Assessing variation in personal health service delivery and workplace smoking ban enforcement by local health departments

Thesis (Ph.D.)--University of Washington, 2016-08

Local Health Department (LHD) services play a crucial role in driving community health outcomes. However, LHDs face critical decisions, in times of budget and staffing shortfalls, around how essential public health services should be delivered. This dissertation describes variation in how LHDs are delivering services, and how other safety net providers, such as Federally-Qualified Health Centers (FQHCs), may be allowing LHDs to move their service portfolio away from clinical services and towards population-focused activities that they are uniquely suited to provide in their communities. This dissertation examines: 1) if higher volume of services provided by FQHCs was associated with discontinuation or absence of LHD clinical services; 2) if variation in FQHC and LHD service delivery was associated with differences in individual health access outcomes; and 3) whether variation in LHD enforcement of the Washington State Clean Indoor Air Act was associated with conditions which could be attributable to workplace smoking exposure. In the first paper of this dissertation, I found that LHDs are less likely to provide certain clinical services where FQHCs provide a greater volume of services, suggesting a substitution effect. However, there are clinical services, such as prenatal care, where the effect was not seen, that may complement a public health mission – and LHDs may be strategically placed to continue delivering these services. In the second paper, I observed a significantly higher likelihood of individuals reporting more positive health access outcomes where FQHC primary care service volumes were high, which suggests that intensive allocation of FQHC resources in a community is associated with improved health care access. In the third paper, I found that half of Washington State LHDs, mainly in rural jurisdictions, are not conducting state-mandated enforcement efforts. The presence of enforcement activities shows directional, but not statistically significant associations with lower WEA prevalence among individuals in a jurisdiction. As both inspection and violations exhibit similar effect magnitude, this suggests that responding to violations may be a cost-effective enforcement strategy. This dissertation examines how LHD service provision decisions are linked to partners in their community, and drive health and health care access. It offers guidance for LHDs in transforming their portfolio of activities so they can provide effective, population-focused services.