State Size and Government Level Matter Most: A Structural Equation Model of Local Health Department Policy Behaviors

Objective: To explore relationships between local health department policy behaviors, levels of government activity, policy focus areas, and selected health department characteristics. Design: Cross-sectional analysis of secondary data from the 2013 National Association of County & City Health Officials (NACCHO) Profile Survey. Setting: Local health departments throughout the United States. Participants: A total of 2000 local health departments responding to the 2013 Profile Survey of Local Health Departments. Survey data were gathered by the NACCHO. Methods: Secondary analysis of reported policy behaviors for the 2013 NACCHO Profile Survey. A structural equation model tested effects on and between state population size, rurality, census region and policy focus, and the latent variables of policy behavior formed from a confirmatory factor analysis. Main Outcome Measures: Policy behaviors, levels of government activity (local, state, and federal), policy focus areas, and selected local health department characteristics. Results: The majority (85.1%) of health departments reported at least one of the possible policy behaviors. State population size increased the probability of local policy behavior, and local behavior increased the probability of state policy behavior. State size increased the likelihood of federal policy behavior and the focus on tobacco, emergency preparedness, and obesity/chronic disease. However, the more rural a state was, the more likely policy behavior was at the state and federal levels and not at local levels. Specific policy behaviors mattered less than the level of government activity. Conclusions: Size of state and rurality of health departments influence the government level of policy behavior.