DOI: 10.3886/icpsr38307.v1
title: Forces of Change Survey, United States, 2018
title: Version 1

description: The National Association of County and City Health Officials' (NACCHO) Forces of Change Survey is an evolution of NACCHO's Job Losses and Program Cuts Surveys (also known as the Economic Surveillance Surveys) which measured the impact of the economic recession on local health departments' (LHD) budgets, staff, and programs. The Forces of Change Survey continues to measure changes in LHD budgets, staff, and programs and assess more broadly the impact of forces affecting change in local health departments, such as health reform and accreditation. The 2018 Forces of Change survey was distributed to a stratified random sample of 966 LHDs in the United States.
The survey included six topics: (1) Budget Cuts and Job Losses, (2) Response to Opioid Use and Abuse, (3) Population Health Activities, (4) Influenza Preparedness and Response, (5) Informatics Capacity, and (6) Environmental Health Activities.
description: For the 2018 Forces of Change Survey, NACCHO surveyed LHDs to assess the impact of the changing environment on their budgets, workforce, and activities.
description: NACCHO administered the questionnaire using Qualtrics, an online survey administration tool. On March 21, 2018, the designated primary contact of every local health department (LHD) in the sample received an invitation via email from NACCHO's president to participate in the survey. After the initial invitation, the potential participants received up to five reminder e-mails. Additionally, NACCHO made reminder calls to people who had yet to complete the survey, targeting states with low response rates. Some state associations of county and city health officials (SACCHOs) assisted by encouraging their members to take part in the survey.
NACCHO generated national statistics using estimation weights to account for sampling and non-response. All data were self-reported; NACCHO did not independently verify the data provided by LHDs. A detailed description of survey methodology is available on NACCHO's Forces of Change webpage.
description: The 2018 Forces of Change Survey contains variables grouped according to several themes:
<b>Budget Cuts and Job Losses</b>
LHDs have eliminated a total of 56,360 jobs over the past decade, reporting an estimated 800 jobs lost in 2017. This is the lowest reported estimate since 2008. In addition, 2017 saw a net gain of 170 job positions within LHDs--driven by large LHDs; small and medium LHDs continued to experience net job losses. This evidence indicates that LHDs continued to show signs of recovery from staffing and budget cuts due to the Great Recession. However, 19% of LHDs expect future budget cuts.
<b>Response to Opioid Use and Abuse</b>
Approximately two-thirds of LHDs reported conducting activities to address the opioid crisis in 2017. To do so, LHDs partnered with local/state government agencies and healthcare organizations. Regardless of population size served, the major barrier to conducting opioid-related activities was a lack of dedicated funding. Combating the opioid epidemic to ensure resilient communities requires an integrated public health effort.
<b>Population Health Activities</b>
As the health of a community is impacted by people's access to resources, LHDs are increasingly working in population health. In 2017, nearly 75% of LHDs conducted activities to address food insecurity. Regardless of topic area, most LHDs reported partnering with local/state government agencies and non-profits to conduct population health activities. Uniquely positioned as the face of public health, LHDs must be a partner and leader in population health work.
<b>Influenza Preparedness and Response</b>
The 2017-2018 influenza (flu) season was particularly bad, and LHDs addressed this risk by focusing on disseminating information to the public through outreach/education and communications activities. In addition, 59% of LHDs participated in immunization-focused partnerships as leaders or conveners.
<b>Informatics Capacity</b>
Informatics enables communication among providers to streamline healthcare systems. More than half of LHDs had access to data from an electronic syndromic surveillance (ESS) system that uses hospital emergency department
data. In addition, LHDs use these ESS systems to detect influenza-like and food-borne illnesses.
<b>Environmental Health (EH) Activities</b>
LHDs reported service reductions in emergency preparedness. In addition, fewer LHDs addressed many EH issues impacted by climate change in 2017 than in 2012. Local EH work protects the public against a wide range of threats that can be worsened by climate change.
description: Unless otherwise stated, national statistics presented were computed using appropriate estimation weights. NACCHO developed estimation weights for the items to account for dissimilar non-response by size of population served and state. Two weights were generated for the analysis: proportional weights (<strong>PWEIGHT</strong>) and scale weights (<strong>SWEIGHT</strong>). Proportional weights for each stratum were calculated by dividing the proportion of LHDs in that stratum among the full study sample by the proportion of LHDs in that stratum among all survey respondents. Scale weights were generated by dividing the number of LHDs in a stratum in the full study sample by the number of LHDs in that stratum that responded to the survey. Scale weights are used for estimating population totals. Either proportional weights or scale weights can be used for generating descriptive statistics such as proportion, mean, and median. Item-specific weights were generated for variables related to staffing reduction, staffing gains, and staff working on opioid activities to account for item nonresponse to better estimate their overall numbers.
description: Response Rates: 591 LHDs completed the survey for a response rate of 61%.
description: NACCHO used a stratified random sampling design for the 2018 Forces of Change survey. A representative sample was used instead of a complete census design to minimize survey burden on LHDs while enabling the calculation of both national- and state-level estimates. LHDs were stratified by two variables: size of the population served and state. For stratification by size of population served, three categories were used: LHDs serving less than 50,000 people, LHDS serving population of 50,000-499,999 people, and LHDs serving population of 500,000 or more people. Because LHDs serving 500,000 or more people represent a relatively small portion of all LHDs, these LHDs were oversampled to ensure enough responses for the analysis. Two states (Hawaii and Rhode Island) were excluded from the study because their states had no agencies that meet the Profile and Forces of Change studies' definition of an LHD.
Additionally, some states did not have any LHDs in a population size category, resulting in a total of 121 strata. The sampling plan was designed to select a minimum of 33 percent of the LHDs in a given stratum and at least two LHDs per stratum whenever possible.
Once the sampling plan was finalized, NACCHO drew a random sample of the specified size from within each stratum. In some centralized states, two or more LHDs had the same person listed as the contact person. To minimize response burden, no more than two LHDs with the same contact person were kept in the sample. However, contacts in Alabama, Oklahoma, and Vermont received three or more surveys each because additional contacts in their state were not available. When LHDs with a common contact person were dropped from sample, or when contact information was not available, a replacement was drawn. Overall, a sample of 966 LHDs was selected.
description: Datasets: 
DS0: Study-Level Files
DS1: Public-Use Dataset
DS2: Restricted-Use Dataset
description: Local health departments (LHD) in 48 states and the District of Columbia. Hawaii and Rhode Island were excluded from the survey because they had no local health departments.
description: web-based surveyAdditional information about this study is available on the Forces of Change website.Additional Forces of Change studies related to this collection are available as ICPSR 37103 (2017 Restricted-Use Level 1) and ICPSR 37141 (2017 Restricted-Use Level 2).