摘要：Objectives. We explored service variation among local health departments (LHDs) nationally to allow systematic characterization of LHDs by patterns in the constellation of services they deliver. Methods. We conducted latent class analysis by using categorical variables derived from LHD service data collected in 2008 for the National Profile of Local Health Departments Survey and before service changes resulting from the national financial crisis. Results. A 3-class solution produced the best fit for this data set of 2294 LHDs. The 3 configurations of LHD services depicted an interrelated set of narrow or limited service provision (limited), a comprehensive (core) set of key services provided, and a third class of core and expanded services (core plus), which often included rare services. The classes demonstrated high geographic variability and were weakly associated with expenditure quintile and urban or rural location. Conclusions. This empirically derived view of how LHDs organize their array of services is a unique approach to categorizing LHDs, providing an important tool for research and a gauge to monitor how changes in LHD service patterns occur. Nationwide shifts in public health practice in recent decades, including recent responses to economic decline, 1–6 have moved many local health departments (LHDs) away from providing intensive, individually focused, personal health services and toward the transfer of public health investments into more population-focused domains of practice such as assessment, planning, and population-based primary prevention. 2,4 Wide variation in the breadth and scale of services provided by LHDs nonetheless persists. 5,7,8 This variation has been attributed to differences of perspective in the primary “role” of governmental public health agencies, 9 the complex sources of categorical funding that often drive the array of local services delivered, 7 varied legal statutes and policies, 10 and assessments of local need along with the availability of community resources. 7 Evidence suggests that LHD investments overall 11 and in relation to specific services 12 have a beneficial relationship to population health outcomes. It may also be the comprehensive and interactive nature of a specific constellation of LHD services that most effectively contributes to healthy outcomes in a community. 8,13 For example, a related mix of individually focused services for women and children (e.g., the Special Supplemental Nutrition Program for Women, Infants, and Children; family planning; and maternal and child home visits) may be most effective for families when provided together as a package by the LHD. An LHD that couples these maternal and child services with an active assessment and surveillance system that helps prioritize services among those populations for whom poor birth outcomes are particularly high may achieve even better results. The constellation of services, therefore, may be more important to the performance of an LHD in promoting health improvement than the delivery of various individual services in isolation. No apparent studies, however, have classified LHDs themselves in terms of their constellation of services provided. Recent studies in public health systems and services research have made advancements in establishing a typology of the systems delivering local public health services. 14 Using data collected in 1998 and 2006, Mays et al. developed this typology, measuring interorganizational network structures and identifying 7 local public health system configurations that include the scope of activities provided by LHDs and by other organizations in their jurisdictions. 14 The urban systems they have tracked over time appear “highly adaptable” and “dynamic,” suggesting opportunities for modifying complex public health system features to improve performance. 14 (p103) As central figures in these local systems, LHDs play a critical role in ensuring adequate public health service delivery. Yet little is known about how their own services tend to be organized and how their constellations of services can be adapting to change. Identifying underlying patterns in these constellations with routinely collected, national data would provide a means to monitor the adaptations of LHDs themselves and to examine how these service constellations are related to local conditions and health outcomes. We describe a major step in exploring service variation among LHDs nationally to characterize LHDs by patterns in the constellation of services they deliver.
