2015 Hearne et al The Future of Urban Health

The Future of Urban Health Needs BarriersOpportunities and Policy Advancement at LargeUrban Health Departments

Shelley Hearne DrPH Brian C Castrucci MA Jonathon P Leider PhD Elizabeth K Rhoades PhDPamela Russo MD MPH Vicky Bass MPH

Context More than 2800 local health departments (LHDs)

provide public health services to more than 300 million

individuals in the United States This study focuses on

departments serving the most populous districts in the nation

including the members of the Big Cities Health Coalition (BCHC)

in 2013 Objective To systematically gather leadership

perspectives on the most pressing issues facing large urban

health departments In addition to quantify variation in policy

involvement between BCHC LHDs and other LHDs Design We

used a parallel mixed-methods approach including interviews

with 45 leaders from the BCHC departments together with

secondary data analysis of the National Association of County amp

City Health Officialsrsquo (NACCHO) 2013 Profile data ParticipantsForty-five local health officials chiefs of policy and chief

sciencemedical officers from 16 BCHC LHDs Results The

BCHC departments are more actively involved in policy at the

state and federal levels than are other LHDs All BCHC members

participated in at least 1 of the 5 policy areas that NACCHO

tracks at the local level 89 at the state level and 74 at the

federal level Comparatively overall 81 of all LHDs participated

in any of the 5 areas at the local level 57 at the state level

and 15 at the federal level The BCHC leaders identified

barriers they face in their work including insufficient funding

political challenges bureaucracy lack of understanding of

issues by key decision makers and workforce competency

Conclusions As more people in the United States are living in

metropolitan areas large urban health departments are playing

increasingly important roles in protecting and promoting public

health The BCHC LHDs are active in policy change to improve

J Public Health Management Practice 2015 21(1 Supp) S4ndashS13Copyright Ccopy 2015 Wolters Kluwer Health | Lippincott Williams amp Wilkins

health but are limited by insufficient funding governmental

bureaucracy and workforce development challenges

KEY WORDS Big Cities Health Coalition (BCHC) local healthdepartments (LHDs) public health practice

The United States faces a very different health land-scape than it did a century ago Where as the na-tionrsquos public health system once focused on sanita-tion and infectious disease public health today facesa new set of challenges dominated by chronic diseasebut with tremendous breadth1(p27) These challenges in-clude but are not limited to opioid abuse23 obesity4

cancer prevention and control5 climate-induced healthrisks6 asthma7 antimicrobial resistance8 and reemerg-ing infectious diseases9 Despite spending far more onhealth care than our international peers Americans dieyounger than people in almost all other industrializednations1011

Health is shaped by biological and physiologicalprocesses individual behaviors and social determi-nants such as education and financial conditions12

Prevention of many of todayrsquos major health problems

Author Affiliations National Association of County amp City Health OfficialsWashington District of Columbia (Dr Hearne and Ms Bass) de BeaumontFoundation Bethesda Maryland (Mr Castrucci and Dr Leider) and Robert WoodJohnson Foundation Princeton New Jersey (Dr Russo)

The authors declare no conflicts of interest

This is an open-access article distributed under the terms of the CreativeCommons Attribution-NonCommercial-NoDerivatives 30 License where it ispermissible to download and share the work provided it is properly cited Thework cannot be changed in any way or used commercially

Correspondence Jonathon P Leider PhD 7501 Wisconsin Ave Suite 1310EBethesda MD 20814 (leiderdebeaumontorg)

DOI 101097PHH0000000000000166

Copyright copy 2015 Lippincott Williams amp Wilkins Unauthorized reproduction of this article is prohibited

S4

Needs Barriers Opportunities and Policy Advancement at Large Urban Health Departments S5

require policy solutions that directly impact the rootcauses of illness and influence personal decision mak-ing The nationrsquos local health departments (LHDs) area critical actor in this process They can be innova-tors and advocates for health policy change becausetheir authority and focus is at the local level1314 Policyinnovations at the local level can drive national changeFor example LHDs were critical to the successfuldrafting and implementation of ordinances to restricttobacco use in restaurants and bars in the early 2000sacross the United States15 Exposure to secondhandsmoke declined by 83 among restaurant and baremployees16 Today 80 of all Americas live in jurisdic-tions with limits on smoking in restaurants and barsprotecting them from this unhealthy exposure

The importance of LHDs is growing in the con-text of US Congressional stagnation and the increas-ing politicization of state legislatures17-19 The extent ofLHDsrsquo role in the policymaking process warrants ad-ditional investigation We used the 2013 National Asso-ciation of County amp City Health Officials (NACCHO)Profile to examine the influence of jurisdictional sizeand involvement in policy making In addition we in-terviewed leaders of public health departments whoparticipate in NACCHOrsquos Big Cities Health Coalition(BCHC)mdasha group of 20 LHDs that serves 46 millionAmericans20mdashto identify the factors that have facili-tated and impeded their efforts to advance new publichealth policies The BCHC is a forum for the leaders ofAmericarsquos largest metropolitan health departments toexchange strategies and best practices and jointly ad-dress issues to promote and protect most effectively thenationrsquos health The BCHC is made up of the LHDs ofAtlanta Baltimore Boston Chicago Cleveland DallasDenver Detroit Houston Los Angeles Miami NewYork Philadelphia Phoenix San Antonio San DiegoSan Francisco San Jose Seattle and Washington DC

Methods

We used a parallel mixed-methods approach with onetrack analyzing data from the NACCHO 2013 Profileto differentiate BCHC members from other LHDs withrespect to policy involvement We also conducted aninterview phase of the study to systematically gatherperspectives from leaders of the BCHC LHDs on relatedareas

The NACCHO Profile collects data approximatelybiannually from 2800 LHDs These condense to N =2532 reporting units In 2013 the NACCHO Profilehad a response rate of 78 Nineteen of 20 BCHCagencies responded to the NACCHO Profile surveyWe divided the non-BCHC LHDs into 3 categories ofpopulation size (as opposed to geographic size) on the

basis of NACCHOrsquos previously published standardssmall LHDs with a population less than 50 000 resi-dents medium-sized LHDs with 50 000 to 499 999 resi-dents and large LHDs with 500 000 or more residentsWe report descriptive statistics comparing departmentsin terms of involvement in policy and advocacy

The second stage of this study involved key infor-mant interviews We interviewed 45 leaders from 16participating BCHC LHDslowast In each jurisdiction weinterviewed leaders in each of 3 positions the localhealth official the chief policysenior deputy and thechief sciencemedical officer Three jurisdictions didnot have chiefs of policy The interviews were con-ducted between August and October 2013 by a singleinterviewer with each interview lasting approximately1 hour all were recorded Interviews were transcribedverified and coded independently by 2 researchersInterview data were independently coded in batchesby the researchers Disagreements in coding were re-solved and interviews were recoded using consensusdecisions

Participants also took part in a brief Web-based sur-vey along with the interview21 In the interview all par-ticipants answered all questions In the Web surveyhowever participants answered only organizationallyoriented questions related to their position and job du-ties The survey mostly included items regarding or-ganizational characteristics and capacities previouslyused in other NACCHO studies as well as questionson data capacity that were used in previous studiesby the Association of State and Territorial Health Offi-cials Additional questions were tailored to BCHC LHDneeds and capacities and were a focal point of pretest-ing Both the interview and survey instruments werepretested with 5 former health officials Quantitativedata were managed and analyzed in Stata 13 (Stata-Corp LP College Station Texas) Qualitative data weremanaged and analyzed in nViVo 10 (QSR InternationalCambridge Massachusetts)

Results

Policy activity by jurisdictional sizemdashresults fromthe 2013 NACCHO Profile

The NACCHO Profile asks about policy involvement in(1) writing issue briefs (2) providing public testimony(3) serving on advisory panels (4) communicating withpolicymakers about specific policies and (5) providingtechnical assistance to partners drafting public health

lowastAt the time of the interview portion of this study 18 LHDsconstituted the BCHC Two additional LHDs have since joinedthose serving San Antonio Texas and San Diego California


S6 Journal of Public Health Management and Practice

FIGURE 1 Local Health Departmentrsquos Involvement in Policy-making Activities at the Local State and Federal Levelsby Jurisdiction Size 2012-2013

Abbreviation BCHC Big Cities Health Coalition



policiesmdashat the local state or federal level There was apositive association between jurisdiction size and pro-portion performing each activity (Figure 1) There was asimilar association for policy involvement at the localstate and federal levels Communicating with legis-lators regulatory officials or other policymakers wasthe most common activity across all groups A greaterproportion of BCHC member LHDs were active at thefederal level than any other group The proportion ofBCHC member LHDs participating in these policy ac-tivities at the federal level was generally double that ofother large LHDs All BCHC members participated inat least 1 of these 5 areas at the local level comparedwith 81 of all LHDs Approximately 74 of BCHCmembers participated in at least 1 area of policy in-volvement at the federal level compared with 36 ofother large LHDs and 15 of all LHDs (Figure 2)

Between 2011 and 2013 all BCHC members reportedhaving been actively involved in policy or advocacyactivities related to tobacco alcohol or other drugs aswell as obesitychronic disease More than two-thirdsof BCHC members worked on smoke-free indoor airpolicy smoke-free outdoor air policy and reducing thesale of cigarettes to minors About 30 worked on rais-ing the cigarette tax and 47 on reducing advertisingNo members reported working to alter alcohol taxes intheir jurisdiction In the area of obesity and chronic dis-ease more than three-quarters of BCHC members re-ported actively engaging in urban design policy school

physical activity policy reducing unhealthy eating atschools expanding recreational facilities and increas-ing fruitvegetable options in retail locations Only 2BCHC LHDs said that they worked on limiting accessto fast food

Ninety percent of BCHC members reported that apublic health ordinance or regulation had been adoptedin their jurisdiction in the past 2 years Several ju-risdictions passed multiple ordinances or regulationsThirteen BCHC jurisdictions passed tobacco alcoholor other drug ordinances 6 passed environmentalhealth ordinances 2 passed health care access-relatedordinances 3 passed occupational health-related ordi-nances 6 passed obesitychronic diseasendashrelated ordi-nances 2 passed injury prevention ordinances and 8passed ldquootherrdquo ordinances Sixty percent of other largeLHDs 44 of medium-sized LHDs and 29 of smallerLHDs adopted a public health ordinance or regulationin the past 2 years

Leadership perspectives from interview data

Demographics

The 45 interview participants from the BCHC depart-ments included 23 women and 22 men (Table 1) Thirtylisted professional or doctoral degrees as their highestlevel of education Participants indicated that they hadworked in their current position 34 years on average

FIGURE 2 LHD Participation in Selected Chronic Disease Policy Areas

Abbreviations BCHC Big Cities Health Coalition LHDs local health departments TAOD tobacco alcohol or other drug



TABLE 1 Demographic Characteristics

Respondent Characteristics Local Health Official Chief of Policy Chief ScienceMedical Officer Total (n = 45)

GenderMale 10 4 8 22

Female 6 9 8 23Highest education level

Bachelorrsquos 0 2 0 2Masterrsquos 3 6 3 12Doctoral or Professional 13 5 13 31

Length in positionMean years in current position 38 29 35 34Median years in current position 35 20 30 30Mean years in management 182 115 146 148Median years in management 155 105 80 130Mean years in public health 194 162 187 181Median years in public health 175 165 150 160

(median 3 years) in management for 148 years on av-erage and had worked in public health for 18 yearson average Seven BCHC directors were appointed bya mayor 1 by a board of health 3 by a county execu-tive and 6 by some other arrangement (typically somecombination of various state and local agencies)

Perceived needs and barriers in BCHC LHDs

We asked BCHC leaders about perceived needs of largeurban health departments The majority thought thatthe biggest barrier faced by health departments wasthe lack of funding for public health activities espe-cially those considered to be core public health and in-frastructure Information management needs were alsocommonly mentioned Overall BCHC leaders identi-fied 3 key policy areas as priorities over the comingyears core funding for public health activities ldquohealthin all policiesrdquo (where the effects of for example trans-portation housing or education policies on health aretaken into account and public health is at the table)and LHDs participation in the implementation of theAffordable Care Act (ACA) Participants commonlycited political barriers including ideological stances onwhere to assign blame for poor health outcomes as wellas outdated laws (Table 2) As one participant noted

Among the decision-makers and also to a large extentamong the electorate the attitude is that there is not arole for government to undertake steps that arecommunal in nature to benefit all There is anunderlying culture that people should be responsiblefor themselves and that if you made a bad healthdecision in some way thatrsquos your own fault Asopposed to recognizing that itrsquos not about blame itrsquosabout where do we know that we can makeinterventions that will lead to fewer people making badchoices

Similarly participants explained that it was some-times difficult to convince decision makers of how toproceed with public health policy and programmingbecause of their lack of understanding of public healthor of how to interpret data Local bureaucracy was con-sidered to be a major barrier by several participantswho explained that the governmental systems in placein their particular jurisdictions made it nearly impos-sible to hire appropriate staff execute purchase ordersor accept grants in a timely fashion Some intervieweesnoted the difficulty in engaging diverse communitystakeholders to formulate comprehensive and unifiedstrategies indicating that a lack of resources and manydifferent community agendas made it difficult to facil-itate collaboration

Workforce Needs

Participants uniformly reported that workforce needsare substantial in BCHC LHDs These needs relate toworkforce development in terms of continuing educa-tion and the acquisition of new skills as well as theability to hire the right people for the job Participantsreported that their departments lacked employees withthe skills required to carry out the full range of activitiescritical to public health services especially advocatingfor policy change and engaging the community Fromtheir perspectives these problems are exacerbated bycomplex and restrictive hiring practices as well as lowemployee mobility

The BCHC leaders were asked specifically about themost important types of skills their staff needed to beeffective (Figure 3) The most commonly-cited skillsneeded by staff were ldquobig picturerdquo or ldquopublic health101rdquo training Systems thinking constituted abilities



were needed to interconnect departmental programsas well as to understand how the health department fitswithin the broader city environment Skills in quanti-tative analysis were also mentioned as being necessaryFinally many said that it was difficult to hire staff in atimely way One participant illustrated her point withthe following response when talking about runninginto challenges while trying to hire for policy-orientedpositions

There just isnrsquot a policy position [in the HR system]And we do have things like a Research Assistant III oran Epidemiologist II but we donrsquot have this kind ofposition carved out and recognized So for example Ihad a really hard time hiring a health economist Wehad to go through a third party contractor to hire thembecause we had no items that he could fit on Therersquos nosuch thing as a health economist before And yet wersquoretrying to do more of this kind of work like healthimpact assessments So that is a really big challenge

Programmatic Budget Cuts

The majority of BCHC departments had approximatelythe same budget in 2013 as 2012 in nominal dollars4 had budget cuts greater than 10 Although manyBCHC LHDs had relatively small changes to total ex-penditures between fiscal year 2012 and fiscal year2013 programmatic budget changes did occur The

BCHC policy chiefs (1 per LHD) were asked to quantifyany changes in programmatic areas over the previousfiscal year Most participants reported some fluctua-tion in their programmatic budgets with more cuts re-ported than growth Those with budget growth had itin areas such as immunization (1 LHD) communicabledisease control (1 LHD) chronic disease (3 LHDs) ma-ternal and child health (2 LHDs) other personal healthservices (2 LHDs) population-based primary preven-tion (2 LHDs) and in other environmental health pro-grams (1 LHD) More commonly BCHC LHDs reportedcuts especially in immunizations epidemiology andpopulation-based prevention services (Figure 4)

Discretion to Reallocate Dollars

One policy chief per department was asked to indicatethe level of control associated with various revenuestreams including local revenue state direct federalpass-through dollars federal direct sources Medicareand Medicaid other clinical revenue and all othersources With the exception of local sources themajority of participants indicated that they had noor only a small amount of control Six of 13 policychiefs said that they felt that they had a great deal ofcontrol for local sources of revenue while 3 othersfelt that they had moderate control Nine participants

TABLE 2 Greatest Barriers to Local Health Department Improving Population Health

Theme Illustrative Quote

Funding (24 respondents) ldquoWhat wersquore finding and the challenge is that the categorical funding tends to be going up and becoming more narrow andwhat is going away is the ability to have more flexible funding to be able to address what the needs arerdquomdashPolicy Director

Political (15 respondents) ldquoThere has been federally as well as locally laws on the books that are not necessarily the things that people are dying fromtoday when we get into critical cuts andor lack of funding people tend to quickly go to whatrsquos on the books as arequirement if you look at things like tuberculosis across the country and you look at things like foodborne illnesses ina variety of areas we have funding for those things that are on the books as critical and legislatively mandated forpublic health what we donrsquot see is that same attention given or policies in place that really lead public health aroundour leading causes of death and chronic diseases within our communitiesrdquomdashPolicy Director

Bureaucracy(9 respondents)

ldquoThe hardest part of my job is that itrsquos 90 focused on the day-to-day milieu of administering the department so it gives younot enough white space to think and work with other thought leaders about how to really lay out a strategy And so thatrsquosthe ongoing challenge of managing a large department and just everything from signing travel vouchers to personnelproblemsrdquomdashLocal Health Official

Community involvement(9 respondents)

ldquoI think the size of our community is really daunting We have a lot of strong stakeholders There are so many players But coming up with a cohesive strategy that a lot of key community stakeholders could agree with are the priorities I thinkis a challengerdquomdashPolicy Director

Lack of public healthknowledge on part ofkey decision makers(6 respondents)

ldquoI think that in coming at this like I do from a purely data perspective that the biggest barrier that we always face is to try andconvince people that while the information that we have may not be perfect the answer is not to just wait for more orperfect data but instead at what point can you reasonably act on imperfect data and at what point do you need to stepback and find other ways to look at a particular issuerdquomdashScience Director

Workforce competency(6 respondents)

ldquoI also think that itrsquos a workforce competency issue where again as we move into this policy arena in addition to not havingenough money we donrsquot necessarily have on staff the range of skills that you need in community partnership building inadvocacy and in thinking about where are the other sources of financing are in the community that you can leverage Theskills to do that are not necessarily part of the historical public health workforce skillsrdquomdashLocal Health Officer



indicated that they felt that they had no discretion toreallocate dollars from federal direct or pass-throughfunds Three said that they felt that they had no controlover state sources 6 said that they felt that they had asmall amount of control over state sources

Discussion

Public health policy has the potential to impactlarge portions of a population and contribute to anenvironment in which the healthy option is the defaultoption This is especially the case in metropolitan areaswhich are now home to almost 83 of Americans22

With the United States facing important health chal-lenges in the 21st centurymdashfrom obesity rates to opi-oid abusemdashlarge urban jurisdictions and their publichealth systems are serving as key hubs for the greatestreturns on health investments

Increasingly over the past decade big city and largemetro governments have become incubators of policyinnovation and strong executive leadership23 In thefield of public health local leadership is critical partic-ularly during a time of federal paralysis Cities are bet-ter positioned to respond quickly to emerging threats

than the slow-moving federal bureaucracy and are ableto take strong stances on governance and local issueswhen partisan gridlock stalls federal efforts Mayorsacross the country have taken risky stands on healthissues from tobacco control to childhood obesity24-27

The BCHC member LHDs have been the most activein policymaking among all LHDs nationally All but 1BCHC jurisdiction passed at least 1 public health ordi-nance in the past between 2011 and 2013 with all work-ing on policy on 2 key fronts tobacco alcohol and otherdrugs and obesity and other chronic diseases Nationalleadership on new strategies and health challengeshas arisen from urban jurisdictions For example LosAngeles County Department of Public Health drovethe development of public letter grading for restau-rants which resulted in improved hygiene reducedrestaurant inspection violations and a lower incidenceof foodborne illness28 In addition Seattle-King Countywas one of the first to regulate electronic cigarettes astobacco products with the aim to decrease adolescentnicotine addiction29 Finally New York City instituteda wide scope of new policies such as restaurant calo-rie postings school and vending machine food stan-dards and bonus food stamp coupons for fruits andvegetables3031

FIGURE 3 Top Skills

Abbreviation GIS Geographic Information Systems



Thomas Frieden former commissioner of the NewYork City Department of Health and Mental Hygieneand current director of the Centers for Disease Controland Prevention noted a decade ago that many pub-lic health agencies had failed to implement effectivepolicies and programs to prevent current health prob-lems in part due to structural inadequacies and insuf-ficient funding30 While large metropolitan health de-partments have advanced important policy initiativesin the past decade the results of the current study con-firm the challenges remaining that prevent LHDs fromachieving optimal impact on improving the popula-tionrsquos health

Insufficient funding is the most frequently identi-fied barrier to LHD impact improving the populationrsquoshealth Big city spending per capita varies tremen-dously which is partially attributable to local sup-port but largely due to variable levels of federal fundsreaching urban centers because state health agenciesare allocating those federal dollars differently Greatertransparency is needed to track this variable distribu-tion and its impacts on effective investments in publichealth The barriers are not merely having too littlemoney but that the fiscal environment hampers de-partmentsrsquo potential impact in policymaking processbecause of restricted fiscal flexibility and discretioninadequate workforce skills and limited policymakerknowledge

Data from the 2013 NACCHO Profile identified op-portunities for greater involvement for LHDs in thepolicymaking process Policy development should bea priority among LHDs individually and in NAC-CHO collectively3233 A key message of the Instituteof Medicinersquos recent report is for government agen-cies to familiarize themselves with the toolbox ofpublic health legal and policy interventions at theirdisposal1(p27)

The BCHC member LHDs were active at the localstate and federal levels for all policy activities queriedbut this was not the case for other large LHDs or LHDswith small or medium-sized jurisdictions It may bethat federal-level policy involvement from all LHDs isan unrealistic expectation except for the largest LHDsHowever some policy activity at the local level regard-less of jurisdictional size should be universal Policydevelopment is a core function of public health practiceand has been instantiated as such in the Ten EssentialServices34 and more recently both as part of the Foun-dational Public Health Services model35 and the healthdepartment accreditation process by the Public HealthAccreditation Board36

Gaps in funding lack of political support and needsfor strengthening professional staff are not new chal-lenges in the management of public health depart-ments For the past 20 years there has been a steadydrumbeat of calls for sustained and strategic funding

FIGURE 4 Cuts in Programmatic Budgets Between Fiscal Year 2012 and Fiscal Year 2013

Abbreviations BCHC Big Cities Health Coalition LHDs local health departments



streams that would allow governmental public healthto respond to emerging health threats build capacity toaddress and prevent chronic conditions and institutepolicies to improve conditions for healthy living Theseneeds persist With their dense populations strongleadership and demonstrated commitment to engagein public health policy innovations large metropolitancenters must become a greater priority at the federaland state levels for achieving improved returns onhealth investments

Limitations

This study had several limitations It is a cross-sectionalstudy and focuses primarily on the members of theBCHC Data from the 2013 NACCHO Profile are widelyused but do have limitations These include potentialissues due to nonresponse bias though a 78 responserate is relatively robust for surveys of this type1(p27) Inaddition the data are self-reported Qualitative resultsshould be interpreted within the context of the largeurban health departments that constitute the BCHC

Conclusion

The need and opportunity exist to increase all LHDsrsquopolicy activities The BCHC members have becomeincubators of policy innovation and strong executiveleadership However even those departments in theBCHC have been hindered from making further gainsin prevention and public health by continued inade-quate funding and constraints in targeting resources toaddress local priorities Leaders from BCHC memberLHDs need to engage leaders in other large LHDs andmedium-sized LHDs to increase their policy involve-ment at the local and state levels to create strongersupport for public health investments Public healthleaders need greater political and financial support tomake concrete progress on the most winnable healthbattles

REFERENCES

1 Institute of Medicine For the Publicrsquos Health Investing in aHealthier Future Washington DC The National AcademiesPress 2012

2 Paulozzi LJ Opioid analgesic involvement in drug abusedeaths in American metropolitan areas Am J Public Health2006961755-1757

3 Paulozzi LJ Budnitz DS Yongli X Increasing deaths fromopioid analgesics in the United States PharmacoepidemiolDrug Saf 200615618-627

4 Mokdad AH Serdula MK Dietz WH Bowman BA Marks JSKoplan JP The spread of the obesity epidemic in the UnitedStates 1991-1998 JAMA 1999282(16)1519-1522

5 American Cancer Society Cancer Facts amp Figures 2014Atlanta GA American Cancer Society 2014

6 Luber G Hess J Climate change and human health in theUnited States J Env Health 200770(5)43-44

7 Bousquet J Bousquet PJ Godard P Daures JP The pub-lic health implications of asthma Bull World Health Organ200583(7)548-554

8 Diekema DJ BootsMiller BJ Vaughn TE et al TE Antimi-crobial resistance trends and outbreak frequency in UnitedStates hospitals Clin Infect Dis 200438(1)78-85

9 Fauci AS Morens DM The perpetual challenge ofinfectious diseases N Engl J Med 2012366454-461doi101056nejmra1108296

10 Centers for Disease Control and Prevention Death and Mor-tality NCHS FastStats Web site httpwwwcdcgovnchsfastatsdeathshtm Accessed December 20 2013

11 Institute of Medicine US Health in International PerspectiveShorter Lives Poorer Health Report Brief Washington DC TheNational Academies Press 2013

12 Adler NE Reaching for a Healthier Life Facts on SocioeconomicStatus and Health in the US Chicago IL The John D andCatherine T MacArthur Foundation Research Network onSocioeconomic Status an Health 2007

13 Koplin A The future of public health a local health de-partment view J Public Health Policy Winter 199011(4)420-437 Palgrave Macmillan JournalsStable Web site httpwwwjstororgstable3342922 Accessed August 5 2014

14 Pomeranz JL The unique authority of state and localhealth departments to address obesity Am J Public Health2011101(7)1192-1197

15 Gostin LO Bloombergrsquos Health Legacy urban innovator ormeddling nanny Hastings Center Rep 201343(5)19-25SSRNWeb site httpssrncomabstract=2334823

16 American Cancer Society ldquoThe effects of second-hand smoke on worker healthrdquo httpacctionacscanorgsiteDoc-ServerEffects-Secondhand-Smokepdf Published2008

17 Shor B McCarty N The ideological mapping of Americanlegislatures Am Pol Sci Rev 2011105(3)530-551

18 Diller PA Why do cities innovate in public health implica-tions of scale and structure Wash Univ Law Rev 201491(5)1ndash75

19 Kleiman N Forman A Ko J Giles D Bowles J Innovationand the city center for urban future httpwagnernyuedufileslabsInnovation-and-the-Citypdf Published 2013

20 Leider JP Castrucci BCC Hearne S Russo P Organizationalcharacteristics of large urban health departments J PublicHealth Manag Pract 201521(1)S14-S19

21 Creswell JW Clark VLP Designing and Conducting MixedMethods Research Thousand Oaks CA Sage Publications Inc2007

22 United Nations Department of Economic and Social AffairsWorld urbanization prospects the 2011 revision file 1 pop-ulation of urban and rural areas and percentage urban 2011[table] httpesaunorgunupCD-ROMUrban-Rural-Populationhtm Published 2012

23 Katz B Bradley J The Metropolitan Revolution How Citiesand Metros are Fixing Our Broken Politics and FragileEconomy Washington DC Brookings Institution Press2013



24 Grinbaum M Judge blocks New York Cityrsquos limits onbig sugary drinks The New York Times March 11 2013httpwwwnytimescom20130312nyregionjudge-invalidates-bloombergs-soda-banhtml

25 Nutter M Keynote remarks National Soda Summithttpcityofphiladelphiawordpresscom20120607mayor-nutters-soda-summit-address Published June 72013

26 Balde L Rahm Cracks Down on Chicago Vending Machines NBCChicago httpwwwnbcchicagocomblogsward-roomRahm-Cracks-Down-on-Chicago-Vending-Machines-179282661html Published November 15 2012

27 Lazar K Merino long championed public health TheBoston Globe March 29 2013 httpwwwbostonglobecommetromassachusetts20130328mayor-menino-has-long-championed-public-health7t9mGv3WBhoY1tN1hXasTMstoryhtml

28 Simon PA Leslie P Run G et al Impact of restau-rant hygiene grade cards on foodborne-disease hospitaliza-tions in Los Angeles county J Environ Health 200567(7)32-36

29 Gilroy J Electronic cigarette regulations in KingCounty Wash State J Publ Health Pract 20124(suppl 1)15

30 Frieden T Bassett M Thorpe L Farley T Public healthin New York City 2002-2007 confronting epidemics of themodern era [published online ahead of print June 7 2008] IntJ Epidemiol 200837(5)966-977 httpwwwpubfactscomauthorThomas+A+Farley

31 Alcorn T Redefining public health in New York City Lancet2012379(9831)2037-2038

32 Beitsch LM Brooks RG Menachemi N Libbey PMPublic health at center stage New roles old propsHealth Aff (Millwood) 200625(4)911-922 doi254911 [pii]101377hlthaff254911

33 Harris JK Mueller NL Policy activity and policy adop-tion in rural suburban and urban local health de-partments J Public Health Manag Pract 201319(2)E1-E8doi101097PHH0b013e318252ee8c

34 Centers for Disease Control and Prevention Ten essen-tial services of public health httpwwwcdcgovnphpspessentialServiceshtml

35 Public Health Leadership Forum Defining and constitutingfoundational ldquoCapabilitiesrdquo and ldquoAreasrdquo version 1 2014

36 Riley WJ Bender K Lownik E Public health departmentaccreditation implementation Transforming public healthdepartment performance Am J Public Health 2012102(2)237-242



require policy solutions that directly impact the rootcauses of illness and influence personal decision mak-ing The nationrsquos local health departments (LHDs) area critical actor in this process They can be innova-tors and advocates for health policy change becausetheir authority and focus is at the local level1314 Policyinnovations at the local level can drive national changeFor example LHDs were critical to the successfuldrafting and implementation of ordinances to restricttobacco use in restaurants and bars in the early 2000sacross the United States15 Exposure to secondhandsmoke declined by 83 among restaurant and baremployees16 Today 80 of all Americas live in jurisdic-tions with limits on smoking in restaurants and barsprotecting them from this unhealthy exposure

The importance of LHDs is growing in the con-text of US Congressional stagnation and the increas-ing politicization of state legislatures17-19 The extent ofLHDsrsquo role in the policymaking process warrants ad-ditional investigation We used the 2013 National Asso-ciation of County amp City Health Officials (NACCHO)Profile to examine the influence of jurisdictional sizeand involvement in policy making In addition we in-terviewed leaders of public health departments whoparticipate in NACCHOrsquos Big Cities Health Coalition(BCHC)mdasha group of 20 LHDs that serves 46 millionAmericans20mdashto identify the factors that have facili-tated and impeded their efforts to advance new publichealth policies The BCHC is a forum for the leaders ofAmericarsquos largest metropolitan health departments toexchange strategies and best practices and jointly ad-dress issues to promote and protect most effectively thenationrsquos health The BCHC is made up of the LHDs ofAtlanta Baltimore Boston Chicago Cleveland DallasDenver Detroit Houston Los Angeles Miami NewYork Philadelphia Phoenix San Antonio San DiegoSan Francisco San Jose Seattle and Washington DC

Methods

We used a parallel mixed-methods approach with onetrack analyzing data from the NACCHO 2013 Profileto differentiate BCHC members from other LHDs withrespect to policy involvement We also conducted aninterview phase of the study to systematically gatherperspectives from leaders of the BCHC LHDs on relatedareas

The NACCHO Profile collects data approximatelybiannually from 2800 LHDs These condense to N =2532 reporting units In 2013 the NACCHO Profilehad a response rate of 78 Nineteen of 20 BCHCagencies responded to the NACCHO Profile surveyWe divided the non-BCHC LHDs into 3 categories ofpopulation size (as opposed to geographic size) on the

basis of NACCHOrsquos previously published standardssmall LHDs with a population less than 50 000 resi-dents medium-sized LHDs with 50 000 to 499 999 resi-dents and large LHDs with 500 000 or more residentsWe report descriptive statistics comparing departmentsin terms of involvement in policy and advocacy

The second stage of this study involved key infor-mant interviews We interviewed 45 leaders from 16participating BCHC LHDslowast In each jurisdiction weinterviewed leaders in each of 3 positions the localhealth official the chief policysenior deputy and thechief sciencemedical officer Three jurisdictions didnot have chiefs of policy The interviews were con-ducted between August and October 2013 by a singleinterviewer with each interview lasting approximately1 hour all were recorded Interviews were transcribedverified and coded independently by 2 researchersInterview data were independently coded in batchesby the researchers Disagreements in coding were re-solved and interviews were recoded using consensusdecisions

Participants also took part in a brief Web-based sur-vey along with the interview21 In the interview all par-ticipants answered all questions In the Web surveyhowever participants answered only organizationallyoriented questions related to their position and job du-ties The survey mostly included items regarding or-ganizational characteristics and capacities previouslyused in other NACCHO studies as well as questionson data capacity that were used in previous studiesby the Association of State and Territorial Health Offi-cials Additional questions were tailored to BCHC LHDneeds and capacities and were a focal point of pretest-ing Both the interview and survey instruments werepretested with 5 former health officials Quantitativedata were managed and analyzed in Stata 13 (Stata-Corp LP College Station Texas) Qualitative data weremanaged and analyzed in nViVo 10 (QSR InternationalCambridge Massachusetts)

Results

Policy activity by jurisdictional sizemdashresults fromthe 2013 NACCHO Profile

The NACCHO Profile asks about policy involvement in(1) writing issue briefs (2) providing public testimony(3) serving on advisory panels (4) communicating withpolicymakers about specific policies and (5) providingtechnical assistance to partners drafting public health

lowastAt the time of the interview portion of this study 18 LHDsconstituted the BCHC Two additional LHDs have since joinedthose serving San Antonio Texas and San Diego California












Demographics

















Workforce Needs



























Discussion






FIGURE 3 Top Skills














Limitations


Conclusion


REFERENCES


















































Demographics

















Workforce Needs



























Discussion






FIGURE 3 Top Skills














Limitations


Conclusion


REFERENCES














































Demographics

















Workforce Needs



























Discussion






FIGURE 3 Top Skills














Limitations


Conclusion


REFERENCES




















































Workforce Needs



























Discussion






FIGURE 3 Top Skills














Limitations


Conclusion


REFERENCES































































Discussion






FIGURE 3 Top Skills














Limitations


Conclusion


REFERENCES










































Discussion






FIGURE 3 Top Skills














Limitations


Conclusion


REFERENCES



















































Limitations


Conclusion


REFERENCES










































Limitations


Conclusion


REFERENCES























































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2015 Hearne et al The Future of Urban Health

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