标题：Laying the Groundwork for Evidence-Based Public Health: Why Some Local Health Departments Use More Evidence-Based Decision-Making Practices Than Others
摘要：We examined variation in the use of evidence-based decision-making (EBDM) practices across local health departments (LHDs) in the United States and the extent to which this variation was predicted by resources, personnel, and governance. We analyzed data from the National Association of County and City Health Officials Profile of Local Health Departments, the Association of State and Territorial Health Officials State Health Departments Profile, and the US Census using 2-level multilevel regression models. We found more workforce predictors than resource predictors. Thus, although resources are related to LHDs’ use of EBDM practices, the way resources are used (e.g., the types and qualifications of personnel hired) may be more important. In 2003, 15 years after The Future of Public Health was published, the Institute of Medicine noted that the United States was not meeting population health goals; specifically, large health disparities existed among socioeconomic groups, racial groups, and men and women, and the US governmental health system was in disarray. 1 To address these problems, the Institute of Medicine recommended that public health system organizations, including state and local health departments (LHDs), adopt a population-level approach to improve the public’s health, make decisions, and take action based on evidence. 1 In 2013, disparities still existed; the United States ranked last among 17 peer high-income countries in health outcomes, including life expectancy, infant mortality, adolescent pregnancy, drug-related mortality, and obesity. 2 Adopting evidence-based approaches allows LHDs, the local “backbone of our public health system,” 1 (p27) to effectively use their limited resources to improve the health of the population. These population health approaches focus on lowering disease risk for the entire population and reducing inequities that affect disease patterns. They are a more effective, less costly means to change disease patterns than providing personal health care. 3–8 Researchers have differed, however, in how they define evidence-based public health (EBPH). 5,7,9,10 Our work relies on the specific definition given by Brownson et al. 7 and we refer to this process as evidence-based decision-making (EBDM). The key processes of EBDM are making decisions using the best available scientific evidence, systematically using data and information systems, applying program-planning frameworks (that often have a foundation in behavioral science theory), engaging the community in assessment and decision making, conducting sound evaluation, and disseminating what is learned. 7 (p177) Little information exists about the types of and frequency with which LHDs use EBDM practices, although many researchers and practitioners have written about barriers to and facilitators of EBDM. 6,11–16 Increasing the extent to which LHDs practice EBDM requires first assessing the extent to which LHDs currently use EBDM practices and then identifying modifiable factors that predict their use. Two frameworks suggest factors that may be related to LHDs’ use of EDBM practices. 17,18 Handler et al. 17 argued that structural capacity (including information, organizational, physical, human, and fiscal resources) must be in place for the functions of the public health system to be achieved. Meyer et al. 18 argued that the organizational capacity of the public health system includes fiscal resources, workforce and human resources, physical infrastructure, interorganizational relations, informational resources, system boundaries and size, governance and decision-making structure, and organizational culture. 18 We used these frameworks to identify workforce, fiscal, and governance factors at the state and local level that may predict variation in the use of EBDM across LHDs. Although investments in public health are associated with decreased mortality 19,20 and improved performance across the 10 essential public health services, 21 estimates have suggested that public health spending makes up only 3% of national health and medical care spending. 22 Moreover, LHD funding continues to decrease. From 2009 to 2010, 44% of LHDs faced budget cuts, and 18% reduced services. 23 Thus, even when LHDs are motivated to use EBDM practices, they may not have the financial resources to do so. Both time and money have been reported as barriers to EBDM use. 5–7,11,12 We therefore hypothesized that funding for local public health would be associated positively with EBDM practices because of the effect of funding on organizational capacity and outcomes and that budget cuts would be negatively associated with EBDM practices. Fewer than 1 in 5 LHD workers are trained in public health 24 ; few LHD top executives have formal public health training 25 or state-required professional credentialing. 26 Previous public health services and systems research has found mixed effects of directors’ qualifications on LHD performance, essential public health services, 27,28 the breadth of different LHD services provided, 29 and reducing health disparities. 30 Although medicine and nursing have had longer histories of evidence-based training than public health, evidence-based practice in these 2 disciplines tends to be clinical, rather than population based, in its focus. 7,10,31 Therefore, we hypothesized that we would find a positive relationship between LHDs with public health–trained leaders and EBDM but no relationship between nurse-led or physician-led LHDs and EBDM. Within public health, some professions have had more exposure to the processes involved in EBDM than others. 5 For example, trained epidemiologists use surveillance data to identify community health problems and risk factors. 32,33 Preparedness coordinators use syndromic surveillance for the early detection of outbreaks. Trained health educators are skilled in community assessment and the development, adaptation, implementation, and evaluation of evidence-based interventions. 34 Not all LHDs have access to personnel with training in these evidence-based approaches. 5,7,10,11,35,36 We hypothesized that LHDs that employed epidemiologists, health educators, and emergency preparedness staff would use more EBDM practices. Because many nutritionists work in clinical roles, we did not expect an association. We also hypothesized that other workforce factors, including the per capita workforce and staff attendance at health impact assessment training, would be positively associated with the number of EBDM practices used. In terms of the local–state governance relationship, we hypothesized that LHDs in states with centralized public health systems (in which LHDs are under the authority of state government), compared with those in decentralized systems (in which LHDs are under the authority of local government), 37 would use more EBDM practices because of the authority of the states to set and enforce local standards. 38–40 Although the LHD performance research on the impact of boards of health is mixed, 41 we hypothesized that a local board of health could influence the use of EBDM by pushing for the use of evidence to increase LHD effectiveness and efficiency 42 or to respond to local needs through the use of epidemiology, community health assessment, and planning. 42 We hypothesized that other local- and state-level contextual variables (e.g., jurisdiction size, percentage of the population living in poverty) would be important predictors of EBDM because of their influence on LHD performance. We treated these contextual variables as control variables because they are less modifiable.
