摘要：Objectives. We examined the associations of local public health system organization and local health department resources with county-level sexually transmitted disease (STD) incidence rates in large US health jurisdictions. Methods. We linked annual county STD incidence data (2005–2008) to local health department director responses (n = 211) to the 2006 wave of the National Longitudinal Study of Local Public Health Systems, the 2005 national Local Health Department Profile Survey, and the Area Resource File. We used nested mixed effects regression models to assess the relative contribution of local public health system organization, local health department financial and resource factors, and sociodemographic factors known to be associated with STD incidence to county-level (n = 307) STD incidence. Results. Jurisdictions with local governing boards had significantly lower county-level STD incidence. Local public health systems with comprehensive services where local health departments shoulder much of the effort had higher county-level STD rates than did conventional systems. Conclusions. More integration of system partners in local public health system activities, through governance and interorganizational arrangements, may reduce the incidence and burden of STDs. US annual sexually transmitted disease (STD) incidence rates have not declined despite the identification of effective surveillance and prevention methods. 1–5 For example, after decreasing annually since 1999, gonorrhea infection rates among adolescents increased 2% from 2004 to 2005, from 421.9 to 431.8 per 100 000, and then increased 6% again from 2005 to 2006, from 431.8 to 458.8 per 100 000. 6,7 Untreated STDs can have serious long-term health effects, such as cervical cancer, infertility, and pregnancy complications. 8 STDs are among the largest Black–White racial disparities in health, 9 which are heavily influenced by social determinants (i.e., area-level sociodemographic factors). 9–12 It is a widely accepted view that local health departments and their system partners play a critical role in controlling the spread of STDs. 13–15 Local health departments differ dramatically in size, organizational structure, and available resources, and these factors can influence the reach and effectiveness of local STD prevention strategies. Previous studies indicate that larger local health departments, better resourced local health departments (as measured by expenditures per capita), and jurisdictions with local boards of health with policymaking authority more consistently provide a diverse set of essential public health functions, 16–19 including diagnosing and preventing health problems and informing and educating the public about health issues. Moreover, recent evidence indicates that increases in STD prevention funding are associated with reductions in gonorrhea 20 and syphilis 21 incidence rates. This suggests that resources available to local health departments and their system partners can affect the “reach” of STD prevention programs. The contribution of community partner organizations to performing essential public health functions 18 may also influence the reach and effectiveness of STD prevention and treatment programs. For example, low integration of local health departments with their local system partners, including physician organizations, community health centers, and faith-based organizations, can impinge on the effectiveness of local STD prevention and treatment efforts. 15 Given that rescreening previously infected individuals is increasingly viewed as central to controlling the spread of STDs, 22 local health departments that have low integration with their health care delivery system partners might face more difficulties curtailing the spread of STDs. It may be difficult for local health departments that have limited integration with system partners to communicate surveillance data and to generate action to combat emerging health epidemics. Little research, however, has assessed organizational and market determinants of local public health system effectiveness using population health indicators. 17–19 Although several studies have assessed the relationship of county-level sociodemographic factors and STD rates, 23,24 to our knowledge, no study has ever assessed the relationship of local public health system organization and STD incidence rates. Consequently, the extent to which the scope of local health department services and their integration with their local health system partners is associated with STD incidence rates remains unclear. Using responses to the National Association of County and City Health Officials (NACCHO) 2005 National Profile of Local Health Departments in the United States (NACCHO Profile) and county-level data from the Area Resource File, we examined the extent to which local health department financing per capita, the existence of a local governing board of health, and integration among key system partners are associated with county-level incidence rates of gonorrhea and chlamydia. Consistent with previous research examining public health spending and medical care expenditures, 25 we hypothesized that local health departments with greater total expenditures per capita have lower STD incidence rates when controlling for county-level sociodemographic and other local health department characteristics. Local boards of health are increasingly considered central to improving community-based linkages and setting priorities for jurisdictions. Accordingly, we hypothesized that county-level STD rates would be lower in jurisdictions where local boards of health have governance responsibility than in those having no local board of health. The integration of local health departments with local public health system partners can influence the dissemination of preventive health care information and epidemiologic data to target interventions. We hypothesized that local health departments with a higher integration with system partners, as measured by the recent typology of local public health systems, 26,27 have lower STD incidence rates, controlling for other factors. Finally, we examined the role of social determinants of STD incidence relative to measurable local public health system factors.
