Examining the Priorities of Local Health Departments in California: A Mixed Methods Study

Objective: Prioritization is an essential task of local health departments (LHDs). We examined the alignment of priorities reported in Community Health Needs Assessments (CHNA) priorities align with priorities in the Community Health Improvement Plans (CHIP). We report factors that influence the choice of priorities and the alignment of the priorities.

Design: A mixed method study design.

Setting: California.

Participants: CHNA and CHIP documents were sought for all 58 counties. Interviews were conducted with 19 state and local public health officials.

Outcome measures: The priorities in the CHNA and the CHIP were coded as i) only in the CHNA, ii) only in the CHIP, or iii) in both the CHNA and the CHIP. The interviewees were asked to share their experiences related to issue prioritization and decision-making in public health agencies. The interviews were coded and thematically analyzed to identify barriers and facilitators of the prioritization process.

Results: The alignment between the needs prioritized in CHNA and the priorities targeted in CHIP was 35%. The interviews identify reasons for the misalignment, including a need to include priorities in the CHNA even though LHDs are not able to address them, political factors that influence the selection of priorities, and a lack of discretionary funding or capacity/expertise within the agency or its community partners to respond to the needs identified. The lack of discretionary funding was particularly acute for smaller (rural) LHDs (CMSP) and resulted in their often having to focus on priorities where there was state or federal funding.

Conclusions: LHDs face numerous challenges in aligning the priorities reported in the CHNA and the priorities they focus upon in the CHIP. LHDs should consider using a formal, transparent, and evidence-based approach to setting aligning. Future research should focus on developing a formal decision-making process that is appropriate for local public health decision-making.