 100,000 persons, the median number of full-time staff was nine, and the median annual expenditure was $350,000. In comparison, for the 18% of LHDs serving 100,000 or more, the median number of full-time staff was 94, and the median annual expenditure was $4.5 million.

Jurisdictional units. Geographic areas served by LHDs were single county (56%), multicounty districts (11%), city (7%), city/county units (13%), and town or township jurisdictions (11%). Reported by: C Brown, N Rawding, D Custer, National Association of County and City Health Officials. Div of Public Health Systems, Public Health Practice Program Office, CDC.

Editorial Note

Editorial Note: The findings from this survey of LHDs are being used to develop plans for a surveillance system for the year 2000 national health objective 8.14 and may be used as a baseline for evaluating potential changes in the role of LHDs associated with changes in the U.S. health-care system. For example, recent proposals have described the primary role for LHDs as the providers of surveillance, health planning, and community prevention programs; responsibilities for clinical prevention services and health-care services currently performed by LHDs potentially might be addressed through managed care or other health-care providers (2,4,6).

The findings in this survey are subject to at least two limitations. First, the results cannot be directly compared with the 1990 NACCHO Profile (5); because the set of respondents for this survey varied from the 1990 survey, temporal trends can be evaluated only by analyzing the subset of respondents that participated in both surveys. Second, no definitions or criteria were provided for reporting services, and the scope, quality, and quantity of services were not verified.

Subsequent analyses by NACCHO and CDC will examine the subset of respondents who participated in the surveys in both 1989 and 1992-1993. Related efforts include development of scientifically valid measures of the effectiveness of public health agencies (7,8). Before implementation of a national surveillance system for the year 2000 national health objective 8.14, methods must be developed to measure whether a community and its LHD are effectively performing the core functions of public health. Specifically, methods are needed to determine means for creating and maintaining a healthy community (3); assess the effectiveness of community-based prevention services, programs, and policies (9); measure the contribution to public health performance made by community providers and agencies other than LHDs; develop a community health "report card" (4); and compare the public health performance of different communities and their LHDs.

References

1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

2. Rundall TG. The integration of public health and medicine. Front Health Serv Manage 1994; 10:3-24.

3. National Association of County Health Officials. Blueprint for a healthy community: a guide for local health departments. Washington, DC: National Association of County Health Officials, 1994.

4. Baker EL, Melton RJ, Stange PV, et al. Health reform and the health of the public: forging community health partnerships. JAMA 1994;272:1276-82.

5. CDC. Selected characteristics of local health departments -- United States, 1989. MMWR 1990; 39:607-10.

6. Oberle MW, Baker EL, Magenheim MJ. Healthy People 2000 and community health planning. Annu Rev Public Health 1994;15:259-75.

7. Turnock BJ, Handler A, Hall W, Potsic S, Nalluri R, Vaughn EH. Local health department effectiveness in addressing the core functions of public health. Public Health Rep 1994;109:653-8.

8. Miller CA, Moore KS, Richards TB, McKaig C. A screening survey to assess local public health performance. Public Health Rep 1994;109:659-64.

9. Fielding J, Halfon N. Where is the health in health system reform? JAMA 1994;272:1292-6.

Table_1
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TABLE 1. Percentage distribution of selected community prevention services, by size of jurisdiction served
-- United States, 1992-1993
=======================================================================================================================
                                             Size of jurisdiction served
                              ----------------------------------------------------------
                                    <100,000 Persons>=100,000 Persons                   Total
                              ----------------------------  ----------------------------  -----------------------------
                                             Respondents +                Respondents +                 Respondents +
                               Total *     ---------------   Total *     ---------------   Total       ----------------
Community service             (n=1710)     No.        (%)   (n=369)      No.       (%)    (N=2079) *   No.        (%)
-----------------------------------------------------------------------------------------------------------------------
Vaccinations                    1707       1626       (95)    368        365       (99)    2075        1991       (96)
Tuberculosis services           1697       1420       (84)    367        348       (95)    2064        1768       (86)
High blood pressure             1704       1460       (86)    367        298       (81)    2071        1758       (85)
Sewage-disposal systems         1704       1231       (72)    367        310       (84)    2071        1541       (74)
Private water supply safety     1699       1232       (72)    368        294       (80)    2067        1526       (74)
Sexually transmitted diseases
  testing and counseling        1702       1119       (66)    368        347       (94)    2070        1466       (71)
HIV/AIDS testing
  and counseling                1705       1073       (63)    368        345       (94)    2073        1418       (68)
Family planning                 1700       1106       (65)    365        296       (81)    2065        1402       (68)
Diabetes                        1700       1033       (61)    363        214       (59)    2063        1247       (60)
Laboratory services             1698        941       (55)    364        305       (84)    2062        1246       (60)
School health                   1693       1015       (60)    363        217       (60)    2056        1232       (60)
Environmental emergency
  response                      1694        909       (54)    363        262       (72)    2057        1171       (57)
Vector control                  1671        916       (55)    366        252       (69)    2037        1168       (57)
Cancer                          1695        899       (53)    367        205       (56)    2062        1104       (54)
-----------------------------------------------------------------------------------------------------------------------

* Total number of local health departments responding to survey questions.
+ Number and percentage of local health departments that directly provided a service or contracted to provide a
  service.
=======================================================================================================================

TABLE 2. Percentage distribution of selected clinical prevention and health-care services, by size of jurisdiction served
-- United States, 1992-1993
===========================================================================================================================
                                             Size of jurisdiction served
                              ------------------------------------------------------------
                                    <100,000 Persons>=100,000 Persons                   Total
                              ------------------------------   ---------------------------    ------------------------------
                                             Respondents +                   Respondents +                   Respondents +
                                Total *     ----------------    Total *     --------------     Total *      ----------------
Service                        (n=1710)      No.        (%)    (n=369)      No.        (%)    (n=2079)      No.         (%)
----------------------------------------------------------------------------------------------------------------------------
Clinical prevention services
  Well-child clinic              1695        1296       (77)     367        338       (92)      2062        1634        (79)
  Women, infants, and children
    (WIC)                        1695        1285       (76)     367        327       (89)      2062        1612        (78)
  Early and periodic screening,
    diagnosis, and treatment
    for low-income children      1683        1155       (69)     359        310       (86)      2042        1465        (72)
  Prenatal care                  1701        1017       (60)     368        304       (83)      2069        1321        (64)

Health-care services
  Children with special
    health-care needs            1701        1069       (63)     363        270       (74)      2064        1339        (65)
  Home health care               1700         946       (56)     362        162       (45)      2062        1108        (54)
  Dental health                  1691         659       (39)     366        247       (68)      2057         906        (44)
  Geriatric care                 1691         613       (36)     362        166       (46)      2053         779        (38)
  Obstetric care                 1691         465       (28)     366        210       (57)      2057         675        (33)
  HIV/AIDS treatment             1694         490       (29)     367        179       (49)      2061         669        (33)
  Primary care                   1690         430       (25)     364        192       (53)      2054         622        (30)
  School-based clinics           1692         393       (23)     363        114       (31)      2055         507        (25)
  Substance abuse                1695         301       (18)     362        134       (37)      2057         435        (21)
  Mental health facilities
    and services                 1699         172       (10)     361         67       (19)      2060         239        (12)
----------------------------------------------------------------------------------------------------------------------------
* Total number of local health departments responding to survey questions.
+ Number and percentage of local health departments that directly provided a service or contracted to provide a
  service.
============================================================================================================================

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