摘要：We explored the association between changes in local health department (LHD) resource levels with changes in health outcomes via a retrospective cohort study. We measured changes in expenditures and staffing reported by LHDs on the 1997 and 2005 National Association of County and City Health Officials surveys and assessed changes in state-level health outcomes with the America's Health Rankings reports for those years. We used pairwise correlation and multivariate regression to analyze the association of changes in LHD resources with changes in health outcomes. Increases in LHD expenditures were significantly associated with decreases in infectious disease morbidity at the state level ( P = .037), and increases in staffing were significantly associated with decreases in cardiovascular disease mortality ( P = .014), controlling for other factors. THE ULTIMATE AIM OF LOCAL health departments (LHDs) is to improve the quality of life for the communities they serve—a part of the larger mission of public health, which is “the fulfillment of society's interest in assuring the conditions in which people can be healthy.” 1 (p7) Since the Institute of Medicine's 1988 report, The Future of Public Health, there have been numerous studies that have described and measured the performance of LHDs, the characteristics associated with performance, and whether and how such performance affects health. 2 Studies have most often described associations of performance with LHD size, jurisdictional size, and funding: LHDs with larger staffs, serving populations greater than 50 000 persons, and with higher funding per capita were more often higher performing. 3 – 14 Higher performing LHDs also had greater community interaction, a director with higher academic degrees, and leadership functioning within a management team. 5 , 9 , 11 , 15 Only 4 published studies have attempted to link LHD characteristics, activities, or performance to health outcomes. 9 , 13 , 16 , 17 All of these studies are limited by their cross-sectional design. One study has examined the longitudinal relationship between LHD inputs and health outcomes, showing significant associations between changes in local public health spending and infant mortality and deaths attributable to cardiovascular disease (CVD), diabetes, and cancer at the county level. 18 We focused on the relationship between changes in LHD inputs (financial resources, staffing), aggregated to the state, and changes in state-level health measures (smoking and obesity prevalence, infectious disease morbidity, infant mortality, cancer and CVD mortality, and premature death). Aggregating LHD inputs to a state level not only allows the opportunity to explore the impact of LHDs' combined resources but also reduces the complexities inherent in studies that have compared LHDs to one another, always a challenging task with the very large differences in LHD size, functions, and jurisdictions. Conceptual and logic models pertaining to public health in general posit that an increase in inputs leads to enhanced capacity to provide the essential public health services, which, in turn, leads to improved public health performance and, ultimately, to improvements in community health status. 19 The health measures included in this study were selected on the basis of amenability to public health interventions for which logic models may be specified. The primary and secondary prevention methods that may lead to improvements in these health measures—e.g., community-based efforts to enhance physical activity opportunities to reduce CVD and targeted immunization campaigns to reduce vaccine-preventable diseases 20 —are interventions that are commonly led by LHDs. The relative paucity of empirical evidence that supports such logic models for LHDs remains a challenge for public health. This serves as rationale for our study, the goal of which is to identify LHD inputs that may ultimately lead to health improvements. We investigated the association between LHD inputs—aggregated to the state—and health outcomes at the state level. This association has relevance both for local public health leaders, who are being held more accountable for how local resources are used, and for state leaders, who are often challenged to show how investments at the local level can deliver on a promise of improving state-level health measures.
