7 Community Public Health Practice

Public Health Functions and Practice

There have been always two main questions: what are the functions of public health, and how the practice of public health looks like [in the past and today’s]? As the content of this chapter develops, the questions will be answered in more detail, but in general, the functions of public health are, assessment, policy development and assurance. The practice is derived from these functions in what we know as the public health essential services. Has public health been always as it is today in the United States? The answer is no, public health has evolved over the years, and its evolution reflects how some programs have been expanded, and other better understood.

Public Health in America

In recent years, the advances made in public health has been divided in the progress made before the 1990s and after the 1990s, and the reason for this is the 1988 release of the Institute of Medicine (IOM, now, the National Academy of Medicine) document, Public Health in America, which among other things, provided a ‘mission statement’ and what is known as the ‘substance’ of public health.^[1]

Image of the original Public Health in America publication. Currently the Link to this picture is not available. The image above is from an old power point used by the author of this book. I am using the image as “Fair Use” of a public document.

In the original document the vision and mission were clearly stated. Although, other versions of the document state the mission of public health as, “…assuring conditions in which people can be healthy,” and the substance of public health as, “…organized community efforts aimed at the prevention of disease and the promotion of health.”^[2]

How public health looked like before 1990?

In terms of public health functions and practices, a key feature during these times included what is known as the “Basic Six” that were established before 1950, these are, vital statistics, sanitation, disease control, maternal and child health, health education and laboratory services. What does this mean? It means that most public health agencies should have these basic six as part of their public services and programs. The 1950 is used also as a crucial point in expanding the roles of public health, and it is after 1950 that the emphasis in quality control (known, as ‘optimal services’) became instituted. Other changes in the evolution of public health services and practices is the addition of more ‘optimal services’ in the 1960s and 1970s with an emphasis also in disease control.^[3]

How public health looked like after 1990?

In terms of public health functions and practices, based on the IOM Public Health in America report, the Core Functions of Public Health, the Essential Public Health Services are introduced. At the same time, accreditation of public health organizations also is required and as a big step in public health for those of us who are interested in community health, the community public  health practice standards became closely linked with accreditation.^[4]

The creation of the AGPALL and the presence of public health governance

In the middle of those two major events (before 1990 and after 1990), the formation and institution of the “Government Presence at the Local Level” (known also just as the AGPALL) appears. As the the previously mentioned Institute of Medicine (IOM-now, the National Academy of Medicine), Public Health in America report states: “The governmental public health agency has a vital function: to see to it that vital elements are in place and the mission is being adequately addressed.” In simple words, the core functions of public health and the essential public health services need to have a local presence in order for the national public health programs to work. Federal guidelines are useful only if they are implemented (and applied) at the local level in the community.^[5]

The Core functions of public health

As it has been mentioned previously, the Public Health in America IOM report clearly state the core functions of public health, these are: Assessment, Policy Development and Assurance. ^[6]These three elements are listed in the periphery of the following wheel that is commonly used to visualize/illustrate these concepts, see image below”

“Core Functions of Public Health” image, from CDC, Public Domain.

Core Public Health Functions in practice ^[7]
In the practice, these core functions can be expressed using the following questions:

• Assessment: What should be done? This refer to the ability to take decisions based on values.
• Policy development: What will be done? How it will be done? By taking decisions based on resources and priorities.
• Assurance: How can we best do it? Taking decisions based on evidence.More specifics will be developed later in the content of these chapter, but for now, the keywords in the above content are underlined and this has been done with the intention to put an emphasis of the words that reflect specific activities that are guided by the main core public health concepts.

The Essential Public Health Services (EPHS)

The Essential Public Health Services (EPHS) which are contained inside the wheel have the intention to list (and explain) how each one of the core functions of public health are accomplished. In other words, what type of activities need to be done at each step in the process. ^[8]See image below:

“The 10 Essential Public Health Services,” image, from Minnesota Dept. of Health, Public Domain.

A list of these services are also listed below – sometimes, the numbers help to remember.

Linking both of the concepts
To operationalize (or, to integrate) the concepts, the core functions of public health are linked with the EPHS.

The first of the core public health functions: Assessment

There are two EPHS (abbreviated above as Essential Service or ES) that need to be accomplished as part of the assessment: ES 1: Monitoring health status to identify community health problems, and ES 2, Diagnosing and investigating health problem and health hazards in the community.^[10],^[11]

The images follow show the components of each Essential Service, and the detailed example of activities as described in the table below:

ES1 – Monitor Health

Monitor Health, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

ES2 Diagnose and Investigate

Diagnose and Investigate, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

The second of the core public health functions: Policy Development

There are three EPHS (abbreviated above as Essential Service or ES) that need to be accomplished as part of the assessment: ES 3: Inform, educate, and empower people about health issues. SE 4: Mobilize community partnerships to identify and solve health problems. And, SE ›5: Develop policies and plans that support individual and community health efforts. The image below visualize the entire group of essential services under policy development.

Policy Development, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

To continue with the content, the images that follow show the above mentioned components for each Essential Service, and the detailed example of activities as described in the table below:

ES 3: Inform, educate, and empower people about health issues.

Inform, Educate, and Empower people about health issues, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

ES 4: Mobilizing community partnerships to identify and solve health problems

Mobilizing community partnerships to identify and solve health problems, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

ES 5: Developing policies and plans that support individual and community health

Developing policies and plans that support individual and community health, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

The third of the core public health functions: Assurance

There are four EPHS (abbreviated above as Essential Service or ES) that need to be accomplished as part of the assurance core function: ›ES6: Enforce laws and regulations that protect health and ensure safety.

Assurance of the public’s health services, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

ES 6: Enforce laws and regulations that protect health and ensure safety

Enforce laws and regulations that protect health and ensure safety, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

›ES 7: Link people to needed personal health services and assure the provision of health care when otherwise unavailable.

Link people to needed personal health services and assure the provision of health care when otherwise unavailable, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

ES 8: Assure a competent public health and personal health care workforce. 

Assure a competent public health and personal health care workforce, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

ES 9: Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

Evaluate effectiveness, accessibility, and quality of personal and population-based health services, Annotation (arrow above) added by Giovanni Antunez from “Core Functions of Public Health” image, from CDC, Public Domain.

Putting it all together
If we go back to where we started (look at the wheel in the image below):

1. The the core functions of public health are in the periphery of the wheel.
2. The Essential Public Health Services (EPHS) are contained inside the wheel.
3. And, finally, the center of the wheel is Research.

“The 10 Essential Public Health Services,” image, from Minnesota Dept. of Health, Public Domain.

Putting research at the center

Putting research at the center of of the wheel is a way to show and remind the public health practitioners that there is room for research in each of the components. For example, if we take Essential Service (ES) 1 Monitor Health, a research focused on the progress made by a well-baby clinic that had introduced a new health education program for parents to learn about nutrition for their babies, the ‘monitoring’ of the progress made in the first three months of the program, and then, six months later can be the center of the research effort.

The Community Health Needs Assessment, also known as the Community Needs Assessment – without the ‘Health’ word, is a process used to identify the needs of a community. It is a collaborative effort between the community health educator and other public health professionals that mobilizes the community to improve the health of its members. The assessment identifies the priorities, resources, and other elements necessary for achieving health improvement in the community. Examples can be found in websites from Local Health Departments and similar programs. ^[12]

How is a Community Health Needs Assessment (CHA) done?

First, ask yourself these questions: what do you want to know about your community? Who are they, where are they located, who lives there, what resources are available to the people who live there? And the questions continue until you decide when to stop asking more questions depending on your goals, and needs.

Secondly, it is customary to use a series of sources to conduct the assessment, the following are the most common sources of information used in this process:

1. The National Census: here you can find the general information about your community, including the demographics of your target population.
2. The county health information (for specifics about the community’s health issues and resources.
3. Chamber of Commerce (for collaboration with local businesses).
4. Educational information from the Education Dept. in the area.
5. Dept. of Labor (for the report on the jobs available in the targeted community.

Write a report to disseminate the results or, to plan further

Prepare a report in which you summarize your findings from the information that you had collected, from your review of sources of information mentioned before, and also from the meetings with the community leaders. The content of the report can be used to answer the questions that you made at the beginning of the process. Use the report to inform the planning of the next step, which is the Community Health Improvement Plan.

“Example of a community health assessment” image, from Tacoma-Pierce Health Dept., no license stated.

Example of the cover report of a “Community Health Improvement Plan” image, from the Healthy Williamson County, no license stated.

“The CHIP (Community Health Improvement) Model,” image fromThe Future of the Public’s Health in the 21st Century, Public Domain.

In addition, the following diagram presents the most commonly tasks when using the PACE-EH protocol^[15]:

“The 13 Tasks of PACE-EH,” image from EPA, Public Domain.

 

PACE EH has several benefits that are listed below:

PACE EH and MAPP

The following is an image presenting the major pieces [components] of the PACE-EH assessment model combined with another common model known as MAPP (Mobilizing for Action through Planning and Partnerships). ^[16]

“The PACE EH in combination with MAPP,” image, PPT – MAPP: What, When and; Why? PowerPoint Presentation, Slide Serve.

PACE-EH and C-FERST

The PACE-EH model can be also used with other more recent approach known as the Community-Focused Exposure and Risk Screening Tool (C-FERST). The Environmental Protection Agency – EPA CARE Program has been a key partner in developing C-FERST. Many EPA CARE communities that have received this type of grant have used the PACE-EH model (which has also a Guidebook)^[17], along with the CARE Roadmap and the CARE Resource Guide, to assist with community assessment. The main reason this is highly recommended is that the C-FERST provides certain tools and pieces of information that can help the program implementation team with the tasks recommended by the PACE-EH model. ^[18]

“Ten Steps to a Healthy Community Environment,” image from Plan Your Project with Community Guides and C-FERST, EPA, Public Domain.

When it comes to the most common community needs assessments and public health planning models, it is important to review MAPP and how it has evolved.

What MAPP is and how it was developed

The APEXPH model evolved into MAPP (Mobilizing for Action through Planning and Partnerships), which over the years has become a very popular approach for community planning and program implementation in public health practice. The following image summarizes the major components of this model:

“MAPP”, image from the Community Tool Box, University of Kansas, Public Domain.

“Mobilizing for Action through Planning and Partnership (MAPP),” image, Sullivan County Health Department, Public Domain.

When a comparison is made about the benefits (advantages) and disadvantages of MAPP compared with the original model, APEXH; the differences are clear that MAPP is an expanded version of its APEXH, making MAPP a highly used model for public health planning, implementation, and evaluation. See the differences below:

Key Takeaways

The preparation of a Community Health Improvement Plan (CHIP) involves the use of several frameworks and protocols. The most used ones are the Assessment Protocol for Excellence in Public Health (APEXPH), the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) – which is used to assist APEXPH when the analyzed issue is environmental – and the Action through Planning and Partnerships (MAPP). MAPP can either be used alone or added to APEXPH.

Putting it all Together

The three main pillars that guide the practice of public health in the United States are:

• Health Improvement Plan,
• Community Health Assessment, and
• The Agency Strategic Plan.

The Health Improvement Plan and Community Health Assessment have already been covered in the previous content of this chapter. The Agency’s Strategic Plan is the third pillar which helps to ensure an effective and coordinated response to public health challenges.

“The three pillars of public health,” Image prepared (modified from original image of the stool available elsewhere in the Internet, used as “Fair Use“) by Giovanni Antunez, Licensed CC BY 4.0

Strategic planning, community health assessment, and community health improvement plans

In this context, the last part of this chapter will cover the use of strategic planning and community health assessments leading to community health improvement plans by local and state public health departments, the use of these tools has increased considerably across the nation with the need (and interest) of public health accreditation (at the professional and local/state health departments. A NACCHO 2016 report states that the participation over time in a community health assessment (CHA), community health improvement plan (CHIP), and/or strategic plan (SP) within five years increased since 2010.  In 2016, more than three-quarters of LHDs had completed a CHA (78%), two-thirds had completed a CHIP (67%), and approximately half had completed an SP (53%) within the past five years. Just under half (44%) had completed all three processes within the past five years, a requirement for PHAB accreditation. ^[20]

In addition to the above-reported information, the level of collaboration between Local Health Departments (LHDs) and Nonprofit Hospitals on Community Health Assessments in, the United States, in 2016 also increased compared with previous years (or the baseline data used by the study/report. Below is an image representing these findings:

“Collaboration between Local Health Departments (LHDs) and Nonprofit Hospitals on Community Health Assessments,” Image from the National Association of County and City Health Officials (NACCHO) 2016).

In recent years, the level of collaboration between LHDs and other organizations including nonprofit hospitals has also increased with the increased access to health insurance in the U.S. population through the Affordable Care Act (also known as ‘Obama Care’); more information has been needed and the Local Health Departments (LDs) had this information that has been collected through the community health needs assessments and related tools/reports.

Strategic Planning

Also, with the need to increase efficiency at the Local Health Departments (LHDs), the use of the strategic planning has become a common practice, creating more and more need for training of how the strategic planning works, and what tools are available to do this. The most common tools used in the strategic planning process include: a) Identifying or, revisiting  (if these already exist) the institution’s or program’s Values, Mission, Vision, and Strategic Priorities; b) conducting a SWOT (Strengths, Weaknesses, Opportunities and Threats) of the institution/program and; c) Layout of a General Logic Model; and other relevant information available including the Community Health Needs Assessment written report. Many of these tools can be identified in a strategic report from the New York Health Department^[21] or, by searching online for other examples. Also, to visualize some of the steps of the strategic planning process, the following images are presented:

“The strategic planning process,” image from Wikimedia Commons, Licensed CC BY-SA 3.0

The image above captures most of the elements of the strategic planning process, especially the setting of a mission (the vision is not mentioned but it is implied), but pay attention that the word, ‘strategy’ is used. Additional element that is considered very useful to conduct before writing the strategic planning is the SWOT analysis, which is visually presented in the image below:

“SWOT analysis diagram,” image from image from Wikimedia Commons,Licensed CC BY-SA 2.5

The SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis can show the institution/organization/program where they are in the process by identifying especially their strengths, and opportunities if we look at the analysis positively. The following image shows in more detail (content) the SWOT process

“SWOT analysis,” image, from Flicker, Licensed CC BY-NC-ND 2.0

And the last part of the content here is the development of a logic model that outlines and shows how the above pieces of the strategic analysis articulate (or, interact) with each one of the components used in the process. See image below:

“Example of Logic Model for Hypertension,” image from CDC Logic model report p 6, Public Domain.

Public Health Department Accreditation

The concepts presented so far in this chapter, which include information about the 10 essential public health services and the core functions of public health, national standards, also on how to plan properly for public health practice using the strategic planning approach are important standards for all local health departments (state, tribal, local, and territorial). These standards can serve as a guide and measurement tool to assess their effectiveness in the state and local communities that they serve. In addition, these standards can be also used as the basis for a system of national accreditation, which helps to promote efficiency, accountability, and visibility among other things.^[22]

“Public Health Accreditation Seal,” image from The St. Mary’s County Health Department (SMCHD), Fair Use.

Accreditation history and benefits

Until recent years, there was no national accreditation program for public health departments but starting in September 2011, the Public Health Accreditation Board (PHAB) has recognized health departments that meet national standards which ensures the provision of the essential public health services in their communities. As today, several public service and health-related entities—such as hospitals, schools, and universities—have accreditation programs. What are the main benefits of institutional public health accreditation? According to a NORC (National Opinion Research Center) report at the University of Chicago, Illinois, U.S., Health departments agree that accreditation helps them to the following: ^[23],^[24]

• Stimulate quality improvement
• Improve accountability and transparency
• Improve the capacity of the department to provide high quality programs and services
• Strengthen the health department’s relationship with key partners in other sectors (e.g., healthcare, social services, education)
• Help the health department use health equity as a lens for identifying and addressing health priorities
• Increase the extent to which the health department uses evidence-based practices
• Strengthen the utilization of resources

“The benefits of Accreditation”, image from CEPH, used as Fair Use because no license is stated.

How the idea of Public Health Accreditation was Born

Accreditation came initially as a recommendation of the Academy of Medicine (known before as the Institute of Medicine-IOM) The Future of Public Health in the 21st Century report, which mentioned that local and state health departments seek accreditation to improve the quality of their services. The idea was supported also by the Centers for Disease and Prevention (CDC), the Robert Wood Johnson Foundation, and other directly related organizations including the American Public Health Association (APHA), the National Association of County Health Departments (NACCHO), and similar. As part of the initiative, the Public Health Accreditation Board (PHAB) was created as an independent non-profit organization that carries out the original recommendations. After years of work, the PHAB produced the standards needed for accreditation which requires that all public health agencies seeking accreditation must complete within the last five years, a strategic plan, a community health needs assessment (CHA), and the Community Health Improvement Plan (CHIP) before submitting an accreditation application. Once the application is submitted, the public health department needs to respond to a questionnaire that contains a series of questions in the 12 domains made up of the 10 Essential Public Health Services. Also, two additional domains are governance and administration and management.^[25],^[26]

What are the domains of public health agencies’ accreditation? The following are the main domains:

Some statistics reported in recent years have provided information about the number of public health agencies that have achieved accreditation – these numbers can. be found in several online resources but mainly on the Public Health Accreditation Board (PHAB) website. ^[28]

Chapter conclusion: the content in this chapter centered on the topic of Community Public Health Practice in the United States. The main topics covered include the history of public health in the United States, the core functions of public health, the ten (10) essentials of public health services, the development of community health assessments, community health improvement plans, strategic planning, and related tools, and also accreditation in the public health services agencies in the United States.