Local Health Department Engagement in Community Physical Activity Policy Karin V. Goins, MPH,1 Jiali Ye, PhD,2 Carolyn J. Leep, MS, MPH,2 Nathalie Robin, MPH,2 Stephenie C. Lemon, PhD1 Introduction: This study assessed correlates of self-reported local health department (LHD) participation in community policy/advocacy activities that support physical activity. Methods: In 2014, cross-sectional data from the nationally representative 2013 National Profile of Local Health Departments study administered by the National Association of County and City Health Officials were analyzed. Outcomes were participation in policy/advocacy activities related to urban design/land use, active transportation, and access to recreational facilities. Independent variables included structural characteristics, performance improvement efforts, and collaboration. Multivariate logistic regression models were computed. Results: Representatives of 490 LHDs participated (79% response rate). Respondents reported similar participation in urban design/land use (25%); active transportation (16%); and recreational facility access (23%) policy/advocacy. LHDs with populations of Z500,000 were more likely to report urban design/land use (p¼0.004) as well as active transportation policy/advocacy participation (p¼0.007) compared with those with populations of r50,000. LHDs with a community health improvement plan were more likely to participate in urban design/land use policy/advocacy (p¼0.001). LHDs who regularly use the Community Guide were more likely to report policy/ advocacy activity on active transportation (p¼0.007) and expanding access to recreation facilities (p¼0.009). LHDs engaged in a land use partnership were more likely to report urban design/land use (po0.001) and active transportation (p¼0.001) policy/advocacy participation. Conclusions: Participation in community physical activity policy/advocacy among LHDs was low in this study and varied by LHD characteristics. Intervention opportunities include assisting smaller LHDs and promoting performance improvement efforts and evidence-based practice resources. (Am J Prev Med 2016;50(1):57–68) & 2016 American Journal of Preventive Medicine
Introduction
T
he burden of disease and associated human and economic costs attributable to physical inactivity in the U.S. and worldwide are high.1 Evidence has accumulated that particular environmental conditions and characteristics correlate with walking and bicycling, including for active transportation.2 Although observational designs of most of the research allow only limited From the1Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; and 2National Association of County and City Health Officials, Washington, District of Columbia Address correspondence to: Stephenie C. Lemon, PhD, UMass Worcester Prevention Research Center, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester MA 01655. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2015.06.033
& 2016 American Journal of Preventive Medicine
causal inference,3,4 the Guide to Community Preventive Services (Community Guide) found sufficient evidence to recommend community- and street-scale policy-based approaches for increasing physical activity as well as creation of or enhanced access to places for physical activity combined with informational outreach activities.5 Public health authorities recommend strategies in the realms of land use and urban design, transportation, and recreation access for communities to become more walkand bicycle-friendly.6,7 These areas are not part of traditional public health training or responsibilities, however, typically falling under disciplines such as planning and public works. There is little information to guide local health departments (LHDs) in collaborating with them.8 As the front line of public health, LHDs have an important role to play in identifying and
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Am J Prev Med 2016;50(1):57–68 57
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addressing pressing public health problems, including policy processes resulting in built environments that discourage physical activity.9,10 Policy development is a core public health function along with assessment and assurance.11 Greater LHD involvement could increase the adoption and implementation of policies needed for physical activity benchmarks to be met,12 but there are critical practice gaps. Knowledge of LHD leaders regarding policy development and implementation appears low.13,14 Recent research shows that compared with other municipal officials, local public health officials report lower participation in development, adoption, and implementation of policy related to land use, transportation, and parks and recreation access, as well as greater barriers to consideration of physical activity in community design decision making.15,16 LHD characteristics and activities have been shown to affect delivery of essential public health services,17 engagement in performance improvement efforts,18 partnership involvement,19 ties to other LHDs that could facilitate implementation of evidence-based programming,20 and public health performance.21 Better understanding of LHD characteristics associated with community physical activity policy participation offers an important first step to developing interventions to increase policy implementation. Using data from the 2013 National Profile of LHDs (Profile) administered by the National Association of County and City Health Officials,22 this study assessed associations of LHD structural characteristics, performance improvement efforts, and collaborations and their participation in community physical activity policy, specifically in the realms of land use, active transportation, and access to recreation facilities. Based on study findings, areas for improvement and increased policy participation of LHDs were identified.
Methods Study Sample Data from the 2013 Profile survey were analyzed in 2014. The National Association of County and City Health Officials has conducted seven Profile studies to document current LHD infrastructure and practice (1989–1990, 1992–1993, 1996–1997, 2005, 2008, 2010, 2013). This analysis was based on organizational surveys, so the National Association of County and City Health Officials deemed it exempt from full IRB approval. All 2,532 LHDs across the country received by mail a core questionnaire, covering broad topics such as leadership, jurisdiction, financing, programs and services, and policy and advocacy activities, and 2,000 (79%) completed it. Randomly selected, nationally representative samples received supplemental questions grouped into two modules. Module 1, administered to 624 LHDs and completed by 490 (79% response), included items on accreditation, use of core
competencies, cross-jurisdictional sharing, and partnership and collaboration. This analysis included LHDs that responded to both the core questionnaire and Module 1.
Measures Respondents first selected specific areas where their LHD had been actively involved in policy/advocacy activities in the past 2 years from a checklist of 18 areas, one of which was obesity/chronic disease. Checking the obesity/chronic disease response brought respondents to eight specific items, of which three pertained to physical activity and were examined as outcomes in this study: community level urban design and land use policies to encourage physical activity, active transportation options, and expanding access to recreational facilities. Each was coded as yes/no. Structural characteristics associated with better public health system performance expressed in the 10 Essential Public Health Services17,21,23–25 were selected. Population size served was categorized as o50,000 residents, 50,000–499,999 residents, and Z500,000 residents. Geographic jurisdiction type was classified as county, city, multicounty, and other and governance type as local, state, and shared local/state. Local Board of Health was categorized as yes/no. Full-time equivalent (FTE) level served as a proxy financial variable; reliability issues and missing data rendered assessment of state and federal revenues in the 2013 Profile data infeasible, and FTE data were better quality than and correlate strongly with total per capita expenditures (r =0.75, po0.001). FTE per 100,000 population served was categorized in quartiles (r27.92, 27.93–r45.94, 45.95–r73.49, 473.49). Geographic region was defined as Northeast, Midwest, South, and West, and was adjusted for in analysis. Public health system performance has been shown to be positively associated with health outcomes.26 The Public Health Accreditation Board (PHAB) voluntary accreditation program27 for LHDs assesses progress in addressing the 10 Essential Public Health Services.23 PHAB status was categorized as (1) applied, submitted statement of intent, plan to apply, state will apply on behalf; (2) undecided; or (3) decided not to apply. PHAB prerequisites include completion of a Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP). CHA “identifies key health needs and issues through systematic, comprehensive data collection and analysis.”28 CHIP is a “longterm, systematic effort to address public health problems based on the results of community health assessment activities and the community health improvement process.”28 Completion of each in the past 5 years (yes/no) was assessed. PHAB standards require LHDs to establish workforce development plans using adopted core competencies.29 Use of these core competencies was characterized as reporting yes to any of the four competencies (writing position statements, conducting staff performance evaluations, assessing staff training needs, developing staff training plans) versus not using any. The Community Guide30 presents evidence-based recommendations based on systematic reviews. Use of the Community Guide over the past 12 months compared LHDs who used it consistently or in some programmatic areas with those who did not use it or reported do not know. Greater LHD capacity is associated with collaboration between LHDs31 as well as with the community via partnerships.19 Any cross-jurisdictional sharing was assessed (yes/no). Participants described their LHD’s work in the past year with other www.ajpmonline.org
Goins et al / Am J Prev Med 2016;50(1):57–68 organizations in the community to accomplish goals related to land use as no programs in this area, not involved in collaboration, networking, coordinating, cooperating, or collaborating. Responses were reclassified to a dichotomous variable indicating any or no collaboration.
Statistical Analysis Descriptive statistics were calculated to examine the frequency distributions of all variables. Bivariate relationships between policy and advocacy initiatives and each independent variable were examined using chi-square tests. Multivariate logistic regression models were conducted to assess the association between the independent variables and each of the dependent variables after controlling for other variables. Multicollinearity tests were conducted among independent variables. All variance inflation factor values were within acceptable range (o10),32 indicating collinearity was not an issue. All analyses were conducted using Stata, version 12.0. Appropriate weights were used to account for sampling design used in the module and differential non-response by population size. All p-values were two-tailed, with values o0.05 considered statistically significant. ORs and 95% CIs were reported for the logistic regression models.
Results Table 1 presents descriptive statistics (n¼490). There were minimal missing data (o5%) for all included items. About a quarter of these LHDs participated in activities related to community-level urban design and land use policies to encourage physical activity, 16% reported policy/advocacy activity related to active transportation options, and 23% reported policy/advocacy activity related to expanding access to recreational facilities. Table 2 presents the results of bivariate analyses (n¼490). LHDs were more likely to report involvement in policy/advocacy activities in urban design/land use, active transportation, and access to recreation facilities if they served populations of Z500,000 (po0.001, po0.001, and p¼0.002, respectively); had been engaged in CHIP in the past 5 years (po0.001, p¼0.016, and po0.001, respectively); had been engaged or intended to engage in PHAB accreditation application (p¼0.001, p¼0.002, and p¼0.006, respectively); had used the Community Guide (all po0.001); or had been involved in any type of partnership or land use collaboration (po0.001, po0.001, and p¼0.005, respectively). Engagement in CHA during the past 5 years was associated with participation in policy/advocacy regarding active transportation (po0.033) and recreation facilities access (po0.001). Governance type (p¼0.045) and geographic region (p¼0.027) were associated with being involved in active transportation policy/advocacy. Use of core competencies was significantly related to involvement in January 2016
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policy/advocacy activities in urban design and land use (po0.037). Table 3 shows associations between LHD characteristics and involvement in policy/advocacy activities for the three areas after controlling for other factors (n¼490). LHDs serving the largest population size were more than three times (OR¼3.6, 95% CI¼1.49, 8.67) more likely to be engaged in urban design and land use policy/advocacy and more than four times more likely (OR¼4.3, 95% CI¼1.48, 12.51) to be engaged in active transportation policy/advocacy compared with LHDs serving jurisdictions of o50,000 people. The relationship between largest population size and engagement in recreational facility access policy/advocacy was marginally significant (OR¼2.48, 95% CI¼0.95, 6.50). A higher number of FTEs per 100,000 population was associated with higher likelihood of engagement in active transportation policy/advocacy (Quartile 2, OR¼2.42, 95% CI¼1.06, 5.50; Quartile 3, OR¼3.07, 95% CI¼1.24, 7.61). LHDs who had engaged in a CHIP process within the past 5 years were more than three times (OR¼3.2, 95% CI¼1.64, 6.27) more likely to report participation in urban design and land use policy/advocacy activity, whereas those undecided about accreditation application had decreased odds of engaging in policy/advocacy for recreational facility access (OR¼0.48, 95% CI¼0.25, 0.92). LHDs reporting consistent use of the Community Guide had increased odds of engagement in policy/ advocacy for active transportation (OR¼2.5, 95% CI¼1.28, 4.86) and recreational facility access (OR¼2.17, 95% CI¼1.22, 3.86), with a marginally significant association with urban design and land use policy/advocacy (OR¼1.65, 95% CI¼0.92, 2.97). LHD participation in a community partnership related to land use was associated with both urban design and land use (OR¼4.04, 95% CI¼2.29, 7.13) and active transportation (OR¼2.74, 95% CI¼1.48, 5.07) policy/advocacy activity, with a marginally significant association with recreational facility policy/advocacy participation (OR¼1.58, 95% CI¼0.91, 2.73).
Discussion This analysis reveals low levels of participation by LHDs in policy/advocacy to increase community physical activity opportunity as well as variation by LHD characteristics. These findings contrast with calls for participation of LHDs in community physical activity policy to meet physical activity and other health goals.9,10,33 Understanding factors associated with participation can inform efforts focused on increasing it. Structural characteristics such as larger population size, county or multicounty jurisdiction, local
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Table 1. Study Sample Characteristics (LHDs Participating in 2013 NACCHO Profile and Module 1, n¼490) % of sample Unweighted
Weighteda
o50,000
48
61
50,000–499,999
39
34
Z500,000
13
5
City
14
12
County
73
74
Other
12
14
State
20
20
Local
70
71
Shared
10
9
No
31
29
Yes
69
71
Quartile 1 (r27.92)
25
21
Quartile 2 (27.93–r45.95)
25
24
Quartile 3 (45.96–r73.49)
25
25
Quartile 4 (473.49)
25
29
No
33
34
Yes
67
66
No
47
48
Yes
53
52
Decided not to apply
14
15
Undecided
37
40
Engaged/intend to engage
50
45
No
73
74
Yes, any
27
26
Characteristic Structural characteristics Population size served
Jurisdiction type
Governance
Local board of health
FTE per 100,000 population
Performance improvement efforts Community health assessment (o5 years)
Community health improvement plan (o5 years)
PHAB accreditation status
Use of core competencies
(continued on next page)
governance, local board of health with power to make policy, and higher expenditures have been found to be associated with better public health system performance expressed in the 10 Essential Public Health Services.17,21,23–25,34,35 Larger LHD size has also been demonstrated to correlate with a range of related outputs, including quality improvement18,36 and other performance improvement efforts such as pursuit of PHAB accreditation.37 In this study, LHDs serving larger jurisdictions were more likely to engage in policy/advocacy activity for land use/urban design and active transportation, and higher FTE levels (a proxy for expenditures) were associated with greater policy/ advocacy participation to increase active transportation. With larger LHDs or those with greater staff resources more likely to engage in policy/advocacy related to community physical activity on their own, focus should be on assisting smaller LHDs and those with fewer resources. Identifying a limited set of priority activities related to built environment decision making may make policy participation by smaller and lower resourced LHDs more feasible. The public health field has engaged in efforts to measure and improve system performance since the 2002 publication of the IOM’s The Future of the Public’s Health in the 21st Century.11 Although evidence suggests local policy www.ajpmonline.org
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and 15% had decided not to pursue.37 Incentivizing LHDs, particularly smaller % of sample ones, to become accredited a could boost participation Characteristic Unweighted Weighted in community physical Use of community guide activity policy. Although fewer than half No/do not know 58 62 of LHDs reported using the Consistently/some areas 42 38 Community Guide consisCollaboration tently, those who did were Cross-jurisdictional sharing significantly more likely to report participation in all No 48 46 three investigated policy Yes 52 54 areas. This variable Any partnerships for land use remained significant for active transportation and No 75 69 expanding access to recreaYes 25 31 tional facilities in multiObesity/chronic disease policy/advocacy activities variate analysis. LHDs have been challenged in Community level urban design and land use policies to encourage physical activity implementing evidenceNo 70 75 based public health stratYes 30 25 egies. Barriers include lack of capacity, incentives/ Active transportation options rewards, and support from No 81 84 legislators, inadequate Yes 19 16 funding, and feeling a need to be an expert on many Expanding access to recreational facilities issues.40,41 Solutions No 75 77 include educating policyYes 25 23 makers and funders to supa port evidence-based Data are weighted to account for sampling design and differential non-response by size of population served. FTE, Full time equivalents; LHDs, local health departments; NACCHO, National Association of County and City approaches, aligning LHD Health Officials; PHAB, Public Health Accreditation Board. activities with the evidence base through the accreditadevelopment often falls victim to funding constraints,38 tion process, and developing standards and competencies policy development is a core public health function along to focus LHD efforts. with assessment and assurance11 and should occur as Resource sharing among LHDs is increasing,42 is more 39 part of improvement efforts such as CHA and CHIP. extensive for LHDs covering multiple jurisdictions and CHIP development in the past 5 years correlated with those with greater financial constraints, and has been policy/advocacy activity in all three areas, and the shown to increase capacity.31 This study found no association remained significant for land use and urban relationship between such collaboration and physical design policy participation when controlling for other activity policy/advocacy activity. Though most LHDs factors. Bivariate analysis revealed that LHDs engaging in reported no community partnerships related to land use, the PHAB process were more likely to report participathose who did were more likely to report activity in all tion in all three assessed community physical activity three policy areas; after controlling for other factors, this policy areas, although participation in land use and relationship held up for policy/advocacy activity regardurban design policy/advocacy was not significant in ing land use and urban design and active transportation. multivariate analysis. Nearly half (45%) of responding Partnerships have been found to be a partial mediator LHDs were engaged or intended to engage in the PHAB between resources and service provision, especially for process, but as of 2013 only 6% had submitted a PHAB LHDs with more-limited resources,19 and partnerships application or statement of intent, 40% were undecided, with non-traditional disciplines such as planning are key Table 1. Study Sample Characteristics (LHDs Participating in 2013 NACCHO Profile and Module 1, n¼490) (continued)
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Table 2. LHD Policy/Advocacy for Increased Physical Activity Facilities in Past 2 Years (n¼490)a Obesity/chronic disease policy/advocacy area Community-level urban design and land use policies to encourage physical activity Characteristic
Yes (%)
No (%)
p-value
Active transportation options Yes (%)
No (%)
p-value
Expanding access to recreation facilities Yes (%)
No (%)
p-value
Structural o0.001
Population size served
o0.001
0.002
o50,000
17.2
82.8
10.8
89.2
18.4
81.7
50,000–499,000
35.4
64.6
22.0
78.0
27.2
72.8
Z500,000
56.8
43.2
43.1
56.9
43.0
57.0
Geographic region
0.159
0.027
0.334
Northeast
16.2
83.8
11.5
88.5
16.0
84.0
Midwest
26.2
73.8
21.4
78.6
25.5
74.5
South
27.8
72.2
11.5
88.5
21.9
78.1
West
30.2
69.8
22.2
77.8
26.4
73.6
Jurisdiction type
0.099
0.372
0.708
City
16.1
83.9
11.8
88.2
19.2
80.8
County
26.1
73.9
17.6
82.4
23.5
76.5
Other
31.9
68.1
12.8
87.2
21.1
78.9
Governance
0.934
0.045
0.085
State
23.9
76.1
9.2
90.8
14.5
85.5
Local
25.7
74.3
18.9
81.1
25.3
74.7
Shared
26.2
73.8
10.5
89.5
19.6
80.4
Local board of health
0.552
0.709
0.124
No
27.5
72.5
17.3
82.7
18.1
81.9
Yes
24.8
75.2
16.0
84.1
24.7
75.3
FTE per 100,000 population
0.202
0.219
0.331
Quartile 1 (r27.92)
19.2
80.8
11.8
88.2
17.3
82.8
Quartile 2 (27.93–r45.95)
32.2
67.4
21.3
78.7
26.7
73.3
Quartile 3 (45.96–r73.49)
26.6
73.4
19.0
81.0
21.7
78.3
Quartile 4 (473.49)
25.1
74.9
14.5
85.5
26.1
73.9
Performance improvement Community health assessment (o5 years)
0.098
o0.001
0.033
No
20.7
79.3
11.2
88.8
13.2
86.8
Yes
27.8
72.2
18.8
81.2
31.3
68.7 (continued on next page)
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63 a
Table 2. LHD Policy/Advocacy for Increased Physical Activity Facilities in Past 2 Years (n¼490) (continued) Obesity/chronic disease policy/advocacy area Community-level urban design and land use policies to encourage physical activity Characteristic
Yes (%)
No (%)
Active transportation options
p-value
Yes (%)
No (%)
o0.001
Community health improvement plan (o5 years)
p-value
Expanding access to recreation facilities Yes (%)
No (%)
o0.001
0.016
No
15.7
84.3
12.0
88.0
13.2
86.8
Yes
34.2
65.8
20.1
79.9
27.4
72.7
PHAB accreditation status
0.001
0.002
0.006
Decided not to apply
18.2
81.8
9.6
90.4
16.4
83.6
Undecided
19.3
80.7
12.0
88.0
16.1
83.9
Engaged/intend to engage
34.8
65.2
24.4
75.6
29.4
70.6
Use of core competencies
0.037
0.208
0.152
No
23.3
76.7
15.1
84.9
21.0
79.0
Yes, any
33.1
66.9
20.0
80.0
27.5
72.5
o0.001
Use of community guide
p-value
o0.001
o0.001
No/do not know
18.0
82.0
8.9
91.1
15.1
84.9
Consistently/some areas
38.0
62.0
29.1
70.9
35.9
64.1
Collaboration Cross-jurisdictional sharing
0.387
0.728
0.259
No
23.6
76.4
16.9
83.1
20.1
79.9
Yes
27.2
72.8
15.7
84.3
24.5
75.5
o0.001
Any partnerships for land use
o0.001
0.005
No
17.1
82.9
12.1
87.9
18.7
81.3
Yes
44.5
55.5
27.1
72.9
30.9
69.2
Note: Boldface indicates statistical significance (po0.05). a Data are weighted to account for sampling design and differential non-response by size of population served. FTE, Full time equivalents; LHDs, local health departments; PHAB, Public Health Accreditation Board.
to increasing community physical activity opportunity.6 A model curriculum for planning and public health students exists,43 but it will take time to develop sufficient academic programs and for graduates to enter the field. In addition, much of the LHD workforce has little formal public health training,44 and implementation challenges may be greatest at the local level given the variation in LHD configuration.45 The overall low level of participation in community physical activity policy/advocacy observed in this study is consistent not only with the authors’ previous research15 but also with data on policy participation by LHD executives generally.14 In addition to financial January 2016
constraints, a plausible reason for the low rate of participation is insufficient knowledge and skills. Only 15% of health commissioner respondents in one study reported their knowledge of the policy process was excellent.14 Assessment of the effects of policies, laws, and regulations was among the most-requested training topics in a survey of public health chronic disease professionals in state and local governments.46 How, then, can LHDs be moved toward greater participation in community physical activity policy/ advocacy activities? Training is available in general policy competencies for shaping the built environment,47–49 but these are not specific to transportation planning, land
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Table 3. Multivariate Factors Associated With Policy/Advocacy for Increased Community Physical Activity Opportunity in Past 2 Years (n¼490)a Obesity/chronic disease policy/advocacy area Community level urban design and land use policies to encourage physical activity Characteristic
OR
95% CI
p-value
Expanding access to recreation facilities
Active transportation options OR
95% CI
p-value
OR
95% CI
p-value
Structural Population size served o50,000
1
1
1
1.75
0.91
3.37
0.094
1.76
0.83
3.72
0.138
1.25
0.66
2.36
0.501
Z500,000
3.60
1.49
8.67
0.004
4.30
1.48
12.51
0.007
2.48
0.95
6.50
0.064
Geographic region Northeast
1
1
1
Midwest
1.83
0.67
5.00
0.238
2.10
0.72
6.11
0.173
1.69
0.66
4.37
0.277
South
1.70
0.53
5.43
0.371
1.01
0.24
4.29
0.994
1.93
0.62
5.98
0.253
West
1.67
0.57
4.91
0.353
1.53
0.48
4.84
0.471
1.68
0.56
5.03
0.350
Jurisdiction type City
1
1
1
County
1.17
0.48
2.90
0.726
0.90
0.32
2.53
0.838
0.63
0.25
1.60
0.331
Other
1.24
0.42
3.62
0.698
0.49
0.12
1.96
0.310
0.54
0.19
1.55
0.250
Governance type
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State
1
1
1
Local
1.25
0.44
3.53
0.670
1.34
0.38
4.73
0.649
2.47
0.80
7.62
0.115
Shared
0.61
0.22
1.72
0.352
0.42
0.11
1.60
0.204
0.84
0.27
2.60
0.756
0.56
1.76
0.969
Local board of health No
1
Yes
0.75
1 0.41
1.37
0.347
0.76
1 0.39
1.49
0.430
0.99
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50,000–499,999
January 2016
Table 3. Multivariate Factors Associated With Policy/Advocacy for Increased Community Physical Activity Opportunity in Past 2 Years (n¼490)a (continued) Obesity/chronic disease policy/advocacy area Community level urban design and land use policies to encourage physical activity Characteristic
OR
95% CI
p-value
Expanding access to recreation facilities
Active transportation options OR
95% CI
p-value
OR
95% CI
p-value
FTE per 100,000 population (quartile) Quartile 1 (r27.92)
1
1
1
2.12
1.00
4.49
0.051
2.42
1.06
5.50
0.035
1.77
0.81
3.87
0.150
Quartile 3 (45.96–r73.49)
2.11
0.92
4.83
0.078
3.07
1.24
7.61
0.016
1.57
0.64
3.80
0.321
Quartile 4 (473.49)
1.67
0.68
4.07
0.260
2.60
0.93
7.28
0.069
2.18
0.86
5.54
0.102
0.85
3.84
0.125
Performance improvement Community health assessment (o5 years) No
1
Yes
0.68
1 0.35
1.32
0.253
1.35
1 0.65
2.80
0.416
1.80
Community health improvement plan (o5 years) No
1
1
1
Yes
3.20
1.64
6.27
0.001
1.32
0.67
2.58
0.416
1.76
0.89
3.47
0.104
Decided not to apply
0.68
0.28
1.68
0.404
0.47
0.18
1.22
0.122
0.64
0.27
1.53
0.314
Undecided
0.68
0.36
1.29
0.239
0.49
0.24
1.00
0.051
0.48
0.25
0.92
0.027
0.50
1.59
0.709
1.22
3.86
0.009
PHAB accreditation status
Engaged/intend to engage
1
1
1
No
1
1
1
Yes
1.10
Goins et al / Am J Prev Med 2016;50(1):57–68
Quartile 2 (27.93–r45.95)
Use of core competencies
0.62
1.96
0.748
0.83
0.42
1.64
0.589
0.90
Use of community guide No/do not know Consistently/some areas/
1 1.65
1 0.92
2.97
0.094
2.50
1 1.28
4.86
0.007
2.17
(continued on next page)
65
Goins et al / Am J Prev Med 2016;50(1):57–68
2.73
2.38
5.07 1.48 2.74 o0.001
1 1
4.04
No
Yes
Any partnerships for land use
2.29
7.13
0.404 2.11 0.74 1.25 Yes
Note: Boldface indicates statistical significance (po0.05). a Data are weighted to account for sampling design and differential non-response by size of population served. FTE, Full time equivalents; PHAB, Public Health Accreditation Board.
0.001
1
0.832 1.70 0.52 0.94
1 1 No
Cross-jurisdictional sharing
Collaboration
1.58
0.91
0.77 1.35
1
p-value 95% CI OR p-value 95% CI OR Characteristic
use, or parks and recreation, and there is no associated technical assistance. Toolkits and training are likely insufficient to build the skills and confidence needed for participation in policy change,50 so affordable technical assistance will be essential.8,50 Following the general public health professional competencies and standards already set, creating competencies in specific public health practice areas is the next step.51 Development of public health emergency preparedness competencies, with training and consultation for local officials widely available through the Preparedness and Emergency Response Learning Centers throughout the U.S., offers a potential model.52–54 A comprehensive process would define priority areas, assess current status of LHDs, develop and deliver training and technical assistance, and measure progress.
0.102
0.294
p-value 95% CI OR
Expanding access to recreation facilities Active transportation options Community level urban design and land use policies to encourage physical activity
Obesity/chronic disease policy/advocacy area
Table 3. Multivariate Factors Associated With Policy/Advocacy for Increased Community Physical Activity Opportunity in Past 2 Years (n¼490)a (continued)
66
Limitations Limitations of this analysis include selfreported data and potential social desirability bias for the policy/advocacy participation, performance improvement, and collaboration measures, particularly due to data being collected by a membership organization. The crosssectional study design precludes causal inference. Additional important independent correlates of policy/advocacy activities were not included. Funding could not be directly assessed owing to reliability concerns and missing data, though LHD FTE per population was used as a proxy indicator. Community health status indicators (e.g., percentage of population obese) were not included. Although county-level indicators are available from sources such as the County Health Rankings, this study includes a mix of county, city, and multicounty LHDs. Health status indicators for the latter two are not uniformly available. Thus, to maintain a nationally representative LHD sample, such data were not included. Additional factors may influence reporting accuracy. There was likely variability www.ajpmonline.org
Goins et al / Am J Prev Med 2016;50(1):57–68
among respondents regarding knowledge of their LHD’s activities. This could result in underestimation of the examined variables. State, federal, and foundation funding to engage in policy, systems, and environmental change strategies to make communities more physical activity–friendly may have fostered greater participation by recipient LHDs. This differential participation could have resulted in overestimation of policy/advocacy participation.
2.
3.
4.
Conclusions Participation in community physical activity policy/advocacy among LHDs was low in this study and varied by LHD characteristics. Results identify specific structural characteristics that are priority targets and performance improvement initiatives and collaborative approaches that provide opportunities to promote LHD policy participation. Intervention opportunities include assisting smaller and lower resource LHDs and promoting the use of performance improvement efforts and evidence-based practice resources currently encouraged for LHDs nationally. Further research is needed to specify roles, responsibilities, and competencies for LHDs in community physical activity policy/advocacy and test cost-effective interventions that align LHD capacity and resources.
5.
6.
7.
8.
9.
10.
This study was funded by CDC, Cooperative Agreement Number U48 DP001933, from the CDC Prevention Research Centers Program. It uses data from the National Association of County and City Health Officials Profile Surveys, which were supported by the Robert Wood Johnson Foundation and CDC. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of CDC. Ms. Goins and Dr. Lemon led study conceptualization and writing of the article. Dr. Ye participated in study conceptualization, performed data analysis, wrote methods and results, and assisted with article revisions. Ms. Leep participated in study conceptualization and article revisions. Ms. Robin assisted with data analysis and development of results. All authors approved the final version. KVG is a paid consultant to the local health department in Worcester, Massachusetts. SL receives an evaluation contract from the local health department in Worcester, Massachusetts. No other financial disclosures were reported by the authors of this paper.
11. 12.
13.
14.
15.
16.
17.
18.
References 1. Ladabaum U, Mannalithara A, Myer PA, Singh G. Obesity, abdominal obesity, physical activity, and caloric intake in U.S. adults: 1988-2010.
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Am J Med. 2014;127(8):717–727. http://dx.doi.org/10.1016/j. amjmed.2014.02.026. Heath GW, Brownson RC, Kruger J, Miles R, Powell KE, Ramsey LT. The effectiveness of urban design and land use and transport policies and practices to increase physical activity: a systematic review. J Phys Act Health. 2006;1:S55–S71. Ferdinand AO, Sen B, Rahurkar S, Engler S, Menachemi N. The relationship between built environments and physical activity: a systematic review. Am J Public Health. 2012;102(10):e7–e13. http: //dx.doi.org/10.2105/AJPH.2012.300740. McCormack GR, Shiell A. In search of causality: a systematic review of the relationship between the built environment and physical activity among adults. Int J Behav Nutr Phys Act. 2011;8:125. http://dx.doi.org/ 10.1186/1479-5868-8-125. Community Prevention Services Task Force. Increasing Physical Activity: Environmental and Policy Approaches. www.thecommunity guide.org/pa/environmental-policy/index.html. U.S. National Physical Activity Plan Coordinating Committee. National physical activity plan for the United States. 2010. www. physicalactivityplan.org/NationalPhysicalActivityPlan.pdf. National Prevention Council, USDHHS, Office of the Surgeon General. National Prevention Strategy. 2011. www.surgeongeneral.gov/initia tives/prevention/strategy/report.pdf. Rube K, Veatch M, Huang K, et al. Developing built environment programs in local health departments: lessons learned from a nationwide mentoring program. Am J Public Health. 2014;104(5):e10–e18. http://dx.doi.org/10.2105/AJPH.2013.301863. National Association of County and City Health Officials (NACCHO). Statement of policy: healthy community design. http://naccho.org/ advocacy/positions/upload/03-02-Healthy-Community-Design.pdf. Published 2003. Accessed August 17, 2015. National Association of County and City Health Officials (NACCHO). Statement of policy: comprehensive obesity prevention. http://naccho. org/advocacy/positions/upload/10-01Comprehensive-Obesity-Preven tion.pdf. Published 2010. Accessed August 17, 2015. IOM. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academies Press; 2002. Healthy People 2020. Physical activity. www.healthypeople.gov/2020/ topics-objectives/topic/physical-activity/objectives. Accessed August 17, 2015. Harris JK, Mueller NL. Policy activity and policy adoption in rural, suburban, and urban local health departments. J Public Health Manag Pract. 2013;19(2):E1–E8. http://dx.doi.org/10.1097/PHH.0b013e318252ee8c. Thompson A, Boardley D, Kerr D, Greene T, Jenkins M. Public policy involvement by health commissioners. J Community Health. 2009; 34(4):239–245. http://dx.doi.org/10.1007/s10900-009-9158-4. Lemon SC, Valentine Goins K, Schneider KL, et al. Municipal officials’ participation in built environment policy development in the United States. Am J Health Promot. 2014 Nov 5. [Epub ahead of print]. Goins KV, Schneider KL, Brownson R, et al. Municipal officials’ perceived barriers to consideration of physical activity in community design decision making. J Public Health Manag Pract. 2013;19(3 suppl 1): S65–S73. http://dx.doi.org/10.1097/PHH.0b013e318284970e. Luo H, Sotnikov S, Shah G, Galuska DA, Zhang X. Variation in delivery of the 10 essential public health services by local health departments for obesity control in 2005 and 2008. J Public Health Manag Pract. 2013;19(1):53–61. http://dx.doi.org/10.1097/ PHH.0b013e31824dcd81. Beitsch LM, Leep C, Shah G, Brooks RG, Pestronk RM. Quality improvement in local health departments: Results of the NACCHO 2008 survey. J Public Health Manag Pract. 2010;16(1):49–54. http://dx. doi.org/10.1097/PHH.0b013e3181bedd0c. Beatty K, Harris JK, Barnes PA. The role of interorganizational partnerships in health services provision among rural, suburban, and
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www.ajpmonline.org
Introduction
T
he burden of disease and associated human and economic costs attributable to physical inactivity in the U.S. and worldwide are high.1 Evidence has accumulated that particular environmental conditions and characteristics correlate with walking and bicycling, including for active transportation.2 Although observational designs of most of the research allow only limited From the1Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; and 2National Association of County and City Health Officials, Washington, District of Columbia Address correspondence to: Stephenie C. Lemon, PhD, UMass Worcester Prevention Research Center, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester MA 01655. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2015.06.033
& 2016 American Journal of Preventive Medicine
causal inference,3,4 the Guide to Community Preventive Services (Community Guide) found sufficient evidence to recommend community- and street-scale policy-based approaches for increasing physical activity as well as creation of or enhanced access to places for physical activity combined with informational outreach activities.5 Public health authorities recommend strategies in the realms of land use and urban design, transportation, and recreation access for communities to become more walkand bicycle-friendly.6,7 These areas are not part of traditional public health training or responsibilities, however, typically falling under disciplines such as planning and public works. There is little information to guide local health departments (LHDs) in collaborating with them.8 As the front line of public health, LHDs have an important role to play in identifying and
Published by Elsevier Inc.
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addressing pressing public health problems, including policy processes resulting in built environments that discourage physical activity.9,10 Policy development is a core public health function along with assessment and assurance.11 Greater LHD involvement could increase the adoption and implementation of policies needed for physical activity benchmarks to be met,12 but there are critical practice gaps. Knowledge of LHD leaders regarding policy development and implementation appears low.13,14 Recent research shows that compared with other municipal officials, local public health officials report lower participation in development, adoption, and implementation of policy related to land use, transportation, and parks and recreation access, as well as greater barriers to consideration of physical activity in community design decision making.15,16 LHD characteristics and activities have been shown to affect delivery of essential public health services,17 engagement in performance improvement efforts,18 partnership involvement,19 ties to other LHDs that could facilitate implementation of evidence-based programming,20 and public health performance.21 Better understanding of LHD characteristics associated with community physical activity policy participation offers an important first step to developing interventions to increase policy implementation. Using data from the 2013 National Profile of LHDs (Profile) administered by the National Association of County and City Health Officials,22 this study assessed associations of LHD structural characteristics, performance improvement efforts, and collaborations and their participation in community physical activity policy, specifically in the realms of land use, active transportation, and access to recreation facilities. Based on study findings, areas for improvement and increased policy participation of LHDs were identified.
Methods Study Sample Data from the 2013 Profile survey were analyzed in 2014. The National Association of County and City Health Officials has conducted seven Profile studies to document current LHD infrastructure and practice (1989–1990, 1992–1993, 1996–1997, 2005, 2008, 2010, 2013). This analysis was based on organizational surveys, so the National Association of County and City Health Officials deemed it exempt from full IRB approval. All 2,532 LHDs across the country received by mail a core questionnaire, covering broad topics such as leadership, jurisdiction, financing, programs and services, and policy and advocacy activities, and 2,000 (79%) completed it. Randomly selected, nationally representative samples received supplemental questions grouped into two modules. Module 1, administered to 624 LHDs and completed by 490 (79% response), included items on accreditation, use of core
competencies, cross-jurisdictional sharing, and partnership and collaboration. This analysis included LHDs that responded to both the core questionnaire and Module 1.
Measures Respondents first selected specific areas where their LHD had been actively involved in policy/advocacy activities in the past 2 years from a checklist of 18 areas, one of which was obesity/chronic disease. Checking the obesity/chronic disease response brought respondents to eight specific items, of which three pertained to physical activity and were examined as outcomes in this study: community level urban design and land use policies to encourage physical activity, active transportation options, and expanding access to recreational facilities. Each was coded as yes/no. Structural characteristics associated with better public health system performance expressed in the 10 Essential Public Health Services17,21,23–25 were selected. Population size served was categorized as o50,000 residents, 50,000–499,999 residents, and Z500,000 residents. Geographic jurisdiction type was classified as county, city, multicounty, and other and governance type as local, state, and shared local/state. Local Board of Health was categorized as yes/no. Full-time equivalent (FTE) level served as a proxy financial variable; reliability issues and missing data rendered assessment of state and federal revenues in the 2013 Profile data infeasible, and FTE data were better quality than and correlate strongly with total per capita expenditures (r =0.75, po0.001). FTE per 100,000 population served was categorized in quartiles (r27.92, 27.93–r45.94, 45.95–r73.49, 473.49). Geographic region was defined as Northeast, Midwest, South, and West, and was adjusted for in analysis. Public health system performance has been shown to be positively associated with health outcomes.26 The Public Health Accreditation Board (PHAB) voluntary accreditation program27 for LHDs assesses progress in addressing the 10 Essential Public Health Services.23 PHAB status was categorized as (1) applied, submitted statement of intent, plan to apply, state will apply on behalf; (2) undecided; or (3) decided not to apply. PHAB prerequisites include completion of a Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP). CHA “identifies key health needs and issues through systematic, comprehensive data collection and analysis.”28 CHIP is a “longterm, systematic effort to address public health problems based on the results of community health assessment activities and the community health improvement process.”28 Completion of each in the past 5 years (yes/no) was assessed. PHAB standards require LHDs to establish workforce development plans using adopted core competencies.29 Use of these core competencies was characterized as reporting yes to any of the four competencies (writing position statements, conducting staff performance evaluations, assessing staff training needs, developing staff training plans) versus not using any. The Community Guide30 presents evidence-based recommendations based on systematic reviews. Use of the Community Guide over the past 12 months compared LHDs who used it consistently or in some programmatic areas with those who did not use it or reported do not know. Greater LHD capacity is associated with collaboration between LHDs31 as well as with the community via partnerships.19 Any cross-jurisdictional sharing was assessed (yes/no). Participants described their LHD’s work in the past year with other www.ajpmonline.org
Goins et al / Am J Prev Med 2016;50(1):57–68 organizations in the community to accomplish goals related to land use as no programs in this area, not involved in collaboration, networking, coordinating, cooperating, or collaborating. Responses were reclassified to a dichotomous variable indicating any or no collaboration.
Statistical Analysis Descriptive statistics were calculated to examine the frequency distributions of all variables. Bivariate relationships between policy and advocacy initiatives and each independent variable were examined using chi-square tests. Multivariate logistic regression models were conducted to assess the association between the independent variables and each of the dependent variables after controlling for other variables. Multicollinearity tests were conducted among independent variables. All variance inflation factor values were within acceptable range (o10),32 indicating collinearity was not an issue. All analyses were conducted using Stata, version 12.0. Appropriate weights were used to account for sampling design used in the module and differential non-response by population size. All p-values were two-tailed, with values o0.05 considered statistically significant. ORs and 95% CIs were reported for the logistic regression models.
Results Table 1 presents descriptive statistics (n¼490). There were minimal missing data (o5%) for all included items. About a quarter of these LHDs participated in activities related to community-level urban design and land use policies to encourage physical activity, 16% reported policy/advocacy activity related to active transportation options, and 23% reported policy/advocacy activity related to expanding access to recreational facilities. Table 2 presents the results of bivariate analyses (n¼490). LHDs were more likely to report involvement in policy/advocacy activities in urban design/land use, active transportation, and access to recreation facilities if they served populations of Z500,000 (po0.001, po0.001, and p¼0.002, respectively); had been engaged in CHIP in the past 5 years (po0.001, p¼0.016, and po0.001, respectively); had been engaged or intended to engage in PHAB accreditation application (p¼0.001, p¼0.002, and p¼0.006, respectively); had used the Community Guide (all po0.001); or had been involved in any type of partnership or land use collaboration (po0.001, po0.001, and p¼0.005, respectively). Engagement in CHA during the past 5 years was associated with participation in policy/advocacy regarding active transportation (po0.033) and recreation facilities access (po0.001). Governance type (p¼0.045) and geographic region (p¼0.027) were associated with being involved in active transportation policy/advocacy. Use of core competencies was significantly related to involvement in January 2016
59
policy/advocacy activities in urban design and land use (po0.037). Table 3 shows associations between LHD characteristics and involvement in policy/advocacy activities for the three areas after controlling for other factors (n¼490). LHDs serving the largest population size were more than three times (OR¼3.6, 95% CI¼1.49, 8.67) more likely to be engaged in urban design and land use policy/advocacy and more than four times more likely (OR¼4.3, 95% CI¼1.48, 12.51) to be engaged in active transportation policy/advocacy compared with LHDs serving jurisdictions of o50,000 people. The relationship between largest population size and engagement in recreational facility access policy/advocacy was marginally significant (OR¼2.48, 95% CI¼0.95, 6.50). A higher number of FTEs per 100,000 population was associated with higher likelihood of engagement in active transportation policy/advocacy (Quartile 2, OR¼2.42, 95% CI¼1.06, 5.50; Quartile 3, OR¼3.07, 95% CI¼1.24, 7.61). LHDs who had engaged in a CHIP process within the past 5 years were more than three times (OR¼3.2, 95% CI¼1.64, 6.27) more likely to report participation in urban design and land use policy/advocacy activity, whereas those undecided about accreditation application had decreased odds of engaging in policy/advocacy for recreational facility access (OR¼0.48, 95% CI¼0.25, 0.92). LHDs reporting consistent use of the Community Guide had increased odds of engagement in policy/ advocacy for active transportation (OR¼2.5, 95% CI¼1.28, 4.86) and recreational facility access (OR¼2.17, 95% CI¼1.22, 3.86), with a marginally significant association with urban design and land use policy/advocacy (OR¼1.65, 95% CI¼0.92, 2.97). LHD participation in a community partnership related to land use was associated with both urban design and land use (OR¼4.04, 95% CI¼2.29, 7.13) and active transportation (OR¼2.74, 95% CI¼1.48, 5.07) policy/advocacy activity, with a marginally significant association with recreational facility policy/advocacy participation (OR¼1.58, 95% CI¼0.91, 2.73).
Discussion This analysis reveals low levels of participation by LHDs in policy/advocacy to increase community physical activity opportunity as well as variation by LHD characteristics. These findings contrast with calls for participation of LHDs in community physical activity policy to meet physical activity and other health goals.9,10,33 Understanding factors associated with participation can inform efforts focused on increasing it. Structural characteristics such as larger population size, county or multicounty jurisdiction, local
Goins et al / Am J Prev Med 2016;50(1):57–68
60
Table 1. Study Sample Characteristics (LHDs Participating in 2013 NACCHO Profile and Module 1, n¼490) % of sample Unweighted
Weighteda
o50,000
48
61
50,000–499,999
39
34
Z500,000
13
5
City
14
12
County
73
74
Other
12
14
State
20
20
Local
70
71
Shared
10
9
No
31
29
Yes
69
71
Quartile 1 (r27.92)
25
21
Quartile 2 (27.93–r45.95)
25
24
Quartile 3 (45.96–r73.49)
25
25
Quartile 4 (473.49)
25
29
No
33
34
Yes
67
66
No
47
48
Yes
53
52
Decided not to apply
14
15
Undecided
37
40
Engaged/intend to engage
50
45
No
73
74
Yes, any
27
26
Characteristic Structural characteristics Population size served
Jurisdiction type
Governance
Local board of health
FTE per 100,000 population
Performance improvement efforts Community health assessment (o5 years)
Community health improvement plan (o5 years)
PHAB accreditation status
Use of core competencies
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governance, local board of health with power to make policy, and higher expenditures have been found to be associated with better public health system performance expressed in the 10 Essential Public Health Services.17,21,23–25,34,35 Larger LHD size has also been demonstrated to correlate with a range of related outputs, including quality improvement18,36 and other performance improvement efforts such as pursuit of PHAB accreditation.37 In this study, LHDs serving larger jurisdictions were more likely to engage in policy/advocacy activity for land use/urban design and active transportation, and higher FTE levels (a proxy for expenditures) were associated with greater policy/ advocacy participation to increase active transportation. With larger LHDs or those with greater staff resources more likely to engage in policy/advocacy related to community physical activity on their own, focus should be on assisting smaller LHDs and those with fewer resources. Identifying a limited set of priority activities related to built environment decision making may make policy participation by smaller and lower resourced LHDs more feasible. The public health field has engaged in efforts to measure and improve system performance since the 2002 publication of the IOM’s The Future of the Public’s Health in the 21st Century.11 Although evidence suggests local policy www.ajpmonline.org
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61
and 15% had decided not to pursue.37 Incentivizing LHDs, particularly smaller % of sample ones, to become accredited a could boost participation Characteristic Unweighted Weighted in community physical Use of community guide activity policy. Although fewer than half No/do not know 58 62 of LHDs reported using the Consistently/some areas 42 38 Community Guide consisCollaboration tently, those who did were Cross-jurisdictional sharing significantly more likely to report participation in all No 48 46 three investigated policy Yes 52 54 areas. This variable Any partnerships for land use remained significant for active transportation and No 75 69 expanding access to recreaYes 25 31 tional facilities in multiObesity/chronic disease policy/advocacy activities variate analysis. LHDs have been challenged in Community level urban design and land use policies to encourage physical activity implementing evidenceNo 70 75 based public health stratYes 30 25 egies. Barriers include lack of capacity, incentives/ Active transportation options rewards, and support from No 81 84 legislators, inadequate Yes 19 16 funding, and feeling a need to be an expert on many Expanding access to recreational facilities issues.40,41 Solutions No 75 77 include educating policyYes 25 23 makers and funders to supa port evidence-based Data are weighted to account for sampling design and differential non-response by size of population served. FTE, Full time equivalents; LHDs, local health departments; NACCHO, National Association of County and City approaches, aligning LHD Health Officials; PHAB, Public Health Accreditation Board. activities with the evidence base through the accreditadevelopment often falls victim to funding constraints,38 tion process, and developing standards and competencies policy development is a core public health function along to focus LHD efforts. with assessment and assurance11 and should occur as Resource sharing among LHDs is increasing,42 is more 39 part of improvement efforts such as CHA and CHIP. extensive for LHDs covering multiple jurisdictions and CHIP development in the past 5 years correlated with those with greater financial constraints, and has been policy/advocacy activity in all three areas, and the shown to increase capacity.31 This study found no association remained significant for land use and urban relationship between such collaboration and physical design policy participation when controlling for other activity policy/advocacy activity. Though most LHDs factors. Bivariate analysis revealed that LHDs engaging in reported no community partnerships related to land use, the PHAB process were more likely to report participathose who did were more likely to report activity in all tion in all three assessed community physical activity three policy areas; after controlling for other factors, this policy areas, although participation in land use and relationship held up for policy/advocacy activity regardurban design policy/advocacy was not significant in ing land use and urban design and active transportation. multivariate analysis. Nearly half (45%) of responding Partnerships have been found to be a partial mediator LHDs were engaged or intended to engage in the PHAB between resources and service provision, especially for process, but as of 2013 only 6% had submitted a PHAB LHDs with more-limited resources,19 and partnerships application or statement of intent, 40% were undecided, with non-traditional disciplines such as planning are key Table 1. Study Sample Characteristics (LHDs Participating in 2013 NACCHO Profile and Module 1, n¼490) (continued)
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Goins et al / Am J Prev Med 2016;50(1):57–68
62
Table 2. LHD Policy/Advocacy for Increased Physical Activity Facilities in Past 2 Years (n¼490)a Obesity/chronic disease policy/advocacy area Community-level urban design and land use policies to encourage physical activity Characteristic
Yes (%)
No (%)
p-value
Active transportation options Yes (%)
No (%)
p-value
Expanding access to recreation facilities Yes (%)
No (%)
p-value
Structural o0.001
Population size served
o0.001
0.002
o50,000
17.2
82.8
10.8
89.2
18.4
81.7
50,000–499,000
35.4
64.6
22.0
78.0
27.2
72.8
Z500,000
56.8
43.2
43.1
56.9
43.0
57.0
Geographic region
0.159
0.027
0.334
Northeast
16.2
83.8
11.5
88.5
16.0
84.0
Midwest
26.2
73.8
21.4
78.6
25.5
74.5
South
27.8
72.2
11.5
88.5
21.9
78.1
West
30.2
69.8
22.2
77.8
26.4
73.6
Jurisdiction type
0.099
0.372
0.708
City
16.1
83.9
11.8
88.2
19.2
80.8
County
26.1
73.9
17.6
82.4
23.5
76.5
Other
31.9
68.1
12.8
87.2
21.1
78.9
Governance
0.934
0.045
0.085
State
23.9
76.1
9.2
90.8
14.5
85.5
Local
25.7
74.3
18.9
81.1
25.3
74.7
Shared
26.2
73.8
10.5
89.5
19.6
80.4
Local board of health
0.552
0.709
0.124
No
27.5
72.5
17.3
82.7
18.1
81.9
Yes
24.8
75.2
16.0
84.1
24.7
75.3
FTE per 100,000 population
0.202
0.219
0.331
Quartile 1 (r27.92)
19.2
80.8
11.8
88.2
17.3
82.8
Quartile 2 (27.93–r45.95)
32.2
67.4
21.3
78.7
26.7
73.3
Quartile 3 (45.96–r73.49)
26.6
73.4
19.0
81.0
21.7
78.3
Quartile 4 (473.49)
25.1
74.9
14.5
85.5
26.1
73.9
Performance improvement Community health assessment (o5 years)
0.098
o0.001
0.033
No
20.7
79.3
11.2
88.8
13.2
86.8
Yes
27.8
72.2
18.8
81.2
31.3
68.7 (continued on next page)
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63 a
Table 2. LHD Policy/Advocacy for Increased Physical Activity Facilities in Past 2 Years (n¼490) (continued) Obesity/chronic disease policy/advocacy area Community-level urban design and land use policies to encourage physical activity Characteristic
Yes (%)
No (%)
Active transportation options
p-value
Yes (%)
No (%)
o0.001
Community health improvement plan (o5 years)
p-value
Expanding access to recreation facilities Yes (%)
No (%)
o0.001
0.016
No
15.7
84.3
12.0
88.0
13.2
86.8
Yes
34.2
65.8
20.1
79.9
27.4
72.7
PHAB accreditation status
0.001
0.002
0.006
Decided not to apply
18.2
81.8
9.6
90.4
16.4
83.6
Undecided
19.3
80.7
12.0
88.0
16.1
83.9
Engaged/intend to engage
34.8
65.2
24.4
75.6
29.4
70.6
Use of core competencies
0.037
0.208
0.152
No
23.3
76.7
15.1
84.9
21.0
79.0
Yes, any
33.1
66.9
20.0
80.0
27.5
72.5
o0.001
Use of community guide
p-value
o0.001
o0.001
No/do not know
18.0
82.0
8.9
91.1
15.1
84.9
Consistently/some areas
38.0
62.0
29.1
70.9
35.9
64.1
Collaboration Cross-jurisdictional sharing
0.387
0.728
0.259
No
23.6
76.4
16.9
83.1
20.1
79.9
Yes
27.2
72.8
15.7
84.3
24.5
75.5
o0.001
Any partnerships for land use
o0.001
0.005
No
17.1
82.9
12.1
87.9
18.7
81.3
Yes
44.5
55.5
27.1
72.9
30.9
69.2
Note: Boldface indicates statistical significance (po0.05). a Data are weighted to account for sampling design and differential non-response by size of population served. FTE, Full time equivalents; LHDs, local health departments; PHAB, Public Health Accreditation Board.
to increasing community physical activity opportunity.6 A model curriculum for planning and public health students exists,43 but it will take time to develop sufficient academic programs and for graduates to enter the field. In addition, much of the LHD workforce has little formal public health training,44 and implementation challenges may be greatest at the local level given the variation in LHD configuration.45 The overall low level of participation in community physical activity policy/advocacy observed in this study is consistent not only with the authors’ previous research15 but also with data on policy participation by LHD executives generally.14 In addition to financial January 2016
constraints, a plausible reason for the low rate of participation is insufficient knowledge and skills. Only 15% of health commissioner respondents in one study reported their knowledge of the policy process was excellent.14 Assessment of the effects of policies, laws, and regulations was among the most-requested training topics in a survey of public health chronic disease professionals in state and local governments.46 How, then, can LHDs be moved toward greater participation in community physical activity policy/ advocacy activities? Training is available in general policy competencies for shaping the built environment,47–49 but these are not specific to transportation planning, land
64
Table 3. Multivariate Factors Associated With Policy/Advocacy for Increased Community Physical Activity Opportunity in Past 2 Years (n¼490)a Obesity/chronic disease policy/advocacy area Community level urban design and land use policies to encourage physical activity Characteristic
OR
95% CI
p-value
Expanding access to recreation facilities
Active transportation options OR
95% CI
p-value
OR
95% CI
p-value
Structural Population size served o50,000
1
1
1
1.75
0.91
3.37
0.094
1.76
0.83
3.72
0.138
1.25
0.66
2.36
0.501
Z500,000
3.60
1.49
8.67
0.004
4.30
1.48
12.51
0.007
2.48
0.95
6.50
0.064
Geographic region Northeast
1
1
1
Midwest
1.83
0.67
5.00
0.238
2.10
0.72
6.11
0.173
1.69
0.66
4.37
0.277
South
1.70
0.53
5.43
0.371
1.01
0.24
4.29
0.994
1.93
0.62
5.98
0.253
West
1.67
0.57
4.91
0.353
1.53
0.48
4.84
0.471
1.68
0.56
5.03
0.350
Jurisdiction type City
1
1
1
County
1.17
0.48
2.90
0.726
0.90
0.32
2.53
0.838
0.63
0.25
1.60
0.331
Other
1.24
0.42
3.62
0.698
0.49
0.12
1.96
0.310
0.54
0.19
1.55
0.250
Governance type
www.ajpmonline.org
State
1
1
1
Local
1.25
0.44
3.53
0.670
1.34
0.38
4.73
0.649
2.47
0.80
7.62
0.115
Shared
0.61
0.22
1.72
0.352
0.42
0.11
1.60
0.204
0.84
0.27
2.60
0.756
0.56
1.76
0.969
Local board of health No
1
Yes
0.75
1 0.41
1.37
0.347
0.76
1 0.39
1.49
0.430
0.99
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Goins et al / Am J Prev Med 2016;50(1):57–68
50,000–499,999
January 2016
Table 3. Multivariate Factors Associated With Policy/Advocacy for Increased Community Physical Activity Opportunity in Past 2 Years (n¼490)a (continued) Obesity/chronic disease policy/advocacy area Community level urban design and land use policies to encourage physical activity Characteristic
OR
95% CI
p-value
Expanding access to recreation facilities
Active transportation options OR
95% CI
p-value
OR
95% CI
p-value
FTE per 100,000 population (quartile) Quartile 1 (r27.92)
1
1
1
2.12
1.00
4.49
0.051
2.42
1.06
5.50
0.035
1.77
0.81
3.87
0.150
Quartile 3 (45.96–r73.49)
2.11
0.92
4.83
0.078
3.07
1.24
7.61
0.016
1.57
0.64
3.80
0.321
Quartile 4 (473.49)
1.67
0.68
4.07
0.260
2.60
0.93
7.28
0.069
2.18
0.86
5.54
0.102
0.85
3.84
0.125
Performance improvement Community health assessment (o5 years) No
1
Yes
0.68
1 0.35
1.32
0.253
1.35
1 0.65
2.80
0.416
1.80
Community health improvement plan (o5 years) No
1
1
1
Yes
3.20
1.64
6.27
0.001
1.32
0.67
2.58
0.416
1.76
0.89
3.47
0.104
Decided not to apply
0.68
0.28
1.68
0.404
0.47
0.18
1.22
0.122
0.64
0.27
1.53
0.314
Undecided
0.68
0.36
1.29
0.239
0.49
0.24
1.00
0.051
0.48
0.25
0.92
0.027
0.50
1.59
0.709
1.22
3.86
0.009
PHAB accreditation status
Engaged/intend to engage
1
1
1
No
1
1
1
Yes
1.10
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Quartile 2 (27.93–r45.95)
Use of core competencies
0.62
1.96
0.748
0.83
0.42
1.64
0.589
0.90
Use of community guide No/do not know Consistently/some areas/
1 1.65
1 0.92
2.97
0.094
2.50
1 1.28
4.86
0.007
2.17
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Goins et al / Am J Prev Med 2016;50(1):57–68
2.73
2.38
5.07 1.48 2.74 o0.001
1 1
4.04
No
Yes
Any partnerships for land use
2.29
7.13
0.404 2.11 0.74 1.25 Yes
Note: Boldface indicates statistical significance (po0.05). a Data are weighted to account for sampling design and differential non-response by size of population served. FTE, Full time equivalents; PHAB, Public Health Accreditation Board.
0.001
1
0.832 1.70 0.52 0.94
1 1 No
Cross-jurisdictional sharing
Collaboration
1.58
0.91
0.77 1.35
1
p-value 95% CI OR p-value 95% CI OR Characteristic
use, or parks and recreation, and there is no associated technical assistance. Toolkits and training are likely insufficient to build the skills and confidence needed for participation in policy change,50 so affordable technical assistance will be essential.8,50 Following the general public health professional competencies and standards already set, creating competencies in specific public health practice areas is the next step.51 Development of public health emergency preparedness competencies, with training and consultation for local officials widely available through the Preparedness and Emergency Response Learning Centers throughout the U.S., offers a potential model.52–54 A comprehensive process would define priority areas, assess current status of LHDs, develop and deliver training and technical assistance, and measure progress.
0.102
0.294
p-value 95% CI OR
Expanding access to recreation facilities Active transportation options Community level urban design and land use policies to encourage physical activity
Obesity/chronic disease policy/advocacy area
Table 3. Multivariate Factors Associated With Policy/Advocacy for Increased Community Physical Activity Opportunity in Past 2 Years (n¼490)a (continued)
66
Limitations Limitations of this analysis include selfreported data and potential social desirability bias for the policy/advocacy participation, performance improvement, and collaboration measures, particularly due to data being collected by a membership organization. The crosssectional study design precludes causal inference. Additional important independent correlates of policy/advocacy activities were not included. Funding could not be directly assessed owing to reliability concerns and missing data, though LHD FTE per population was used as a proxy indicator. Community health status indicators (e.g., percentage of population obese) were not included. Although county-level indicators are available from sources such as the County Health Rankings, this study includes a mix of county, city, and multicounty LHDs. Health status indicators for the latter two are not uniformly available. Thus, to maintain a nationally representative LHD sample, such data were not included. Additional factors may influence reporting accuracy. There was likely variability www.ajpmonline.org
Goins et al / Am J Prev Med 2016;50(1):57–68
among respondents regarding knowledge of their LHD’s activities. This could result in underestimation of the examined variables. State, federal, and foundation funding to engage in policy, systems, and environmental change strategies to make communities more physical activity–friendly may have fostered greater participation by recipient LHDs. This differential participation could have resulted in overestimation of policy/advocacy participation.
2.
3.
4.
Conclusions Participation in community physical activity policy/advocacy among LHDs was low in this study and varied by LHD characteristics. Results identify specific structural characteristics that are priority targets and performance improvement initiatives and collaborative approaches that provide opportunities to promote LHD policy participation. Intervention opportunities include assisting smaller and lower resource LHDs and promoting the use of performance improvement efforts and evidence-based practice resources currently encouraged for LHDs nationally. Further research is needed to specify roles, responsibilities, and competencies for LHDs in community physical activity policy/advocacy and test cost-effective interventions that align LHD capacity and resources.
5.
6.
7.
8.
9.
10.
This study was funded by CDC, Cooperative Agreement Number U48 DP001933, from the CDC Prevention Research Centers Program. It uses data from the National Association of County and City Health Officials Profile Surveys, which were supported by the Robert Wood Johnson Foundation and CDC. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of CDC. Ms. Goins and Dr. Lemon led study conceptualization and writing of the article. Dr. Ye participated in study conceptualization, performed data analysis, wrote methods and results, and assisted with article revisions. Ms. Leep participated in study conceptualization and article revisions. Ms. Robin assisted with data analysis and development of results. All authors approved the final version. KVG is a paid consultant to the local health department in Worcester, Massachusetts. SL receives an evaluation contract from the local health department in Worcester, Massachusetts. No other financial disclosures were reported by the authors of this paper.
11. 12.
13.
14.
15.
16.
17.
18.
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