Assessing local public health capacity and performance in diabetes prevention and control Deborah Porterfield, MD MPH University of North Carolina-Chapel Hill and RTI International AcademyHealth PHSR Interest Group 6.07

Problem statement: Local public health and chronic disease Available evidence suggests that chronic disease activities in local health departments (LHDs) lag behind the historically important issues of control of infectious diseases, maternal and child health, and environmental health. (NACCHO, 2006) In order to improve LHD performance in chronic disease, we must first describe current practice, and develop valid measures of performance

Measuring diabetes prevention and control in North Carolina LHDs Diabetes as a model chronic disease for study State Diabetes Prevention and Control Program  Provides technical assistance and funding to LHDs (Diabetes Today)

Objectives 1. Measure capacity of NC LHDs to conduct diabetes prevention and control activities. 2. Measure levels of performance in diabetes related prevention and control services and programs in NC LHDs. 3. Assess characteristics of local health departments and their jurisdictions (communities) that may be associated with higher performance.

4. Examine differences in capacity and performance between LHDs that have received training and funds through a specific federal and state program, Diabetes Today, and those who have not, in order to assess if participation has increased capacity and performance.

Survey administration Mailed survey Participants: All local health departments in North Carolina (n=85) Instrument adapted from the Local Public Health System Performance Assessment  10 Essential Services  Additional diabetes-specific questions

Measuring “capacity” and “performance” Capacity defined as FTEs in diabetes prevention or control Performance defined as self-reported provision of program or service  33 yes/no questions combined into a 10 point index, one point for each Essential Service

Based on model of public health performance by Handler, et al (2001) Other characteristics of LHD and community under categories of “Macro Context”, “Structural Capacity”, and “LHD Mission” Main predictors of interest: History of Diabetes Today (or Project IDEAL) funding; Mission statement; estimates of need  Size of LHD considered to be a confounder  Accreditation status not considered as confounder

Secondary data sources County-specific sociodemographic and medical care data  Diabetes Prevention and Control Program, DPH  NC Health Professions Data system  US Census  NC Community Health Center Association Profile survey of the National Association of City and County Health Officers (NACCHO)

Data Analysis Univariate descriptions Bivariate analyses to examine relationship between performance and LHD or jurisdiction characteristics  T-tests and Spearman correlation coefficients Limited multiple linear regression modeling  the effect of confounding assessed one variable at a time

Results 100% response  2 mailings, reminder postcards, phone follow up

LHD characteristics Number of FTEs (median) 80 (IQR ) Expenditures, million (median) $ 4.81 (IQR ) Accredited 31% Diabetes Today funding 35% Project IDEAL funding 4% Full time medical director 20% DM or chronic disease in mission 18.9%

Characteristics of LHD jurisdictions Single-county 93% Population >100k 31% Urban 47% % population below poverty (mean) 14% (sd 4.2) Any C/MHC or free clinic 71% Physician/100k ratio (median) 62.0 (IQR ) Est. diabetes prevalence (mean) 9.1% (sd 0.93)

Capacity: FTEs Prevention FTEs (median) 0.05 (IQR 0-0.5) Control FTEs (median) 0.1 (IQR 0-0.5)  40% have no FTEs devoted to prevention or control

Performance by Essential Service No. questions Median (IQR) ES1 Monitor health60.5 ( ) ES2 Diagnose, investigate30.33 ( ) ES3 Inform, educate40.75 (0.5-1) ES4 Mobilize partnerships20.5 (0-1) ES5 Develop policies, plans30 (0-0.33) ES6 Enforce laws10 (0-0) ES7 Link persons70.43 ( ) ES8 Assure competent workforce30.33 (0-0.33) ES9 Evaluate20 (0-0) ES10 Conduct research20.5 (0-0.5)

Performance index Mean 3.5 (range 0-9.2; sd 1.9)

Associations between index and LHD characteristics R* or Mean index P Number of FTEs Expenditures, in millions Accredited Yes No3.23 Diabetes Today funding Yes No3.15 Project Ideal funding Yes No3.36

Associations between index and jurisdiction characteristics R* or Mean index P Population>100k Yes No3.13

Regression models To understand the association between Diabetes Today funding and performance index Controlling for population size did not change the association between DT funding and the performance index.

Conclusions Limited capacity (FTEs) Variation in performance of Essential Services  Surveillance, health education, linking to services HIGH  Research, evaluation, policy LOW  Specific questions with notable results: Assessment of availability of clinical care or diabetes education LOW Community based screening HIGH

Total performance not higher in areas with greater need (prevalence of diabetes, availability of primary care) Funding from state health department or foundation and the size of the LHD are associated with performance

Limitations Self-report  Types, numbers of respondents Item validity and reliability  Measuring capacity and performance Cross-sectional design Generalizability Other characteristics of LHD not measured

Implications Although some NC LHDs are able to provide diabetes services and programs with limited resources, the findings suggest the opportunity to enhance local public health practice through targeted funding Specific findings can influence technical assistance provided by the state DPCP to LHDs

Acknowledgments The NC Association of Local Health Directors Health Promotion Committee: Curtis Dickson and Beth Lovette NC Division of Public Health: Janet Reaves, RN, MPH; Marcus Plescia, MD, MPH UNC School of Public Health and the NC Institute for Public Health: Ed Baker, MD, MPH; Mary Davis, DrPH, MSPH; Bob Konrad, PhD; Bryan Weiner, PhD Data for this study were obtained from the 2005 National Profile of Local Health Departments, a project supported through a cooperative agreement between the National Association of County and City Health Officials and the Centers for Disease Control and Prevention (U50/CCU302718). Work funded by the Pfizer Scholars Grants in Public Health

Deborah Porterfield, MD, MPH Department of Social Medicine UNC Chapel Hill School of Medicine 919/