摘要：Objectives. We examined the availability and perceived effectiveness of 20 basic public health activities in the communities where most Americans reside. Methods. A self-administered questionnaire was mailed to the 497 directors of US local health departments serving at least 100 000 residents. Results. On average, two thirds of the 20 public health activities were performed in the local jurisdictions surveyed, and the perceived effectiveness rating averaged 35% of the maximum possible. In multivariate models, availability of public health activities varied significantly according to population size, socioeconomic measures, local health department spending, and presence of local boards of health. Conclusions. Local public health capacity varies widely across the nation’s most populous communities, highlighting the need for targeted improvement efforts. A strong public health infrastructure is essential for preventing, preparing for, and responding to health threats on a populationwide basis. 1, 2 This infrastructure includes systems for identifying health risks in the population, preventing and controlling communicable disease outbreaks; educating the public and health professionals about health risks and prevention practices; ensuring access to needed health services; and protecting the safety of water, food, and other environmental health resources. 3 Although the importance of the public health infrastructure is widely recognized, efforts to measure and improve performance in public health have lagged behind comparable activities in medical practice. 4– 11 In the present study, we sought to aid in addressing this gap by examining the performance of core public health activities in the nation’s most populous communities. The performance of the nation’s public health system has received growing attention in recent years as this system has been challenged by emerging health threats and by trends in health policy and the health care marketplace. Fifteen years ago, a study commission convened by the National Academy of Sciences’ Institute of Medicine (IOM) found that an array of factors—including stagnant public funding, new and resurgent diseases, a leadership deficit, and a persistent indigent care burden—had left the nation’s public health system in disarray. 4 The IOM report and related studies helped to mobilize public health improvement initiatives across the nation, many of which focused on local health departments as the essential public health providers in most communities. 12– 16 Federal health objectives for the year 2000 established the target that at least 90% of the US population be served by a local health department that effectively carries out core public health functions. 17– 19 More recently, growing public concern about health threats such as new and resurgent infectious diseases, community violence, and bioterrorism has given emphasis and urgency to the task of improving the nation’s public health infrastructure. 20– 24 Recognizing this fact, Congress passed the Public Health Improvement Act in November 2000 and, more recently, committed new federal funds for bioterrorism preparedness to help strengthen the public health infrastructure at the local, state, and national levels. Previous efforts to measure the availability and adequacy of essential public health services at the community level have produced evidence of substantial gaps and wide variation in terms of performance. A 1993 study based on a national sample of local public health agencies showed that, on average, only 50% of 10 activities regarded as important elements of public health practice were performed by these agencies. 25 A similar study of local public health agencies in 6 states showed that in 1993 only 56% of 26 activities regarded as essential public health practices were available within the jurisdictions served by the departments. 26 A third survey involving a national sample of local agencies in 1995 revealed that only 56% of 20 activities deemed important to public health practice were performed by the average agency. 27 Because local public health agencies carry much of the responsibility for implementing state and federal public health programs, local gaps in basic public health activities may compromise the effectiveness of the nation’s public health system in preventing, detecting, and controlling potential health threats. 4, 5, 13, 16 The adequacy of the nation’s public health infrastructure cannot be determined fully without examining the contributions made by organizations other than official governmental public health agencies. 1, 28– 30 Studies in selected communities have suggested that medical care providers, community-based organizations, and even managed care plans are contributing to public health activities with increasing frequency and intensity. 31– 39 Nonetheless, little systematic evidence exists regarding the roles that these organizations play within the nation’s public health system. This study revisited the question of local public health performance, seeking systematic evidence about who contributes to basic public health activities at the community level. We focused attention on the most populous local public health jurisdictions—those with 100 000 or more residents. We chose to examine these jurisdictions because they serve approximately 70% of the total US population and because they exhibit greater homogeneity in regard to public health resources than do smaller jurisdictions. 40 The goals of this study were 3-fold: (1) to examine variation in the availability and perceived effectiveness of essential public health services in the nation’s most populated areas, (2) to examine the types of organizations that contribute to these services, and (3) to examine the organizational and community characteristics associated with local public health performance.
