Environmental Factors and Quality Improvement
in County and Local Health Departments
Valerie A. Yeager, DrPH; Nir Menachemi, PhD, MPH; Peter M. Ginter, PhD; Bisakha P. Sen, PhD;
Grant T. Savage, PhD; Leslie M. Beitsch, MD, JD
Objective: On the basis of resource dependency theory and the
uncertainty principle, this study examines the relationship
between the local public health market environment and the use
of quality improvement (QI) strategies in local health
departments. Design: This cross-sectional study uses secondary
data from the 2008 National Association of County & City Health
Officials profile study, the Health Resources and Services
Administration’s Area Resource File, and the County Health
Rankings 2010 data set. Setting and Participants: US local
health departments. Main Outcome Measures: Seven binary
dependent variables that represented the use of QI processes or
QI training within local health departments were used. Eight
independent variables were identified and operationalized to
measure the constructs of munificence, dynamism, and
complexity for the local public health market environment.
Bivariate and multivariate regression analyses were used.
Results: Two of the 3 munificence variables were positively
associated with QI, as predicted. These included percentage of
zip codes with healthy food outlets (β =+.016, P < .05) and
the number of primary care physicians per capita (β =+1.327,
P < .05). Two of the 3 measures of complexity were, as
predicted, negatively associated with indicators of QI. These
included smoking prevalence (β =−.118, P < .05) and obesity
rates (β =−.081, P < .10). With respect to dynamism, 1
variable (change in population size over a 5-year period) was
unexpectedly, positively related to QI (β =+.118, P < .10 and
β =+0.235, P < .05). Conclusions: Overall findings provide
moderate support for the use of resource dependency theory and
the uncertainty perspective to understand the influence of the
external environment on QI within the local public health setting.
J Public Health Management Practice, 2013, 00(00), 1–10
Copyright
C
2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Future research should examine other ways of operationalizing
these environmental constructs to examine the relationship
between the environment and other elements of public health
practice.
KEY WORDS: environment, local health department, public
health, quality improvement, resource dependency theory
Public health has faced numerous pressures in the
last 2 decades, including the call for increased account-
ability and improved efficiencies in the public health
system.
1
One strategy to continually improve organi-
zational performance is to implement formal quality
improvement (QI) activities.
2
Public health QI has re-
cently gained momentum through a growing trend to-
ward public health accreditation initiatives.
3-5
At the
state level, surveys indicate that 76.5% of state health
departments are performing QI, although it is only be-
ing used throughout the entire health department in
7.8% of states.
6
At the county and local levels, findings
suggest that just over half of local health departments
(LHDs) are using formal QI in some ways.
7
Although
QI remains underutilized, there is an increased need
and demand on public health agencies to pursue QI
strategies.
7-10
Author Affiliations: School of Public Health and Tropical Medicine, Tulane
University, New Orleans, Louisiana (Dr Yeager); School of Public Health
(Dr Menachemi, Ginter, and Sen) and School of Business (Dr Savage), University
of Alabama at Birmingham, Birmingham; and College of Medicine, Florida State
University, Tallahassee (Dr Beitsch).
No acknowledgements or funding to report.
The authors declare no conflicts of interest.
Correspondence: Valerie A. Yeager, DrPH, School of Public Health and Trop-
ical Medicine, Tulane University, 1440 Canal St, Suite 1900, New Orleans, LA
70112 (vayeager@tulane.edu).
DOI: 10.1097/PHH.0b013e31825f74b2
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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