Avoiding Unintended Consequences in Public Health: Ensuring that PHAB Accreditation Reduces Health Disparities Between Public Health Jurisdictions
It is vital to ensure that PHAB accreditation is accomplished in a way that maximizes its impact on health equity and does not systematically leave out jurisdictions.
In our article titled, “An Analysis of How Characteristics of Local Health Department Jurisdictions Influence Involvement in PHAB Accreditation: Implications for Health Equity,” my colleague, Ashlyn Lipnicky and I set out to explore how variations in local health departments’ (LHDs’) involvement with PHAB accreditation might impact health equity. As someone who studied public health accreditation from an academic standpoint and went through the rigors of working towards PHAB accreditation, I know firsthand how it can help health departments build capacity and refocus on health equity. But public health is rife with well-meaning and effective interventions that exacerbated health inequities anyway. Our worry was that PHAB accreditation could improve health equity within jurisdictions and exacerbate health inequities between jurisdictions if LHDs serving whiter, wealthier, and healthier populations were more likely to pursue accreditation.
To examine this question, we linked data from the National Association of County and City Health Officials’ (NACCHO’s) 2016 National Profile of LHDs Survey with data from the American Community Survey, National Center for Health Statistics, Behavioral Risk Factor Surveillance System, and 2016 presidential election. We analyzed how variables related to socioeconomic position, demographics, population health status, political ideology, and LHD characteristics influenced involvement in PHAB accreditation.
WHAT DID WE FIND?
We found both positive indications for how PHAB accreditation was rolling out, as well as potential concerns worth further examination and strategic action. Our findings were quite complex, and much appreciation goes to the editors and peer reviewers of the Journal of Public Health Management and Practice that pushed us to use a nuanced lens in how we interpreted the results.
We found both positive indications and potential concerns with regard to the socioeconomic position of LHD jurisdictions. The poverty rate and income inequality had little impact on LHDs’ involvement with PHAB accreditation. However, LHDs serving jurisdictions with higher median household income were slightly more likely to be formally engaged with PHAB accreditation, and much more likely to plan to apply. This suggests that poorer communities may not benefit as much from PHAB accredited LHDs as their wealthier counterparts. Left unchecked, this could exacerbate health disparities between the rich and poor.
Race and Ethnicity
Again, we found positive indications and potential concerns with regard to the racial and ethnic makeup of LHD jurisdictions. Overall, the results were positive. Our crude analysis showed that more diverse jurisdictions were much more likely to be formally engaged with PHAB accreditation and more likely to plan to apply in the future. This is important because eliminating disparities in jurisdictions with the largest Black, Indigenous, and People of Color populations would make the greatest improvement for health equity nationally. However, after controlling for other factors, we found that jurisdictions with larger African American populations were actually less likely to be formally engaged with PHAB accreditation and less likely to plan to apply in the future. This suggests that jurisdictions with a larger African American population that are served by a more typical health department may not benefit as much from PHAB accreditation. Overall, these findings are generally optimistic and should have a positive impact on racial health equity. But there are concerns about how variations in PHAB accreditation may impact African American communities served by more typical LHDs.
Population Health Status
We found mostly positive indications related to population health status. LHDs serving less healthy jurisdictions were either as likely or more likely to be involved with PHAB accreditation, compared to their healthier peers. We only included the obesity rate in our adjusted analysis, due to statistical procedures. But here, we found that jurisdictions with higher obesity rates were dramatically more likely to be involved with PHAB accreditation. These findings are very positive and show that health departments serving sicker populations are working diligently towards improving their capacity and performance through PHAB accreditation.
We originally viewed political ideology as a potential confounder. However, the findings here are worth mentioning because they have implications for gaining buy in from elected officials that may need to approve LHDs’ pursuit of PHAB accreditation. LHDs serving more conservative jurisdictions (as measured by the percent that voted for Donald Trump in the 2016 presidential election) were much less likely to be involved in PHAB accreditation. Like most public health issues, the pursuit of PHAB accreditation has political implications.
HOW CAN WE ENSURE THAT PHAB ACCREDITATION REDUCES HEALTH DISPARITIES BETWEEN PUBLIC HEALTH JURISDICTIONS?
PHAB accreditation is an important milestone in public health. Some studies have already shown how it improves the performance of LHDs, which should improve population health outcomes. Nevertheless, it is vital to ensure that PHAB accreditation is accomplished in a way that maximizes its impact on health equity and does not systematically leave out jurisdictions. The implications of our findings are many and include:
- Monitoring PHAB Accreditation: This study shows that external data sources can be linked to NACCHO’s Profile of LHD’s Survey to monitor health equity implications of PHAB accreditation. This should be repeated with each iteration of NACCHO’s Profile as a method of quality improvement.
- Assisting LHDs with PHAB Accreditation: National and state organizations should develop funding mechanism and technical assistance to improve the uptake of PHAB accreditation in jurisdictions less likely to be involved. This includes small jurisdictions, jurisdictions with a lower median household income, and diverse jurisdictions served by more typical health departments.
- Political Acumen: The pursuit of PHAB accreditation appears to be another public health issue where leaders need good political acumen. Public health leaders may need training and resources to sell PHAB accreditation to politicians from different political backgrounds. Liberal leaning politicians may be persuaded more by focusing on social justice and the public good, while conservative leaning politicians may be persuaded more by focusing on improving the efficiency and accountability of the LHD.
To learn more, read our research report, “An Analysis of How Characteristics of Local Health Department Jurisdictions Influence Involvement in PHAB Accreditation: Implications for Health Equity” in the September/October issue of the JPHMP, focused on local public health agencies.
- Public Health Agencies’ Level of Engagement in and Perceived Barriers to PHAB National Voluntary Accreditation
- Benefits and Perceptions of Public Health Accreditation Among Health Departments Not Yet Applying
- Changes in Local Public Health System Performance Before and After Attainment of National Accreditation Standards
- Dr. Kevin A. Kovach is an epidemiologist and public health professional. He is the Senior Manager of the American Academy of Family Physicians’ Department of Population and Community Health. Prior to this, he worked in local and state public health for almost 15 years. Dr. Kovach’s work focuses on health equity, social determinants of health, interdisciplinary collaboration, mixed-methods research, implementation science, and capacity building.
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