Activities and Workforce of Small Town Rural Local Health Departments: Findings from the 2005 National Profile of Local Health Departments Study

Activities and Workforce of Small Town Rural Local Health Departments: Findings from the 2005 National Profile of Local Health Departments Study

1100 17th Street, NW 2nd Floor Washington, DC 20036 (202) 783-5550 (202) 783-1583 Fax www.naccho.org is the national organization representing local public health departments. works to support efforts that protect and improve the health of all people and all communities by promoting national policy, developing resources and programs, seeking health equity and supporting effective local public health practice and systems. Funding for this project was provided by the Centers for Disease Control and Prevention (under cooperative agreement U50/CCU302718) and by the Health Resources and Services Administration. The contents of this document are solely the responsibility of the authors and do not necessarily represent the official views of the sponsors. May 2007

Executive Summary This report uses data collected in the 2005 National Profile of Local Health Departments (2005 Profile) study to characterize the workforce and activities of small town rural local health departments (LHDs) and to compare them to those of larger rural, suburban, and urban LHDs in the U.S. For the purpose of this report, small town rural jurisdictions include small towns (population less than 10,000) and frontier areas. Nearly all small town rural LHDs serve single county or multi-county jurisdictions, which may include several small towns and frontier areas. The small town rural group does not include larger towns and small cities that are also considered rural in other classification systems. Approximately 40 percent of the LHDs in the U.S. serve small town rural areas. The typical (median) small town rural LHD serves a population of 15,000, has a budget of approximately $500,000, and employs nine FTE staff. The 2005 Profile study shows that the percentage of LHDs providing almost any service is higher for LHDs serving large populations than small populations. Small town rural LHDs serve populations that are, on average, an order of magnitude smaller than other LHDs. Consequently, two factors could account for a difference in the percentages of small town rural versus other LHDs providing a service: jurisdiction population and degree of urbanization. Comparing LHDs serving small populations (less than 50,000 total residents in the jurisdiction) makes it easier to identify those differences that are related to degree of urbanization. Health Services. Small town rural LHDs are as likely or more likely to provide all of the health services included in the 2005 Profile study than other LHDs serving small populations. Epidemiology and Surveillance. Small town rural LHDs are as likely or more likely to engage in epidemiology and surveillance activities than other LHDs serving small populations. Primary Prevention. Small town rural LHDs are more likely to provide most populationbased primary prevention services than other LHDs serving small populations. Environmental Health. Small town rural LHDs are less likely to provide environmental health services than other LHDs serving small populations. Furthermore, many environmental health services are less likely to be provided by any governmental agency in small town rural LHD jurisdictions than in other jurisdictions. The workforce in small town rural LHDs reflects the types of services these LHDs most often provide. Small town rural LHDs employ more nurses and few environmental health specialists than other LHDs. The 2005 Profile study suggests that small town rural LHDs experience many of the same challenges as other LHDs serving small populations. Their relatively small number of staff and narrow range of occupations may limit the range of services that they are able to provide. Small town rural LHDs typically focus more on provision of healthcare services, while other small LHDs typically focus more on environmental health services. Additional research would be needed to determine the extent to which the local public health systems in these jurisdictions have the capacity to meet their communities public health needs.

Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study Introduction For many years, the adage if you ve seen one local health department, you ve seen one local health department was used to convey the uniqueness of each local health department (LHD). Rural health departments were viewed as fundamentally different from urban health departments, and two health departments in neighboring counties might be very different from each other, even if they were both considered rural. More recently, public health leaders have recognized that, although the characteristics and needs of any community are unique, all communities should reasonably expect a consistent and robust set of public health services. 1 In 2005, the National Association of County and City Health Officials () conducted a National Profile of Local Health Departments study (2005 Profile). The aim of the 2005 Profile was to develop a comprehensive and accurate description of LHD infrastructure and practice. This report uses data collected in the 2005 Profile to examine the activities and workforce of the most isolated rural LHDs and compare them with larger rural, suburban, and urban LHDs. Methodology The 2005 Profile questionnaire was structured as a core questionnaire (sent to every LHD in the U.S., N=2,864) and three separate module questionnaires (sent to samples of approximately 520 LHDs each). The questionnaires were Web-based and were fielded from June through October 2005. Extensive follow-up efforts resulted in an overall response rate of 80 percent for the core questionnaire. Additional details about the methodology are available in the main study report. 2 The response rate for small town rural LHDs was slightly higher than for other LHDs (83% versus 79%). All of the data presented in this report were collected via the core questionnaire The unit of analysis for the 2005 Profile study is the LHD jurisdiction; thus every LHD is categorized based on the rural-urban commuting areas (RUCA) method (see box on page 3). The two groups compared are small town rural areas and all other LHDs. This study focuses on a subcategory (RUCA codes 7 and higher) that represents the smallest and most isolated jurisdictions, which are termed small town rural LHDs. Consequently, it is important to note that the all other LHDs category includes LHDs designated as rural in more traditional geographic classifications. Because many LHDs serve both rural and non-rural areas, this classification method is not ideal, but it is a practical approximation, given the absence of census tract-level data to characterize LHD jurisdictions. Thus, many LHDs that are not classified as small town rural may serve such areas. It is less likely that LHDs classified as small town rural serve significant non-rural areas, as LHD offices tend to be located in more populated areas within jurisdictions. The great difference in the size of population served by small town rural versus other LHDs is important to consider when examining differences in many of the LHD characteristics included in the 2005 Profile study. A great majority of these characteristics vary by the jurisdiction s population size not only characteristics such as budget and number of staff. Items ranging from education of top agency executive to occupations employed to number and types of services provided all vary by size of population served (regardless of whether the population is in a rural or non-rural area). Consequently, the population of the jurisdiction is an important confounding factor in analyses comparing LHDs

Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study serving areas with different degrees of urbanization. To account for this factor, some data are presented both for all LHDs and for LHDs serving populations less than 50,000 (which include nearly all small town rural LHDs). Without accounting for the variation in the distribution of size of population served between the two groups, it is not clear how much of the differences between small town rural and other LHDs should be attributed to differences in urbanization or differences in size of population served. Statistical analyses were performed using Stata version 9.0. Statistical significance was determined by inspecting Wald 95 percent confidence intervals for the statistics. What Is Rural? The terms rural and urban are familiar to everyone, but their definitions are imprecise. In general, rural and urban are considered endpoints on a continuum that describes the degree of urbanization of an area. Definitions of what is rural may depend on the purpose of the analysis (e.g., geography versus political science) and the context (e.g., Montana versus Pennsylvania). Rural areas are classifed in several ways. The Office of Management and Budget uses a county-based classification system that designates Core-Based Statistical Areas (CBSAs), which are made up of either Metropolitan areas or Micropolitan areas. All other counties are not part of CBSAs. Given that county sizes vary greatly across the country, this classification system lacks precision. The rural-urban commuting areas (RUCA) methodology is another way to classify rural areas. RUCAs use census tracts rather than counties as building blocks and are designed to define rural and urban based on the Census Bureau s carefully constructed definitions of urbanized areas and urban clusters, which are based on complex criteria including population density and population work commuting patterns. Thus, the RUCA taxonomy is based on the size of cities and towns and their functional relationships as measured by work commuting flows. 3 For this study, LHDs were classified by matching the zip code of the LHD s main office to the zip code approximation for RUCAs. RUCAs 7 and higher were categorized as small town rural. The group all other LHDs includes RUCAs 1-6. The jurisdictions classified as small town rural in this study include small towns (population less than 10,000) and frontier areas. Areas in RUCA codes 4 through 6 are large town rural areas. The Health Resources and Services Administration classifies RUCA codes 4 and higher as rural, while codes 1-3 are considered urban. Because of the diversity among LHDs serving rural areas, this study focuses on the more isolated rural census tracts (codes 7 and higher). It is important to recognize that over half of the census tracts classified as rural are in RUCA codes 4-6, and thus, by design, are included in the all other LHDs group for the purpose of this analysis.

Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study Results Approximately 40 percent of the LHDs in the U.S. are categorized as serving small town rural areas using the methodology described above. Figure 1 highlights some of the differences in structure and size of small town rural LHDs compared with all other LHDs. Small town rural LHDs are more likely than other LHDs to serve a county jurisdiction and to be a unit of the state health agency. Other LHDs are more varied in jurisdiction type and are more likely than small town rural LHDs to be units of local government. Small town rural LHDs serve populations that are, on average, nearly an order of magnitude smaller than other LHDs, and their budgets and numbers of staff are correspondingly smaller. Ninety-two percent of small town rural LHDs serve populations less than 50,000. Median annual expenditures for small town rural LHDs are approximately one-quarter that of other LHDs, and small town rural LHDs employ, on average, a much smaller number of staff than other LHDs. On average, small town rural LHDs have higher expenditures, on a per capita basis, than other LHDs. The 2005 Profile study collected information about the provision of 75 different public health-related services and activities. Data on all these services and activities except licensing and inspection activities are presented in this report. The 2005 Profile study also collected information about the total number of LHD employees and about the presence and number of employees within selected occupations. The results below illustrate similarities and differences between small town rural and other LHDs. Figure 1 Characteristics of Small Town Rural and Other LHDs Small town rural LHDs All other LHDs Number (and percentage) of 2005 Profile respondents 914 (40%) 1384 (60%) Percentage serving county jurisdictions 75% 48% Percentage that are units of state health agencies 26% 17% Percentage serving populations <50,000 92% 42% Mean jurisdiction population size 22,000 200,000 Median jurisdiction population size 15,000 64,000 Median annual LHD expenditures $500,000 $2,000,000 Median per capita LHD expenditures $35 $26 Median number of LHD staff (full time equivalents) 9 29 LHD Activities and Services Figures 2, 3, and 4 provide data on the percentages of LHDs that provide selected services or activities (directly or via contract) in their jurisdictions. Figure 2 shows that small town rural LHDs are more likely to provide some health services (e.g., childhood immunizations, tuberculosis screening, and family planning) and less likely to provide others, (e.g., HIV/AIDS screening, oral health, and STD treatment) compared with other LHDs. When comparing only LHDs serving fewer than 50,000 residents, small town rural LHDs are as likely or more likely to provide all of these health services than other LHDs.

Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study Figure 2 Percentage of LHDs Providing Selected Health Services All LHDs LHDs serving populations <50,000 Activity or service Small town rural All other LHDs Small town rural All other LHDs IMMUNIZATIONS Adult immunizations Ñ 93% Ñ 90% Ñ 94% Ñ 82% Childhood immunizations Ñ 95% Ñ 86% Ñ 94% Ñ 75% SCREENING FOR DISEASES/CONDITIONS HIV/AIDS Ñ 56% Ñ 66% Ñ 55% Ñ 44% Other STDs Ñ 60% Ñ 67% Ñ 58% Ñ 44% Tuberculosis Ñ 87% Ñ 83% Ñ 87% Ñ 70% Cancer 44% 48% 43% 37% Cardiovascular disease 36% 37% 35% 30% Diabetes Ñ 56% Ñ 47% Ñ 56% Ñ 44% High blood pressure Ñ 79% Ñ 67% Ñ 80% Ñ 67% Blood lead 67% 65% Ñ 66% Ñ 54% COMMUNICABLE DISEASE TREATMENT HIV/AIDS Ñ 20% Ñ 29% 19% 18% Other STDs Ñ 56% Ñ 64% Ñ 54% Ñ 41% Tuberculosis 77% 73% Ñ 76% Ñ 56% MATERNAL AND CHILD HEALTH Family planning Ñ 62% Ñ 55% Ñ 61% Ñ 40% Prenatal care 43% 41% Ñ 41% Ñ 31% Obstetrical care Ñ 12% Ñ 17% 12% 11% WIC Ñ 73% Ñ 63% Ñ 72% Ñ 46% EPSDT Ñ 52% Ñ 42% Ñ 51% Ñ 32% OTHER HEALTH SERVICES Comprehensive primary care Ñ 10% Ñ 17% 8% 8% Home health care Ñ 34% Ñ 24% Ñ 34% Ñ 24% Oral health Ñ 23% Ñ 35% 22% 17% Behavioral/mental health services Ñ 10% Ñ 15% 9% 9% Substance abuse services Ñ 6% Ñ 14% 6% 7% School-based clinics Ñ 28% Ñ 22% Ñ 28% Ñ 19% School health 42% 40% Ñ 42% Ñ 33% Outreach and enrollment for medical insurance 42% 42% Ñ 41% Ñ 28% Correctional health 21% 18% Ñ 21% Ñ 13% Colored numeric entries indicate areas where there is a statistically significant difference in the proportion of small town rural versus other LHDs providing that service. Ñ more small town rural LHDs Ñ more other LHDs

6 Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study Small town rural LHDs are less likely to conduct several types of epidemiology and surveillance activities (injury, environmental health, and syndromic) and are equally likely to provide most types of population-based primary prevention services, compared with other LHDs (Figure 3). When comparing only LHDs serving fewer than 50,000 residents, small town rural LHDs are as likely or more likely to provide epidemiology and surveillance activities and more likely to provide all but one category of prevention services (mental illness) than other LHDs. Figure 3 Percentage of LHDs Providing Epidemiology/Surveillance and Population-Based Primary Prevention Services All LHDs LHDs serving populations <50,000 Activity or service Small town rural All other LHDs Small town rural All other LHDs EPIDEMIOLOGY AND SURVEILLANCE Communicable/infectious disease 87% 90% 86% 83% Chronic disease 39% 43% Ñ 38% Ñ 32% Injury Ñ 21% Ñ 26% 20% 16% Behavioral risk factors 34% 37% 33% 27% Environmental health Ñ 68% Ñ 80% 68% 71% Syndromic Ñ 29% Ñ 35% Ñ 28% Ñ 21% POPULATION-BASED PRIMARY PREVENTION Injury 41% 40% Ñ 39% Ñ 25% Unintended pregnancy Ñ 55% Ñ 48% Ñ 54% Ñ 32% Obesity 57% 55% Ñ 56% Ñ 41% Violence 24% 26% Ñ 23% Ñ 15% Tobacco 68% 69% Ñ 67% Ñ 58% Substance abuse 25% 26% Ñ 26% Ñ 17% Mental illness 13% 14% 13% 9% Colored numeric entries indicate areas where there is a statistically significant difference in the proportion of small town rural versus other LHDs providing that service. Ñ more small town rural LHDs Ñ more other LHDs

Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study 7 The picture is very different when environmental health (EH) and other miscellaneous public healthrelated services are examined (Figure 4). Small town rural LHDs are less likely than other LHDs to provide almost all of these services, and the difference persists when examining only LHDs that serve populations less than 50,000. Figure 4 Percentage of LHDs Conducting Environmental Health and Other Public Health Activities All LHDs LHDs serving populations <50,000 Activity Small town rural All other LHDs Small town rural All other LHDs ENVIRONMENTAL HEALTH ACTIVITIES Indoor air quality Ñ 14% Ñ 38% Ñ 14% Ñ 36% Food safety education Ñ 66% Ñ 81% Ñ 64% Ñ 76% Radiation control Ñ 7% Ñ 12% 7% 9% Vector control Ñ 43% Ñ 62% Ñ 42% Ñ 54% Land use planning Ñ 12% Ñ 19% Ñ 11% Ñ 19% Groundwater protection Ñ 27% Ñ 47% Ñ 27% Ñ 45% Surface water protection Ñ 23% Ñ 39% Ñ 23% Ñ 38% Hazmat response Ñ 12% Ñ 24% Ñ 12% Ñ 23% Hazardous waste disposal Ñ 10% Ñ 23% Ñ 10% Ñ 24% Noise pollution Ñ 3% Ñ 21% Ñ 3% Ñ 26% OTHER PUBLIC HEALTH ACTIVITIES Emergency medical services Ñ 4% Ñ 8% 4% 4% Animal control Ñ 11% Ñ 28% Ñ 11% Ñ 28% Occupational safety and health Ñ 8% Ñ 15% Ñ 8% Ñ 13% Veterinarian public health activities Ñ 13% Ñ 26% Ñ 12% Ñ 22% Laboratory services Ñ 23% Ñ 37% 22% 22% Colored numeric entries indicate areas where there is a statistically significant difference in the proportion of small town rural versus other LHDs providing that service. Ñ more small town rural LHDs Ñ more other LHDs

8 Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study Figure 5 shows the organizations that provide selected EH activities in small town rural and other LHDs. Each of the EH activities is provided less frequently by a local or state governmental agency in small town rural jurisdictions than in other jurisdictions. For example, hazmat response is provided by a governmental agency in 71 percent of small town rural jurisdictions compared to 89 percent of other jurisdictions. The differences range from seven percent for food safety education to 23 percent for noise pollution activities. Furthermore, the percentage of LHDs reporting that the service is not available in their jurisdiction is higher for small town rural than other LHDs for radiation control, hazmat response, and pollution prevention. The difference in availability from any source for each of these services is small, however, ranging from three to four percent. A particularly interesting finding is that the percentage of respondents indicating that they did not know who provided the service in their jurisdictions was higher for small town rural than for other LHDs for every EH activity except hazmat response. The differences ranged from three percent for food safety education to 12 percent for land use planning. Figure 5 Organizations Conducting Selected Environmental Health Activities: Small Town Rural and Other Jurisdictions Food safety education R N Vector control R N Groundwater protection R N Indoor air quality R N Pollution prevention R N Hazmat response R N Land use planning R N 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% R = small town rural LHDs N = all other LHDs Percentage of jurisdictions n LHD n Other governmental n Non-governmental only n Not available n Unknown

Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study 9 The data on provision of other miscellaneous public health activities show similar patterns. Each of these activities is less likely to be provided by a local or state governmental agency and more likely to be provided only by non-governmental organizations in small town rural jurisdictions compared to other jurisdictions. Animal control is more likely to be unavailable in small town rural jurisdictions, and respondents in these jurisdictions were less likely to know who provided animal control and occupational safety and health activities than respondents in other jurisdictions. The percentage of jurisdictions where an activity or service is not available is similar for small town rural and other jurisdictions for most activities and services. Figure 6 lists those activities and services for which the percentage of jurisdictions reporting the activity or service to be unavailable differs significantly between small town rural and other LHDs. In all cases where the percentages differ, the availability of the activity or service is lower in small town rural than other jurisdictions. The largest difference in availability is eight percent for obstetrical care (unavailable in 12 percent of small town rural and four percent of other jurisdictions). The 2005 Profile data provide no information, however, about the adequacy of these services, either in terms of quantity or quality. Figure 6 Percentage of LHD Jurisdictions Where Activity or Service Is Not Available: Differences Between Small Town Rural and Other LHD Jurisdictions Unavailable in jurisdiction Activity or service Small town rural All other LHDs HIV/AIDS treatment 7% 3% Prenatal care 7% 3% Obstetrical care 12% 4% Substance abuse services 7% 4% Radiation control 9% 5% Housing inspection 8% 4% Animal control 5% 1% Pollution prevention 6% 2% Hazmat response 4% 1% Note: All differences are statistically significant.

10 Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study LHD Workforce The composition of the workforce of small town rural LHDs reflects the differences in the types of activities and services these LHDs provide compared to other LHDs (Figure 7). Specifically, the small town rural LHD workforce includes a larger percentage of nurses and a smaller percentage of EH specialists (sanitarians) than the workforce of other LHDs. The 11 professional occupations/occupational categories included in the 2005 Profile questionnaire (listed in Figure 8, below) comprise approximately 53 percent of the workforce of small town rural LHDs and 57 percent of the workforce of other LHDs. Figure 7 Composition of LHD Workforces Small Town Rural LHDs All Other LHDs 21% 7% 14% 7% 31% 27% 29% 26% 3% 3% 2% 7% 5% 3% 3% 12% Estimated Total FTEs = 19,000 Estimated Total FTEs = 120,000 n Managers/directors n Nurses n EH specialists and scientists n Health educators n Nutritionists n Other Profile categories n Clerical staff n Occupations not categorized

Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study 11 A smaller percentage of small town rural LHDs (compared with other LHDs) employ each of the occupations included in the 2005 Profile questionnaire, except for clerical staff and nurses (Figure 8). The percentage of LHDs employing most of these occupations is strongly related to the size of population served. 4 When the analysis is restricted to those LHDs serving populations less than 50,000, the percentages of LHDs employing health service managers/directors, epidemiologists, health educators, information systems (IS) specialists, public information (PI) specialists, and emergency preparedness (EP) coordinators are similar for small town rural and other jurisdictions. Small town rural LHDs serving fewer than 50,000 residents are more likely to employ nurses, nutritionists, and clerical staff and are less likely to employ EH specialists, EH scientists, and physicians than other LHDs in this size category. Figure 8 Percentage of LHDs Employing Selected Occupations All LHDs LHDs serving <50,000 Small town rural All other LHDs Small town rural All other LHDs Managers/directors Ñ 85% Ñ 92% 85% 84% Nurses 96% 93% Ñ 96% Ñ 86% Physicians Ñ 26% Ñ 54% Ñ 24% Ñ 32% EH specialists (sanitarians) Ñ 69% Ñ 87% Ñ 67% Ñ 83% Other EH scientists Ñ 17% Ñ 41% Ñ 15% Ñ 22% Epidemiologists Ñ 7% Ñ 36% 6% 10% Health educators Ñ 40% Ñ 64% 36% 38% Nutritionists Ñ 48% Ñ 62% Ñ 46% Ñ 36% IS specialists Ñ 14% Ñ 39% 12% 12% PI specialists Ñ 7% Ñ 25% 6% 5% EP coordinators Ñ 47% Ñ 66% 44% 43% Clerical staff 97% 96% Ñ 97% Ñ 91% Colored numeric entries indicate areas where there is a statistically significant difference in the proportion of small town rural versus other LHDs providing that service. Ñ more small town rural LHDs Ñ more other LHDs The mean number of LHD staff per thousand jurisdiction residents also differs between small town rural and other LHDs (Figure 9). Small town rural LHDs employ an average of 0.93 workers per thousand residents compared with 0.57 workers per thousand residents for other LHDs. The average number of nurses per thousand residents is twice as high for small town rural LHDs as for other LHDs (0.30 versus 0.15). The average number of EH specialists per thousand residents is similar for small town rural and other LHDs (0.05). Figure 9 Mean Number of LHD Staff per Thousand Jurisdiction Residents Staff per thousand residents Small town rural LHDs All other LHDs All LHD staff 0.93 0.57 Nurses 0.30 0.15 EH specialists 0.05 0.05

12 Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study Discussion Activities and Service Provision Most public health services are available (from some source) in approximately the same percentage of small town rural jurisdictions as in other jurisdictions. There are a few exceptions (see Figure 7), but the differences in availability are relatively small. There are, however, significant differences in the organizations that provide these services. LHDs in small town rural areas frequently provide health services that in other areas are provided by other organizations, probably due to shortages of other providers (particularly safety net providers) in small town rural areas. Environmental health services are more frequently provided by a governmental agency other than the LHD in small town rural areas, and are more frequently available only through non-governmental organizations in small town rural areas compared to other areas. The finding that more respondents in small town rural LHDs did not know who provided certain EH services suggests that these services are not available locally. It also suggests that small town rural LHDs may be less aware than other LHDs of the extent to which the EH needs of their communities are being met. Workforce The 2005 Profile study indicates that, while LHDs serving small town rural jurisdictions are less likely to employ most occupations than LHDs serving other jurisdictions, the picture changes considerably when differences in the sizes of population served are taken into account. LHDs in small town rural jurisdictions of 50,000 residents or less are more likely than LHDs in other jurisdictions of the same size to employ nurses, nutritionists, and clerical staff. LHDs serving smaller small town rural jurisdictions are less likely than LHDs serving smaller jurisdictions of other types to employ EH specialists and scientists or physicians. LHDs in small town rural jurisdictions have a higher number of total LHD staff and nurses per capita than LHDs serving other jurisdictions, but have similar numbers of EH specialists per capita as other LHDs. This seems consistent with the finding that LHDs in small town rural areas are more likely to provide a number of public health nursing functions than LHDs in other areas, but are less likely to provide EH services. K e y F i n d i n g s n Small town rural LHDs are more likely to provide many public health nursing services than other LHDs. n Small town rural LHDs are less likely to conduct EH activities than other LHDs. n Similar percentages of small town rural and other LHDs serving small populations provide epidemiology, surveillance, and population-based primary prevention services. n Some EH activities are less likely to be provided by a governmental agency in small town rural jurisdictions compared to other jurisdictions. n The small town rural LHD workforce includes a higher percentage of nurses and a lower percentage of EH specialists and scientists than the workforce of other LHD jurisdictions. n LHDs in small town rural areas have more financial and human resources on a per capita basis than LHDs in other areas.

Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study 13 Implications This research suggests that, in many ways, rural LHDs are similar to other LHDs that serve small populations. LHDs serving small populations typically provide a narrower range of activities and services compared to LHDs that serve larger populations. They also employ a narrower range of occupational categories, often limited to a manager/director, nurses, EH specialists, and clerical staff. The mix of services provided differs, however. Small town rural LHDs provide more public health nursing services and conduct fewer EH activities than other LHDs. This research cannot, however, assess the extent to which the public health needs of communities are being met nor whether there are differences in the adequacy of public health services provided between LHDs in rural and non-rural areas or between LHDs serving larger and smaller populations. This is accomplished at the individual community level through community health assessment and strategic planning processes. The emerging voluntary accreditation program for local and state health departments 5 may shed some light on differences in LHD capacity in a way that this type of study cannot. The differences in the composition of local public health systems in rural jurisdictions will present some additional challenges to rural LHDs. The 2005 Profile results suggest that small town rural LHDs are providing more direct health services than other LHDs. A reason for this difference (not assessable in this study) could be the absence of other safety net providers in their local public health systems. The need to provide clinical services may limit the ability of these LHDs to adequately fulfill other population-based functions. Because EH activities are more frequently conducted by organizations other than the LHD and less frequently conducted by governmental agencies in small town rural than in other areas, small town rural LHDs may experience more challenges in assuring quality EH activities within their communities. Rural and non-rural LHDs serving small populations face some common challenges from a workforce perspective. Though many of these LHDs are active in epidemiology, health education, and policy development, few of them employ members of specialized occupations who are likely to have had public health training in their formal education, such as physicians, epidemiologists, and health educators. In order to provide these services, these agencies must use a variety of strategies to access skills in these areas. Some possibilities include obtaining expertise from their state health agency, either from the central office or a district or regional office; from larger LHDs in their region; and from other local governmental agencies or non-governmental community partners, such as universities or hospitals. LHDs also might seek training in specialized areas for staff with a variety of job responsibilities (e.g., public health nurses who also conduct epidemiological studies or provide health education). Staff with education and experience in nursing or environmental health may need training and leadership development to acquire broader public health competencies to fulfill their wide range of roles effectively. Regionalization either of specific public health functions and services or of entire LHDs is frequently discussed as a way to strengthen public health capacity in areas where there are many LHDs each serving a relatively small population. Sharing of LHD services is certainly more easily accomplished over smaller geographic areas. In some non-rural parts of the U.S. (e.g., Connecticut, New Jersey, and Ohio), multiple LHDs serving small populations actually have merged in some cases into single LHDs serving several cities or towns. But for rural LHDs in frontier areas, neighboring LHDs may be quite distant, making it more challenging to share services across a very large geographic area.

14 Activities and Workforce of Small Town Rural LHDs: Findings from the 2005 National Profile of Local Health Departments Study In many parts of the U.S., however, rural areas are served by multicounty district LHDs. The entire state of Idaho is served by multicounty district LHDs, as are nearly all of the rural areas in Nebraska. Many states with mostly single county LHDs (e.g., North Carolina, Michigan, and Minnesota) have district LHDs in rural areas. The method used to classify LHDs for the 2005 Profile study does not permit an analysis that would compare the staffing and services available to rural areas served by district LHDs versus single county LHDs. An analysis that used census tracts rather than LHDs as the unit of analysis would be more appropriate for making these comparisons. Such an analysis would be useful in exploring the potential benefits of combining single-county LHD jurisdictions in rural areas into multicounty jurisdictions. (Endnotes) 1 National Association of County and City Health Officials. (2005). Operational Definition of a Functional Local Health Department. Washington, DC:. Available from http://www.naccho.org/topics/ infrastructure/operationaldefinition.cfm 2 National Association of County and City Health Officials. (2006). 2005 National Profile of Local Health Departments (page 2). Washington, DC:. 3 Available from http://depts.washington.edu/uwruca/index.html 4 National Association of County and City Health Officials. (2006). 2005 National Profile of Local Health Departments (page 32). Washington, DC:. 5 Association of State and Territorial Health Officials and National Association of County and City Health Officials. (2006). Final Recommendations for a Voluntary National Accreditation Program for State and Local Public Health Departments. Available from http://www.exploringaccreditation.org/doc/ EAFinalRecommendations10-27-06.pdf

Acknowledgments This report was authored by Carolyn J. Leep, who also served as study director for the 2005 National Profile of Local Health Departments study. Carol Brown (), Caren Clark (), Grace Gorenflo (), Anjum Hajat (University of North Carolina), Carol Moehrle (North Central [ID] Health District), and Julie Nelson Ingoglia () provided comments and editorial assistance with this report. gratefully acknowledges the financial support of the Centers for Disease Control and Prevention, which supported the 2005 National Profile of Local Health Departments study, and of the Health Resources and Services Administration s Office of Rural Health Policy, which provided funding and advice for the analysis of rural LHDs and the preparation of this report.

1100 17th Street, NW 2nd Floor Washington, DC 20036 (202) 783-5550 (202) 783-1583 Fax www.naccho.org