As noted in reports by the Institute of Medicine and others (1-3), as well as in a growing body of research (4,5), the US public health system is not adequately addressing current population health challenges. The September 11 attacks, anthrax dispersal, and Hurricane Katrina have focused attention on preparedness and bioterrorism issues, and substantial federal resources have flowed to state and local agencies to address gaps in personnel and programs. Although there is some evidence that these new dollars have increased capacity and performance across the board in the functioning of public health systems (6,7), others are concerned that existing resources at federal, state, and local levels have also been shifted to accommodate the current, urgent priority of preparedness (8).

Less visible public health challenges are the epidemics in chronic diseases, such as obesity and diabetes (9). Chronic diseases cause 70% of deaths in the United States and affect 90 million people (10). Yet chronic disease prevention and control in public health practice have been neglected, probably because of the historical roots of public health in addressing acute, infectious illnesses, the mechanisms of public health funding, and the possible perception that chronic diseases are not amenable to public health action (11). Limited evidence suggests that chronic disease programs and services in local public health lag behind the historically important issues of control of infectious diseases, including sexually transmitted diseases and tuberculosis; maternal and child health; and environmental health (12).

To improve the public health system's ability to prevent and control chronic diseases, it is necessary first to understand current practice and then to develop appropriate and valid strategies for measuring performance. Among the chronic diseases, diabetes is an optimal choice for studying the performance of governmental public health agencies in chronic disease prevention and control. The nation is facing an epidemic in type 2 diabetes and its related risk factor, obesity (9), and diabetes is widely recognized as a public and population health issue (13). Diabetes has also been a model for studying quality of care in the clinical setting, and well-accepted performance measures exist for the clinical setting (14) as well as evidence-based recommendations for both clinical and population services (15,16). Finally, public health funding and evaluation for diabetes programs through the Centers for Disease Control and Prevention (CDC) has a long history (17).

The objectives of our study were to measure capacity and performance in diabetes prevention and control in local health departments (LHDs) and to understand the characteristics of the LHD and the community that are associated with performance. The study was a collaboration among investigators at the University of North Carolina at Chapel Hill (UNC-Chapel Hill), the North Carolina Division of Public Health, Diabetes Prevention and Control Program (NC DPCP), and the North Carolina Association of Local Health Directors. North Carolina has a decentralized local public health system: the LHDs are overseen by local government and local boards of health and are independent of the state health department. A state health department grant program, Diabetes Today, provides funding to some LHDs, but otherwise LHDs receive no specific funding for public health activities related to diabetes.

The response rate was 100%. Forty-six LHDs received a second mailing of the survey, and 8 LHDs requested a third copy of the survey on follow-up telephone calls. Survey responses were obtained over the telephone at the request of the LHD in 3 instances. On average, 2.2 people were involved in completing each survey on behalf of the LHD. The most common respondents were nurses, followed by health educators, health directors, and nutritionists. Health directors directly participated in 25% of the responses.

The median number of FTEs per LHD was 80, and the median yearly expenditures were $4.81 million (Table 1). Slightly more than one-third (35%) of LHDs had received diabetes-specific funding through Diabetes Today, and only 3 (4%) had received funding through Project IDEAL. Only 19% had "chronic disease" or "diabetes" in their mission statement. Almost half the jurisdictions were urban, defined as containing a metropolitan statistical area within the jurisdiction, and nearly one-third had a population of more than 100,000.

Health departments reported limited capacity in diabetes: the median number of FTEs was 0.05 in prevention (interquartile range [IQR], 0-0.5), 0.1 in control (IQR 0-0.5), and 0.3 in prevention or control (IQR 0-1.0) (data not shown). Forty percent reported no FTEs devoted to diabetes prevention or control. In terms of specific provider types, only 16% reported having a certified diabetes educator on staff. The most common provider types reported by LHDs were nurses, followed by nutritionists, health educators, nurse practitioners or physician assistants, and physicians. Only 12% reported any physician FTEs devoted to diabetes prevention or control.

Self-reported performance varied widely across the essential services (Table 2). Most LHDs reported access to data on diabetes prevalence (87%) and risk factors (70%), and many reported monitoring changes in these prevalences. Other activities commonly reported by LHDs included providing information to the public and policy makers, using media to communicate diabetes health information, providing health education for people with diabetes, and screening for diabetes and prediabetes.

Other programs and services were reported less commonly. Only half had a coalition or committee that focuses on diabetes. Less than half reported assessing the extent to which primary care or diabetes education was available in their community, and only 11% reported conducting a recent diabetes-related public and personal workforce assessment. Other activities less commonly reported involved public policy; training for health care providers; modification of laws, regulations, or ordinances; research; and evaluation.

The mean score for all LHDs on the 10-point index of performance was 3.5 (SD = 1.9). Of the main characteristics of interest, only the history of diabetes-specific external funding (Diabetes Today or Project IDEAL) was associated with performance (Table 3). LHDs with a history of funding from Diabetes Today had a mean index of 4.1 compared with 3.2 for those without (P = .03). LHDs with a history of funding through Project IDEAL had a mean index of 6.7 compared with 3.4 for those without (P = .002). Measures of need (diabetes prevalence, presence of a community or migrant health center or free clinic, and physician-to-population ratio) were not associated with performance, nor were having "diabetes" or "chronic disease" in the mission statement. Population size of the jurisdiction and LHD size (measured by FTEs or expenditures) were also associated with performance. Health departments that had received accreditation were also more likely to have a high total performance score.

Multiple linear regression was used to investigate whether the observed association between Diabetes Today funding and the performance index was confounded by other factors. (All 3 LHDs with Project IDEAL funding had also received Diabetes Today funding). Complete data on FTEs and expenditures were not available (because of the item response rate of the Profile survey [12], the source for those variables), and therefore, these could not be used in the model as measures of health department size. Instead, we used population size of the county as a surrogate measure because this measure was highly correlated with FTEs (0.89). However, controlling for population size did not change the association between Diabetes Today funding and the performance index. We also assessed the following variables as potential confounders, and none had any effect on the relationship of Diabetes Today funding to the performance outcome: presence of any community or migrant health center or free clinic, physician-to-population ratio, rural or urban status, percentage of population below the poverty level, or diabetes prevalence.

This survey of North Carolina LHDs found that most have limited capacity to conduct or coordinate diabetes prevention or control programs in local communities. Self-report of some programs and services was high, particularly in areas such as surveillance, health education, and screening. However, we found limited performance in other areas such as assessing availability of health services or health education for people with diabetes or participating in public policy. One finding was that total performance of the LHD was not higher in areas of greater need (higher diabetes prevalence or lower capacity of the medical care delivery system). A history of diabetes-specific external funding was associated with LHD performance even when controlling for potential confounders such as LHD size.

This is the first study known to the authors to measure performance of LHDs in a chronic disease. Previous studies of LHDs have focused on measuring global performance (20,21,23), preparedness (29), or maternal and child health. Although global performance studies may be more germane for long-term performance measurement (30), this study provides a key insight into the lack of programs for an important chronic disease. More work is needed to measure LHD performance in other chronic disease areas, such as obesity, cardiovascular disease, and cancer prevention and control. In addition, a comprehensive, integrated assessment of prevention and control activities for all of the major chronic diseases would provide a fuller picture of how LHDs are able to address chronic disease than this study can provide.

This study and the survey itself do, however, provide an important example of how a state program (the NC DPCP) can measure LHD performance for evaluation and program improvement and measure the effect of its grants to LHDs. A similar instrument, developed by the Diabetes Council of the National Association of Chronic Disease Directors (31), exists for state programs to measure the performance of the state public health system. Although results must be interpreted cautiously, the data offer some evidence for the effectiveness of the funding and technical assistance that the NC DPCP provides to LHDs through the Diabetes Today program. A more comprehensive evaluation, including how the Diabetes Today model is implemented in different states, appears warranted. The data also point out areas where additional technical assistance is needed, for example, gaps noted between LHD programs and certain evidence-based practices such as screening or provision of diabetes education.

The findings that LHD size or population size and LHD funding affect performance are consistent with those of other studies (4,20,21). Unlike in studies of LHD performance in other areas of disease prevention and control, poverty rate (4) or type of jurisdiction (21) was not related to performance. This finding may be due to the sample size, the range of variation in these variables in the state examined, or features unique to the development of diabetes programs. One finding was that need of the jurisdiction was not associated with LHD performance, and this attempt to examine the association is rare in public health performance literature.

This study represents a snapshot of all possible types of diabetes-related programs and services, not necessarily those that are most important to local public health practice. The index itself is weighted to represent each essential service equally, which may also not be appropriate. Key informants and stakeholders should be interviewed to refine the instrument by identifying which items are the priorities for LHDs.