Local health departments (LHD) provide a range of public health programs and services that includes environmental health (EH) as a recognized foundational area that seeks to ensure and promote a safe and healthful environment (Leider et al., 2015). LHDs most commonly provide EH services associated with food safety, vector control, and drinking water quality, as well as regulating and licensing facilities such as restaurants, schools, daycares, and swimming pools (NACCHO, 2013). EH programs provide these services with the intention of preventing environment-related diseases, a category that includes enteric diseases such as giardiasis and salmonellosis (Salvato, 1992; Newbold, McKeary, Hart & Hall, 2008; Wohlgenant, Fraser, Chapman & Chen, 2014).

LHD EH program responsibilities span beyond the performance of routine regulatory and inspection services with activities such as conducting surveillance, education, and developing policy. The 10 Essential Environmental Public Health Services (EEPHS) represent these broader responsibilities by describing necessary actions for protecting and improving EH (CDC, 2014). The Environmental Public Health Performance Standards (EnvPHPS) provide a self-assessment framework that EH programs, or systems that include partner agencies, can use to examine their performance of the 10 EEPHS. The EEPHS and EnvPHPS were adapted from the 10 Essential Public Health Services and National Public Health Performance Standards to specifically address EH program performance (Sarisky, 2008; Gerding & Price, 2012; Gerding et al., 2016).

The 10 Essential Public Health Services and National Public Health Performance Standards were catalysts for research efforts that examined relationships between public health department performance, health department structural capacity, and population health outcomes (Scutchfield, Knight, Kelly, Bhandari & Vasilescu, 2004; Bhandari, Scutchfield, Charnigo, Riddell & Mays, 2010; Ingram, Scutchfield, Charnigo & Riddell, 2012). The constructs of structure, process, and outcomes are derived from Donabedian’s quality assurance model (Donabedian, 2003). Conceptual models for public health performance research drew from this model to describe connections between health department structural capacity and organizational characteristics, processes described by the performance of the essential services, and outcomes regarding effectiveness, efficiency, and equity (Handler, Issel & Turnock, 2001; Kennedy, 2003). The availability of the 10 EEPHS and EnvPHPS presented an opportunity to engage in similar research specific to EH.

This cross-sectional study included EnvPHPS performance self-assessment results representing all 67 Florida county health department EH programs. However, two EH programs conducted a joint assessment resulting in 66 total observations. The EH programs completed their self-assessments between the years 2011 and 2014. The EnvPHPS Version 2.0 document describes the 10 EEPHS, provides standards for each essential service, and contains a total of 64 scaled measures organized by the EEPHS (see Table 1 for a list of the 10 EEPHS). The performance measures allow five possible responses including no activity (0%), minimal (>0 – 25%), moderate (>25 – 50%), significant (>50 – 75%), and optimal activity levels (>75 – 100%) (CDC, 2014). The number of staff participating in the self-assessments varied, some assessments included representatives from other health department programs or agencies. During the self-assessment process, EH program employees and representatives contributing to the assessment discussed and considered a response for each measure. Following the self-assessments, responses were recorded and entered into a tool that calculated an overall composite result as a percentage of fully performing the EEPHS (CDC, n.d.). The FDOH provided electronic copies of each EH program’s completed tool containing self-assessment results.

The FDOH supports and maintains the Community Health Assessment Resource Tool Set (CHARTS), which is an online and publicly available resource providing access to data regarding community health status, population and social characteristics, and health indicators to inform health improvement activities. The system also provides a range of disease rates based on state mandated reporting of notifiable diseases (Charts, 2016). CHARTS was accessed to download county-level enteric disease rates per 100,000 population, corresponding to the year each EH program conducted their self-assessment. The most prevalent enteric diseases were selected, which included campylobacteriosis, cryptosporidiosis, giardiasis, salmonellosis, and shigellosis.

Previous public health performance, systems, and services research included a variety of organizational characteristic variables considered to potentially impact performance (Scutchfield et al. 2004; Bhandari et al. 2010; Meyer, Davis & Mays, 2012). Additionally, increased food safety program organizational capacity regarding staff size, experience, and budgets has shown association with decreased incidence of foodborne illness (Zablotsky Kufel et al., 2011). The study included organizational characteristics, related to those used in previous research, as potential confounding variables. The selected organizational characteristics were important because of their potential relationship with EH program performance. The FDOH provided information about EH program organizational characteristics including budgets, the number of full-time equivalents (FTE), and the number of various EH services rendered between June 1, 2014, and May 30, 2015. These data were used to calculate budget per capita, along with FTE and volume of services per 100,000 population. The volume of services variable represented an aggregate number of food, drinking water, and pool inspections and complaint responses conducted within the one-year period. County-level figures for population per square mile and percent living in poverty were obtained from the U.S. Census American Fact Finder and included in the dataset to represent the populations served by the EH programs (American Fact Finder, n.d.).

EH program performance self-assessment results, enteric disease rates, and organizational characteristics were combined in a spreadsheet and organized by county. Disease rates and organizational characteristic values were averaged for the two programs that completed a joint assessment. There were three missing values for EH program full-time equivalents and budgets variables, representing less than five percent of all values. Two EH programs did not report the year when they conducted the self-assessment. Those EH programs were paired with 2014 enteric disease rates considering most self-assessments were carried out during that year. Three EH programs shared a budget and reported the same total amount. The value was divided into thirds, and those values were included in the dataset for each of the programs.

Correlation analysis revealed statistically significant association between two EEPHS and cryptosporidiosis and salmonellosis, although the correlations were weak. Regression analysis with organizational characteristics as independent variables and potential confounders showed statistically significant associations between one EEPHS and cryptosporidiosis and salmonellosis. All IRR values for EEPHS variables were relatively close to 1.00, which indicated minimal potential for those independent variables to change disease incidence. However, there was an indication that improved performance of certain EEPHS may have changed enteric disease incidence. Considering these results, FDOH EH programs might benefit from improving their performance of EEPHS 2 diagnose and EEPHS 4 mobilize to address cryptosporidiosis and salmonellosis, respectively. These results may present implications for EH practice and policy by encouraging closer consideration of performance and its impact on health outcomes.

Correlation analyses showed a significant association between cryptosporidiosis, primarily a waterborne illness, and EEPHS 2 that reflects surveillance and investigation activities. Regression analysis indicated that increases in the performance of this EEPHS may have decreased cryptosporidiosis incidence in the presence of organizational characteristics. EH programs with stronger surveillance and investigation of waterborne diseases, namely cryptosporidiosis, could potentially impact the incidence of this disease. FDOH EH programs are responsible for public swimming pool inspections and permitting, and may benefit from a closer examination of improved performance and its impact on prevention of cryptosporidiosis. FDOH EH programs share services related to drinking water safety with the Florida Department of Environmental Protection. It may be beneficial to maintain strong collaboration among the two agencies to increase surveillance and investigation efforts to prevent cryptosporidiosis and other waterborne diseases.

Correlation analysis results also indicated statistically significant relationships between salmonellosis and EEPHS 4 about mobilizing partnerships along with EEPHS 6 addressing enforcement of laws and regulations. Regression analysis showed a potential for increased performance of both EEPHS to decrease the incidence of salmonellosis, although only the association with EEPHS 4 was statistically significant. As a common foodborne illness, the prevalence of this disease can be impacted by legislation and regulatory inspections of food service establishments (Patel et al., 2010). FDOH EH programs enforce regulations through routine inspections of facilities such as institutional food establishments and other types including daycares, while another state agency has regulatory responsibility for inspecting restaurants and commercial food operations. Partnership building among agencies with a stake in food safety may prove especially important given the statistically significant relationship between EEPHS 4 concerning the mobilization of community partnerships and salmonellosis rates.

Organizational characteristics likely confounded the relationships between performance and enteric disease rates; however, the relationships among these variables are likely impacted by many extraneous variables beyond the scope of the EH programs’ missions, services, and the organizational characteristics addressed by this study. For example, a conceptual model for public health performance identified macro context including socioeconomic and political factors that can impact a public health system (Handler et al. 2001). Assessing performance of individual EH programmatic areas such as food safety and incidence of diseases originating from an identified source may strengthen the ability to control for the many possible confounding factors impacting enteric disease rates. For example, Zablotsky Kufel et al. (2011) examined local food safety program capacity and its impact on foodborne illness, using data derived from foodborne disease outbreak reporting and surveillance systems.

Performance improvement is a priority for public health and is encouraged by the relatively recent release of the Public Health Accreditation Board’s national voluntary accreditation process for health departments (Scutchfield et al., 2009; Riley, Bender & Lownik, 2012; Chen et al., 2015). Public health departments and EH programs have used self-assessment results to inform the implementation performance improvement efforts using methods, such as the Plan-Do-Check-Act process, with intentions of addressing identified gaps in performance (Dilley, Bekemeier, Harris, 2012; Gerding & Price, 2012; Gerding et al., 2016). As a component of these improvement activities or a standalone effort, FDOH EH programs might benefit from evaluating performance improvement efforts by considering impacts to prevailing community concerns and important health outcomes specific to their respective counties.

Assessing EH program impact with health outcomes and environmental indicators versus process-oriented measures is inherently difficult. A study of local EH programs in California illustrated the tendency to use process measures, customer satisfaction, and absence of complaints as common measures of success (Dyjack, Case, Marlow, Soret & Montgomery, 2007). Identifying and tracking environmental indicators ranging from contaminants and health impacts is critical for surveillance and generating data to inform EH practice (Malecki, Resnick & Burke, 2008). FDOH EH programs may consider the use of environmental indicators concerning health hazards, issues, and exposures as effective outcomes for measuring the impact of EH program performance in addressing community health needs. The Florida CHARTS system provides access to data on various health outcomes and EH indicators such as air quality and unsatisfactory inspection results (CHARTS, 2016). FDOH EH programs have the opportunity to leverage CHARTS to obtain data and incorporate various indicators into performance improvement activities. Additionally, community EH assessments could supply relevant data or identify indicators for performance improvement and identification of service delivery needs. For example, frameworks such as the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) support efforts to identify factors adversely impacting health and the environment. FDOH EH programs have successfully implemented PACE EH to determine and address community-based environmental health issues (Hubbard, 2006; Harduar-Morano, Price, Parker & Blackmore, 2008).

EH programs sometimes factor community need into decisions about the delivery of services and activities (Dyjack, Case, Marlow, Soret & Montgomery, 2007; Resnick et al., 2009). The Florida public health system is classified as having a shared governance structure that facilitates coordination of operations, activities, and resources between the state level department of health and county health departments. This situation may contribute to consistency in EH program services delivered across the state; however, each county potentially faces different community health challenges or issues creating specific service needs. At a national level, this is likely the case for all county health departments and their EH programs, and there may be value in understanding the criteria used to determine priorities and inform decision-making about service delivery. Enteric disease rates may be one of those factors, yet EH programs routinely respond to broader issues that involve community-based concerns, environmental hazards, and exposures that might relate more closely to performance.

The EH services delivery system is complex and consists of multiple agencies and organizations (IOM, 1988; NEHA, 1993; Resnick, Zablotsky, Janus, Maggy & Burke, 2009). In most communities, agencies other than county health department EH programs also provide services with the intention of promoting healthy environments and preventing environment-related disease. Identifying partner organizations and understanding their contributions to the public health system is recognized as an important factor for public health services and systems research (Thomas, Corso & Monroe, 2015). EH programs in Florida share some responsibilities for food safety and drinking water quality services with other governmental agencies. Several of the FDOH EH program self-assessments included representatives from health department programs other than EH and partner agencies within their communities. Whereas this could have affected assessment results, it may be a major consideration to include partners when examining EH program performance and its impact on environment-related disease.

The results of this study indicated that county health departments’ environmental health program performance of certain EEPHS may be associated with environment-related disease rates and could potentially impact the incidence of select enteric diseases. The EnvPHPS provide a framework for conducting performance self-assessments that might produce important results for planning and implementing performance improvement efforts to address environment-related diseases. Specifically, consideration may be given to improving the performance of EEPHS 2 diagnose and EEPHS 4 mobilize with intentions of addressing the incidence of cryptosporidiosis and salmonellosis. Continued efforts to assess EH program performance and its impact on environment-related disease could reveal critical information to increase the efficiency and effectiveness of the EH services delivery system.

This study used a unique approach to examining relationships between EH program performance and environment-related disease. It produced results that contributed to the current understanding of EH program performance and could provide information for FDOH EH programs engaging in performance improvement efforts. The identified associations between performance of certain EEPHS and enteric disease rates, along with the potential to decrease disease incidence, may provide support for continued performance assessment and improvement efforts. FDOH EH programs might consider closely examining their performance of EEPHS 2 regarding surveillance and investigation activities and EEPHS 4 mobilizing partnerships and the potential to impact the incidence of enteric diseases, particularly cryptosporidiosis and salmonellosis.

The methodology employed may serve as a framework for other studies intended to examine EH program performance and its impact on community health outcomes or environmental indicators. Future research might consider the performance of specific EH program areas and disease known to occur from a related source whether water, food, or vector-borne diseases. Additional research might also include longitudinal studies to examine performance improvement and its impact on environment-related disease rates over time and determining the plausibility of certain indicators such as environmental contaminants or even critical inspection violations to serve as proxies for health outcomes. Continued efforts to describe the impact of EH programs on reducing environment-related disease and improving health outcomes could strengthen the Florida and national EH services delivery system and improve health status.