摘要：Objectives. We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina. Methods. We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality. Results. Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births ( P < .05). Provision of women and children’s services was associated with a reduction of 1 to 2 infant deaths per 1000 live births ( P < .05). Conclusions. Our findings, in the context of other studies, provide support for investment in local public health services to improve community health. The length and severity of the recent economic recession created challenging conditions for local health departments (LHDs). Faced with reduced financial resources, many LHDs eliminated staff and cut or reduced services. Nearly half (48%) of LHDs reduced or eliminated services in 2008. 1 By 2012, the combined workforce loss in the United States since the start of the recession in 2008 was estimated at almost 44 000. 2 The common mantra of local health directors in the past has been that they are often asked to do more with less. Now, they have found themselves trying to determine how to do less with less—a task made more complicated by a limited evidence base to inform decision-making. In a national survey of local health officials, the effectiveness of a service was the factor listed by most as being influential in their decisions about resource allocation. 3 Yet, evidence of the impact of public health services is not clear. Similarly, data on capacity measures such as spending, staffing, or services are sparse, and systematic evaluation is challenging. 4 This challenge is especially true at the local level at which many funding and programmatic decisions are made. The national public health systems and services research agenda has identified the need for evidence demonstrating which investments and strategies have the largest effect on community health outcomes. 5 The Consensus Statement on Quality in Public Health has stated that public health practices should be efficient, which includes understanding the costs and outcomes associated with programs. 6 The field of public health systems and services research has also recognized that investments in data and methods are needed. 7 Our study was conducted in this context. We examined the association between investments in local public health and community health outcomes in North Carolina, with the aim of contributing to the evidence base linking public health services with community outcomes. Our work builds on previous studies of the associations between community outcomes and public health capacity (usually measured in terms of spending, staffing, and services) and processes (usually measured through performance of essential services or community outcomes). Our analytic approach was guided by the conceptual model proposed by Meyer et al. 4 This framework illustrates that public health outcomes are influenced by performance and services provided by public health systems, which are in turn influenced by the organizational capacity of the public health systems. Using this model, funding is categorized as an economic resource and staffing as a human resource, which are 2 of the types of organizational resources that influence the capacity of LHDs to perform services. This model depicts a temporal pathway from capacity to services to outcome, but it does not identify specific measures of the model components or the interrelationships between indicators of capacity (such as funding and staffing). Literature in the field of public health systems and services research has consistently measured the association between community outcomes with either capacity measures or processes measures, but seldom with both. Mays and Smith 8 examined associations between levels of local public health spending and preventable mortality over a 13-year period. Spending was significantly associated with reductions in 4 outcomes—infant mortality and deaths from cancer, heart disease, and diabetes—but not in influenza deaths or all-cause mortality. Erwin et al. 9 examined changes in local resources and staffing, aggregated to the state level, from 1995 through 2005, as predictors of community health outcomes. They found reductions in infectious disease morbidity associated with higher local health spending and reductions in cardiovascular mortality associated with greater full-time-equivalent (FTE) staffing. They found no associations between spending or FTEs for the outcomes of smoking, obesity, cancer deaths, infant mortality, and years of potential life lost. In a similar study over a longer time, researchers reported associations between LHD expenditures and infant mortality and years of potential life lost. 10 A 2008 literature review identified 23 peer-reviewed articles on LHD performance. 11 LHD characteristics associated with higher performance included greater funding, more staffing, and a larger population served. Two landmark studies have examined public health system performance using indicators based on performance of the 10 essential services. 12,13 These studies observed associations between higher public health system performance and higher levels of funding. However, a later study showed significant associations between higher performance and other metrics, including larger size of the population served, presence of boards of health, and educational background of the top officer in the LHD. 14 Direct federal per capita spending was significantly associated with only 1 of 10 essential services. Staffing was not associated with performance. In a recent study looking at the association between outcomes and spending, Bekemeier et al. 15 observed an association between LHD investments in maternal and child health services and reduced rates of low birth weight babies. A few North Carolina–specific studies have examined the capacity indicators as predictors of LHD performance. Hajat et al. 16 measured performance of 9 service categories. They observed workforce characteristics, such as staff education, certification, and experience, were important predictors for most services. Staffing, measured as FTEs, and spending were significantly associated with only 1 service area each. Porterfield et al. 17 examined LHD diabetes prevention and control activities and characteristics associated with performance. Health department FTEs, expenditures and accreditation status, and diabetes-specific external funding were significantly associated with diabetes prevention and control performance. Although previous studies 8–10,18 have shown some support for the hypothesis that investments in public health improve LHD performance and community health, results have been inconsistent. This may be, in part, a result of conceptual and methodological differences in the studies. The use of different measures for capacity, services, and outcomes; differential emphasis on specific parts of the temporal pathway; and modeling strategies likely contribute to the lack of consistency in study findings related to public health investments and outcomes. In an effort to enhance understanding of the relationships among capacity, services, and outcomes, we incorporated multiple constructs to explore the potential pathways by which capacity and services may influence outcomes.
