摘要：Objectives. We examined local health department (LHD) preparedness capacities in the context of participation in accreditation and other performance improvement efforts. Methods. We analyzed preparedness in 8 domains among LHDs responding to a preparedness capacity instrument from 2010 through 2012. Study groups included LHDs that (1) were exposed to a North Carolina state-based accreditation program, (2) participated in 1 or more performance improvement programs, and (3) had not participated in any performance improvement programs. We analyzed mean domain preparedness scores and applied a series of nonparametric Mann–Whitney Wilcoxon tests to determine whether preparedness domain scores differed significantly between study groups from 2010 to 2012. Results. Preparedness capacity scores fluctuated and decreased significantly for all study groups for 2 domains: surveillance and investigation and legal preparedness. Significant decreases also occurred among participants for plans and protocols, communication, and incident command. Declines in capacity scores were not as great and less likely to be significant among North Carolina LHDs. Conclusions. Decreases in preparedness capacities over the 3 survey years may reflect multiple years of funding cuts and job losses, specifically for preparedness. An accreditation program may have a protective effect against such contextual factors. Federal, state, and local public health agencies have made substantial investments in improving state and local health department (LHD) preparedness capacities and capabilities to effectively prevent, detect, or respond to public health emergencies. 1 A lack of valid and reliable data collection instruments as well as evolving preparedness standards has made it difficult to determine the impact of these investments. 2,3 As recently as 2011, the Centers for Disease Control and Prevention released 15 public health preparedness capabilities designed to serve as national public health preparedness standards to assist state health departments and LHDs with strategic planning. 4 In addition, few studies have examined the impact of LHD contextual factors and participation in improvement efforts on the performance of preparedness capacities. 5 We examined LHD preparedness capacities in the context of participation in performance improvement efforts over a 3-year period using a validated survey instrument. 6 LHDs are essential to emergency preparedness and response activities. They have statutory authority to perform key functions including community health assessments and epidemiologic investigations, enforcement of health laws and regulations, and coordination of the actions of the agencies in their jurisdictions that make up the local public health system. 7 Preparedness also involves specialized functions such as incident command, countermeasures and mitigation, mass health care delivery, and management of essential health care supply chains. 8 The Centers for Disease Control and Prevention organized these functions into capabilities or standards that are supported by foundational capacities or resources elements in the 15 public health preparedness capabilities. 4 Despite the considerable investment in public health preparedness after the September 11, 2001, attacks on the United States and the anthrax attack, funding for public health preparedness declined 38% between federal fiscal years 2005 and 2012. 9 Although LHDs received funding supplements in 2009 and 2010 to address the H1N1 virus and through the American Recovery and Reinvestment Act, 10 median per capita revenues for LHD preparedness activities in the most recently completed fiscal year, 2013, declined to $1.15 from $2.07 in 2010. 11,12 In 2012, approximately half of LHDs reported reducing or eliminating services, with preparedness being among the most common services to be affected. 12 The specific impact of these and other funding reductions on preparedness capacities has yet to be formally studied. After more than a decade of focused effort, gaps and variation in the performance of preparedness activities remain. 6,12 Heterogeneity in the composition and structure of public health systems continues to be an important source of variation in preparedness, as in other aspects of public health practice. 14,15 Other factors affecting LHD general performance and preparedness include LHD governance structure, community, and organizational characteristics, such as funding, leadership characteristics, and partnerships. 7,16,17 Over the past decade, efforts to improve public health infrastructure, and performance more generally, have gathered momentum. These efforts included development and use of the National Public Health Performance Standards Program instruments, the implementation of state-based accreditation programs and the Public Health Accreditation Board, and initiatives to encourage the use of performance management and quality improvement tools. 18-22 The Public Health Accreditation Board is charged with developing and managing national voluntary public health accreditation for tribal, state, local, and territorial health departments. The national accreditation final standards, released in 2011, include a specific emergency preparedness standard as well as additional standards that are linked to preparedness measures. 23 The National Public Health Performance Standards Program provides a framework to assess the capacity and performance of public health systems and public health governing bodies and identify areas for system improvement. LHDs and their partners use tailored instruments to assess the performance of their public health system against model standards, including preparedness standards, which are based on the 10 essential services (National Public Health Performance Standards Program version 2.0; NPHPS Partners, Atlanta, GA). More than 400 public health systems and governing entities used the version 2 assessment instruments (Centers for Disease Control and Prevention, http://www.cdc.gov/nphpsp/archive.html ). Preparedness performance improvement programs have also been implemented to address variation. Project Public Health Ready is a standards-based recognition program with 300 LHDs (27 states) recognized as meeting all the Project Public Health Ready requirements individually or working collaboratively as a region since 2004. 24 To achieve recognition, LHDs must meet nationally recognized standards in all-hazards preparedness planning, workforce capacity development, and demonstration of readiness through exercises or real events. In addition, the Institute of Medicine has recommended that an accreditation program could be a performance monitoring and accountability system for agency preparedness. 25,26 One previous study examined the effects of performance and accreditation programs on LHD performance of 8 preparedness domains on a validated instrument. 5 Controlling for LHD characteristics, a significant positive effect on domain scores was found for LHDs that participated in the North Carolina state-based accreditation program and select performance improvement programs (National Public Health Performance Standards, the Public Health Accreditation Board beta test, Project Public Health Ready) when compared with a national matched comparison group that did not participate in any program. Findings, however, were limited to 1 year of survey data—2010. In this article, we explore trends in preparedness capacities in the present climate of declining resources for public health preparedness activities.
