Policy Development and Implementation
Room: Crimson Clover
Wednesday, April 22, 2015, 2:00 to 3:30 PM
Moderator: Katherine F. Papa, MPH
Erika Martin, PhD, MPH
Implementing Updated Recommendations on Screening for Hepatitis C Virus: Translating Federal Guidance into State Practice
Co-Investigator(s): Amanda Norcott, BA; Hina Khalid, MPP; & Daniel O'Connell, MA
Background: Chronic viral hepatitis affects 3.2 million Americans and is a major cause of liver cirrhosis and liver cancer, making it a leading infectious cause of death. Increasing the proportion of hepatitis C virus (HCV)-infected individuals who are aware of their infection and averting new infections are major goals of the national viral hepatitis action plan. The Centers for Disease Control and Prevention (CDC) recently released updated recommendations for HCV testing, including recommending that all individuals born from 1945 to 1965 be tested once. However states’ compliance with these national testing guidelines is unknown. Research Objective: This study evaluates the extent to which state health departments have updated their recommendations to be consistent with the CDC guidelines. Data Sets and Sources: Websites from the 50 state departments of health were reviewed from January 2013 to April 2013 and again in March to May 2014 to document their testing recommendations for each population risk group. Study Design: The CDC recommendations on HCV testing were used to identify important risk groups. These include population-based risks, behavioral risks and health care exposures. They were categorized by whether testing is recommended, not recommended, or with unclear testing recommendations. Analysis: Data are summarized as descriptive statistics of the percentage of states recommending testing for each group and presenting other information such as strategic plans for viral hepatitis. Principal Findings: There is substantial variation in compliance with CDC guidelines. Among the risk groups that the CDC current recommends for testing, only 48% of states updated their guidelines to include individuals born from 1945 to 1965. All states recommend testing among current and / or former injection drug users, however only 56% recommended testing among HIV positive individuals. Most (96%) states recommend testing after workplace exposures. However, there were differences in state recommendations for patients with healthcare exposures or having persistent abnormal alanine aminotransferase levels. One quarter (28%) of states recommend testing nonsexual household contact, although the CDC does not recommend testing this group. Among the risk groups where the CDC has issued uncertain recommendations, states most frequently recommended testing among persons with tattoos or body piercing done with unsterile materials (44%), persons with a history of multiple sex partners (32%) or sexually transmitted diseases (14%), and long-term steady sexual partners of HCV-positive persons (28 percent). Two-fifths (42%) of states had guidelines that were fully consistent with the CDC’s recommendations, and 4% had recommendations that diverged for 5 or more risk groups. Conclusions: There is substantial variation in states’ compliance with the CDC’s updated guidelines, and the public health importance of risk factors is not perfectly correlated with their inclusion in state guidelines. Limited public health funding for HCV; relatively low levels of HCV disease awareness, activism, and political attention; and public health staff turnover have potentially limited state health departments’ attention to updating their HCV screening guidelines. Implications: States’ HCV screening policies are critical to implementing the national viral hepatitis action plan.
Lara Lamprecht, DrPH, MPH, BS
An Exploration of Policy Activities by Local Health Departments to Improve Population Health
Background The local health department (LHD) plays a key role in the functioning of the public health system—particularly the policy development core function. Policy strategies are increasingly seen as effective strategies to improve current population health problems that are not amenable to individualistic, biomedical approaches. However, less is known about LHD policy activities than about assurance or assessment activities. Research Objective The objective of the study was to determine what organizational, service area, and leadership characteristics might be associated with LHDs conducting policy activities to improve population health. Data Sets and Sources The study used secondary data from the 2010 NACCHO Profile Questionnaire. The final analyses were conducted using weighted data for the 337 LHDs that had complete data for all variables examined. Study Design The goal of this exploratory design was to develop a grounded picture of what level of policy activity is taking place in U.S. LHDs at the local level; and what community, organizational and leader attributes are present in those LHDs that are policy active. Analysis LHDs were categorized as “not or less policy active” or “more policy active” at the local level. Independent variables--to represent LHD, service area, and leader characteristics that were identified in professional literature as being potential factors--were selected or created from the Profile Questionnaire questions and response options. The dataset was assessed for potential selection bias due to non-response. A sensitivity analysis was conducted to test data assumptions. SAS survey procedures were used to account for complex sampling and to generate descriptive and analytic statistics. Logistic regression with backward stepwise selection was used to obtain the bivariate and multivariable models. Two approaches (a priori and domain-based) for the multivariable models were used and the results were compared. Principal Findings One-fifth of LHDs did not participate in local policy activities. Fewer LHDs tended to participate in complex policy activities. LHDs that served a larger population (AOR=4.31, p<.0001) or were locally governed (AOR=1.69, p<.0001) were more policy active. Other important variables included: a leader that held a public health degree, the gender of the local health department leader, five occupation categories, the local board of health’s policy authority, and three variables (community health assessment, health improvement planning, and health impact assessment) that are indicative of a high-functioning local health department. Conclusions While answering a “what” question, this study made a foundational contribution in the policy area. However, further research is needed on how characteristics are associated with—and how and why LHD leaders pursue—policy development. Implications for Public Health Practice and Policy If policy is an important lever to have a meaningful impact on the health across the Nation, public health leaders can think about ways to improve policy development capacity in small- and mid-sized jurisdictions. Effective leaders can also influence policy levers that are not within their direct control; therefore collaborating with others that govern local jurisdictions such as peers (agriculture, urban development, etc.), city council members, an administrator, in addition to the local board of health might also be useful—particularly to implement a health in all policies strategy. Characteristics might be used by state health departments, academia, and others to target LHDs for policy practice improvements. The study also identified improvements that might be made to the Profile Questionnaire to improve the quality of information available to researchers that want to focus on policy-related questions.
Shannon Carrillo, BA
Local Health Policy Networks of 15 Local Health Departments in the Big Cities Health Coalition
Co-Investigator(s): Carothers Bobbi, PhD; JP Leider, PhD; Vicky Bass, MPH; & Jenine Harris, PhD
Background: The Big Cities Health Coalition (BCHC) is a project of the National Association of County and City Health Officials (NACCHO). BCHC provides a forum for the leaders of America’s largest metropolitan health departments to exchange strategies and jointly address issues to promote and protect the health and safety of the 46 million people they serve. One tool local health departments (LHDs) have at their disposal is cultivating policies and building partnerships. Developing a strong local policy network has the potential to improve local public health policy. However, little is known about the city and county partnerships that LHDs employ to support public health policy and advocacy activity. Research Objective: Characterize health policy networks in 15 urban areas in the United States, including size of the networks and connectedness between policy partners in each city. Data Sets and Sources: A social network analysis dataset consisting of 15 cities and 385 respondents. Study Design: In each of 15 cities, we conducted a three-stage social network survey. First, we worked with the chief of policy in the city’s health department to identify policy partners across five main policy areas (i.e., core local funding, tobacco control, obesity and chronic disease, injury and violence prevention, and infant mortality). Next, we built and finalized the roster by reaching out to key leaders in each of those policy spaces. Finally, we sent a web-based survey to each member of the policy network asking about whether and to what extent they collaborated with other members in the network. Analysis: We evaluated the composition and structures of local policy networks in the five policy areas across all 15 cities. We examined the centrality of organizations and organization types in each policy area and overall, compared the composition of policy networks within and between the health departments, and identified predictors of collaboration overall and in the various policy areas. Principal Findings: Networks included between 12 and 54 local organizations. On average, we received responses from between 63% and 100% of local partners in a given city. Three agency types comprised the majority of LHD policy partners: non-profit agencies (25%), government agencies (22%), and schools/universities (17%). Up to 6% of network members were identified as key partners in Core Local Funding, 16% to 25% of network members were key in Tobacco Control, 28% to 42% of network members were leaders or key in Obesity and Chronic Disease, 4% to 33% of network members were key in Injury and Violence Prevention, and up to 60% of network members were key in Infant Mortality. The majority (72%-90%) of organizations worked in a single policy area while a small number worked in multiple policy areas. Preliminary analyses indicated that different agency types were central to each of the policy areas. For example, government agencies were central in the core local funding policy network, hospitals/clinics were most central in the tobacco control policy network, and non-profits were most central in the obesity/chronic disease policy network. Conclusions: Study results will allow LHDs to better understand the composition and structures of their local policy networks and identify opportunities for strengthening existing connections and pursuing additional links. Implications for Public Health Practice and Policy: Policy networks include diverse local partners and vary in central partner types. While LHDs are well connected in all policy networks, they are not as central as some of their partners to this work and may be missing opportunities to connect with others in their city and/or county.
Valerie A. Yeager, DrPH
Public Health Workforce Recruitment: Understanding State Hiring Laws
Co-Investigator(s): Mollye Demosthenidy, JD
Background: For over a decade, public health agencies have experienced workforce shortages and expect the impending retirement of a large portion of valuable employees. The Association of State and Territorial Health Officials (ASTHO) recently released an issue brief that identified lengthy hiring processes as barriers to the successful recruitment of public health workers. To date, no one has collected information on state hiring laws that guide the hiring of public health employees. Without this data, it is difficult to empirically examine state hiring laws as they relate to workforce shortages, hiring processes or recruitment strategies although previous reviews have highlighted the need for such research. Given workforce needs, information about hiring laws and processes may inform strategies to recruit new employees. Research Objective: Using legal mapping techniques and methods, we collected and coded current state hiring laws and regulations governing the hiring processes in state public health agencies across all 50 states. This purpose of this presentation is to summarize the methods used, the data collected, and findings about workforce laws. This data will soon be available as a shareable resource for future public health workforce studies. Data Sets and Sources: We quantified and coded variables associated with merit-based systems, civil service exams, exceptions to these systems, hiring rules, and other relevant information. Primary data on laws and regulations were collected from legal databases (e.g., Westlaw and Lexis Nexis) and official state agency websites. Secondary data, collected by ASTHO in the 2012 Profile Survey, were also used. Study Design: Cohort study using primary and secondary data. Analysis: State hiring laws and regulations were collected and coded in Excel. Summary statistics are provided. Bivariate relationships between hiring laws/regulations and select secondary variables (governance, organization and workforce characteristics) from the 2012 ASTHO Profile survey were also examined. Principal Findings: According to current laws and regulations, a total of 25 states require new employee candidate lists from an external department or board. These same states require that new employees must come from these specific employment lists. A total of 17 states have exceptions to their merit system hiring rules. A total of 35 states require a civil service exam for state public health employees, with 8 states that limit this exam to a written test. Of the 35 states that require a civil service exam, 17 of these public health agencies must administer the exam themselves. A total of 34 states have hiring exceptions for former employees and all states have exceptions for veterans. Conclusions and Implications for Public Health Practice and Policy: Findings indicate that half of all states require new employee candidate lists from external departments or boards. This is important as the legal rules governing hiring may influence the duration of the hiring process and ultimately the time required to hire new employees. Such a finding is important when considering that new public health graduates, an important pool of potential new employees, may not be financially capable of enduring long hiring processes. Exceptions to merit based hiring rules vary across states, potentially complicating the hiring process for new graduates and other potential employees. Analyses examining the relationship between hiring laws/regulations and public health agency governance, organizational, and workforce characteristics are ongoing and will be complete in January 2015. The data on state hiring laws/regulations collected in this study may be useful for future public health workforce research.