Date of Award

12-2024

Degree Name

Doctor of Philosophy

Department

Interdisciplinary Health Sciences

First Advisor

Rob Lyerla, Ph.D.

Second Advisor

Kieran Fogarty, Ph.D.

Third Advisor

Jessica Cataldo, Ph.D.

Keywords

Public health systems, system structure

Abstract

Public health thought leaders such as the Institute of Medicine and National Academies of Science, Engineering, and Medicine have long been concerned about the lack of standardization among state-level public health systems (IOM, 1988; NASEM, 2023). However, little research studies these systems, their structures, and whether structural constructs affect population health outcomes.

This study attempted to examine the structural constructs that make up these systems and the impact of those constructs using an exploratory sequential mixed-methods design. Variables from management science were qualitatively extracted from materials describing all 50 state-level public health systems. Those variables were then analyzed using a Categorical Principal Component Analysis (CATPCA) to detect underlying patterns. Three key constructs of state public health system structure emerged: system size, state focus, and practice scope and autonomy. Multiple linear regression analyses were then conducted to determine if those constructs were associated with performance on behavioral, physical, and holistic population health outcome indicators. Despite the wide range of outcome indicators, the analyses found no evidence that the three constructs were associated with differences in population health performance.

The results from this study affirm the varied and complex nature of public health systems, including the importance of participants outside the nominal public health system. Second, while management principles can and should be applied to public health systems, the results provide evidence that there is no "one size fits all" approach. Instead, public health leaders should strategize and operate in response to local contexts and threats. Future research is needed to inform public health management and ensure that public health systems operate at maximal effectiveness.

Implications:

This dissertation has specific implications for state-level public health leaders. While the underlying factors discovered during the analysis were theoretically and statistically sound, the finding that structural constructs were not associated with population-level health outcomes suggests that while structural, systemic changes may help achieve other goals, such variations are unlikely to be related to population-level health. Good management practice has a place in all organizations, and public health researchers should continue to study state-level public health systems to identify mechanisms that lead to population-level health improvement. However, the impact of the confounders on the analyses suggests that focusing on those issues might be more prudent when considering population-level health improvement. Finally, public health leaders should prioritize administering evidence-based programs using the management practices that best fit their goals and operating contexts.

Access Setting

Dissertation-Open Access

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