Local Health Department Values and Organizational Authorities Guiding Cross-Sector Work During COVID-19

Abstract

Objective

The COVID-19 pandemic highlighted the role that local health departments (LHDs) have in cross sector can address alone, including the work of value alignment and the strategic use of organizational authorities. The practices by which LHDs used their authorities to conduct cross-sector work during the pandemic need exploration.

Method

We conducted semi-structured interviews with 19 public health leaders from metropolitan LHDs across the United States. Our interview guide assessed the values that LHD leadership prioritized in their cross-sector work as well as the range of organizational authorities they leveraged to influence external decision-making in other sectors.

Results

We found that LHDs approached cross-sector work by leaning on diverse values and authorities, each with unique implications for their work. The LHDs emphasized their approach to value alignment on a sector-by-sector basis, strategically using diverse organizational authorities—economic, political, moral, scientific, and logistical. While each authority and value we assessed was present across all interviewees, how each shaped action varied. Internally, LHDs emphasized certain authorities more than others to the degree that they more closely aligned with prioritized core values.

Conclusion

Our findings highlight the ongoing need for LHD leadership to improve their ability to effectively communicate public health values and the unique authorities by which health-supporting work can be facilitated, including how this message must be adapted, depending on the specific sectors with which the LHD needs to partner and the governance arrangement in which the LHD is situated.

Keywords

local health departments COVID-19 public health values health equity

Throughout the COVID-19 pandemic (hereafter, COVID-19), local health departments (LHDs) across the United States served an integral role in the public health response (Gostin & Wiley, 2020). The complexity of COVID-19 has also demanded cross-sector work—including a mix of collaboration, coordination, and cooperation—to achieve system-level changes that no sector can address alone (Castañer & Oliveira, 2020). In this context, many LHDs have worked with academia, health care, social services, education, and others to develop better informed and more impactful strategies to protect the health of their community (Burwell-Naney et al., 2021; Ravenhall et al., 2021).

Identifying common values is essential to cross-sector work (Landers et al., 2020). When making decisions with partners in the community, LHDs are often placed at a difficult juncture, balancing the needs and values of various sectors while upholding the core values of public health (DeBruin & Leider, 2020). Value alignment, defined as leveraging one or more shared values between organizations, is a critical tool for motivating cross-sector action that would not otherwise be realized. Whereas universal alignment (sharing all values across all partners) is rare, partial alignment among a few values is critical for driving collective action (de Montigny et al., 2019). Moreover, the challenge of value alignment likely varies across sectors, depending on the overlap in commonly held values in each sector. It has been demonstrated that traditional public sector values (e.g., altruism and justice) are more likely to align with commonly held values in community-based organizations (CBOs) than those in the private sector (e.g., entrepreneurship and individualism), implying that value alignment between government and CBOs may be more likely than alignment between government and the private sector (Miller-Stevens et al., 2014).

Cross-sector work also demands the use of various “authorities” that governmental organizations can leverage to influence behavior in other sectors. As outlined by public administration research on the various “policy tools” of government agencies, such influence can include but need not be limited to legal action (Acciai & Capano, 2021; Capano & Howlett, 2020). To affect behavior in their community, government agencies, such as LHDs, can lean on “soft” authorities that involve actions such as logistically coordinating action, communicating data and evidence, financially incentivizing desired outcomes, and appealing to morals (Blomqvist, 2016; Howlett & Fraser, 2009).

Cross-sector work has been especially challenging during COVID-19 as public health authority and values have received heightened scrutiny (Halverson et al., 2021; Juliano et al., 2021). To mitigate the spread of COVID-19 in their community, local governmental public health actions—stay-at-home orders, mask mandates, and travel restrictions—were often enacted (Gostin & Wiley, 2020). Pushback to these actions prompted the approval of new laws that limit public health’s legal authority (e.g., banning mask mandates; Weber & Barry-Jester, 2021) and lawsuits against public health agencies remain an ongoing challenge (Holt et al., 2021). These legislative actions have illuminated the complexities that emerge when conflicting values collide and organizational authorities are contested across sectors (Angeli et al., 2021).

Calls for improved cross-sector, health-related decision-making have reinvigorated the need to view local public health as a complex, multi-sector system (Brownson et al., 2020). Recognizing this call, we aimed to understand how LHDs leaned on organizational values and authorities to conduct cross-sector work during COVID-19, with the hope that our learnings will inform cross-sector work supporting health in this and other public health crises.

Method

During November and December 2021, we conducted semi-structured interviews with leadership from metropolitan LHDs across the United States to assess prioritized values and organizational authorities used to facilitate cross-sector work during COVID-19.

Interview Recruitment and Design

To ensure interviewees were aware of cross-sector concepts and skills, we recruited leaders from LHDs that participated in the Kresge Foundation’s Emerging Leaders in Public Health program (kresge.org/elph). Interviewees were not financially compensated for their participation. Two members of the study team (K.J. and K.H.L.) developed a semi-structured interview guide (Supplemental Appendix 1) and one researcher (K.J.) conducted the interviews. All interviews were conducted virtually and lasted between 45 and 90 minutes. The University of North Carolina at Chapel Hill (UNC) Institutional Review Board exempted this study (No. 20-2087).

The American Public Health Association’s (APHA) Public Health Code of Ethics, updated in 2019, identifies six core values for the field: professionalism and trust, health and safety, health justice and equity, interdependence and solidarity, human rights and civil liberties, and inclusivity and engagement (APHA, 2019). Using this code as a framework, our interview guide explored how these values were prioritized by LHD leadership in their cross-sector work. We also explored the range of organizational authorities they leveraged to influence external decision-making in other sectors. Organizational authorities were explored in relation to three different sectors, chosen to represent a spectrum of sector-specific values: business, CBOs, and local government.

Analytical Approach

We employed conventional content analysis to analyze transcripts (Hsieh & Shannon, 2005). After outlining a codebook based on our interview guide, additional codes were added while analyzing three randomly selected transcripts until all data fit an existing code (Supplemental Appendix 2). Using MAXQDA 2020 qualitative analysis software, two researchers (C.B. and K.J.) independently applied codes to all transcripts, initially resulting in a kappa coefficient of 0.58. Kappa coefficients above 0.60 are considered “substantial” (McHugh, 2012); C.B. and K.J. resolved coding disagreements until the percent agreement for all codes was above 0.60, establishing an overall kappa coefficient of 0.67.

Results

Seeking diversity among midsize, metropolitan LHDs, Emerging Leaders in Public Health Initiative (ELPH) staff connected us with leadership from 24 midsize, metropolitan LHD leaders across a range of perceived capability levels for cross-sector work, jurisdiction size, and political context. Of the 24 individuals approached, 19 (79%) agreed to participate. Our final sample of 19 participants represented LHD jurisdictions ranging from approximately 200,000 to 750,000 residents. Based on, in large part, the relationship between local and state public health employees, local–state governance models can be decentralized, centralized, mixed, or shared (Meit et al., 2012). The majority (n = 16/19) worked in states with decentralized or largely decentralized public health systems and within single-county jurisdictions (n = 11/19; Supplemental Appendix 3).

The Roles, Challenges, and Strategies to Uphold Public Health Values During COVID-19

Throughout COVID-19, the six APHA Core Values of Public Health were leveraged in different ways and contexts. Table 1 outlines each value’s unique role, as well as the associated challenges and strategies employed to adhere to each value during COVID-19.

Table 1

Roles, Challenges, and Strategies of the APHA Code of Ethics Values During COVID-19

Role of the value	Strategies to advance the value	Challenges with advancing the value
Professionalism and Trust was the necessary condition for cross-sector work: “I feel like if we worked on the professionalism and trust, a lot of the other things would fall in line.” (LHD-04)	- Build trust at the organizational level: Articulate how data informs decisions, and the desire to overcome data limitations in data to make better, scientifically informed decisions. - Build trust with organizational leaders: Build trust by showing up to meetings among different organizations and routinely emphasizing the LHD’s support. - Build trust with community leaders: If a community is resistant to public health authority, work with trusted members in the community to build organizational trust.	- Communities interpreted LHD guidance as politically motivated. - Seemingly conflicting and/or changing scientific information about public health policies. - Historical mistrust of public health due to historical harms public health had caused or because public health represented government at large (an institution not trusted in the community).
Health and Safety was the LHD’s singular agenda, unlike other community organizations that may be motivated by profit and election cycles and therefore have “a vested interest [in] what they’re gonna communicate.” (LHD-13)	- Coordinate service delivery with other sectors within the community, especially health care institutions and community-based organizations. - Where possible, implement local public health policies that protect the health of the community from disease spread (e.g., mask mandates).	- Changing federal guidelines throughout the COVID-19 pandemic. - Balancing demands of COVID-19 with routine public health activities. - Balancing disease spread while mitigating the mental health implications of preventive policies.
Health Justice and Equity was a critical implication to address to ensure health and safety of the entire population, given that not everyone is equally vulnerable to disease due to social and economic forces.	- Collect and monitor disaggregated COVID-19-related data during the pandemic, indicating health disparities among different populations. - Marshall resources to increase accessibility of services (e.g., testing and vaccination) to those in most need.	- Speaking about social justice or equity was sometimes discouraged by elected officials. - Limited availability of disaggregated data on COVID-19 outcomes, especially across race.
Interdependence and Solidarity was the social reality that informed the design of their work as LHDs recognized that a decision in one sector affects everyone in the community.	- Ensure the community that “we’re all in this together,” especially early on when communities were “scared and they didn’t know anything.” (LHD-18)	- The current political unrest and “unraveling social fabric” across the country. - True interdependence demands a balance between being an authority in the community and being honest and vulnerable about one’s weaknesses.
Inclusivity and Engagement was the means by which cross-sector work was conducted: “If you engage people, if you’re more inclusive, and you’re actually understanding what they need and what they’re looking for, then you can address all these other values with the inclusivity and engagement piece.” (LHD-13)	- Engage leaders within the community to help communicate the health department’s message (through informal relationships or formal agreements). - Emphasize in-person or/and one-on-one interactions, such as physically going to community groups or hosting events at community sites. - Allow other people or organizations to be the “center stage” (LHD-02), including granting access to more power in decision-making than the LHD may historically be comfortable with.	- Balancing a rapid pandemic response with the time needed for engagement. - Those most difficult to engage are often those who most need to hear the health department’s message and the least likely to receive that message through other means. - True inclusivity includes engaging those of different ideological backgrounds.
Human Rights and Civil Liberties was the constraint upon the scope and substance of cross-sector work by limiting how much individual behavior could be restricted.	- Communicate the value of civil liberties from a “public health perspective” (LHD 02): emphasize that restrictive policies in the present allows individuals more freedom in the future. - Impose restrictions in such a way that minimizes restrictions on free movement and economic impact. - Focus on providing accurate information for individuals to make their best decision—one that aligns with their values but is informed by the most recent science.	- The value of “civil liberties” was often championed by those in the community who actively resisted public health policies. - Many public health policies naturally restricted civil liberties during the pandemic.

Source: The data used to create this table strictly comes from interviewee commentary gathered for this study.

Note. APHA = American Public Health Association; LHD = local health department.

Conflicts and Synergies for Each APHA Value

Interviewees discussed the strong overlap between the value of inclusivity and engagement with health justice and equity as pursuing equity demanded bringing historically marginalized communities “to the table and sharing power and listening to them and using their solutions” (LHD-09). Interviewees noted tension between promoting health and safety and the need to preserve the value of human rights and civil liberties through advancing “restrictive policies” that necessarily curtailed individual freedoms (e.g., mask mandates, social distancing). This tension was exacerbated by challenges with other values: The perceived lack of interdependence and solidarity in the country (“all of this has happened at a time when we ripped apart our society” [LHD-08]) made it difficult for LHDs to convince their communities to sacrifice for the common good. Threats to professionalism and trust also challenged the LHDs ability to convince “people that you’re wanting to do something . . . that’s going to benefit them” (LHD-13).

Importance and Challenge of Sector-Specific Value Alignment

Given the perceived “interconnectedness . . . of these decisions that get made” (LHD-12) across sectors, interviewees emphasized their role in seeking cross-sector value alignment. As opposed to persuading all sectors to seek alignment on values at the same time, LHDs spoke about value alignment as being “sector-specific,” both to avoid an overwhelming number of conflicting viewpoints “when you have everybody at the table” (LHD-02) and because “every sector had their own questions, they had their own concerns” (LHD-13). Six strategies for practicing sector-specific value alignment emerged from the interviews: practice humility, know your own values and how to articulate them, understand the values of the other sector, find points of connection between values, tailor your message to your audience, and work with trusted messengers (Figure 1).

Figure 1

Reported Strategies for Cross-Sector Value Alignment Between LHDs and Other Sectors During the COVID-19 Pandemic

Challenges with value alignment were noted. Given that the crisis was public health focused, there was minimal room for compromise with sectors that did not share public health’s values. Challenges with value alignment were compounded in newer partnerships that lacked the baseline trust and familiarity with the other’s values common to long-lasting collaborations. LHDs also had to balance a rapid pandemic response with the substantial time needed for genuine value alignment.

The Use of Public Health’s Organizational Authorities During COVID-19

Effective Use of Diverse Organizational Authorities

Organizational authority exercised by LHDs in cross-sector work was categorized as being scientific, moral, economic, political, and logistical (Supplemental Appendix 2 outlines how authorities were defined within interviews). At least one instance of each authority was documented regarding the LHDs’ work with businesses, CBOs, and local government officials (Table 2).

Table 2

Use of Local Health Department Organizational Authorities Across Sectors During COVID-19

Authority	Business	CBOs	Local government	Cross-cutting examples
Moral authority involves imploring organizations to do what is right for the community’s health	Finding shared motivation with businesses in wanting to keep the community safe and businesses open: “And so it was super helpful to be able to say, ‘We’re in it together, we want the health of the community, but we also want you guys to be open.’ Yes, but we can’t make it, and we can’t change any of that. Let’s figure out what we can do.” (LHD-13)	Shared goals of protecting/serving the community came naturally with CBOs: “And it’s all that moral authority of, ‘This is the right thing to do. This is why I need to do this. This is gonna be hard. We’re gonna be making some sacrifices. But it’s for the common good.’” (LHD-05)	Allowing politicians to place blame on LHDs to protect the community: “I told the political people too, the mayors and whoever, ‘If somebody needs to be the bad guy, that’s me, that’s fine. I am fine with that. Blame me for what you have to do, but you have to do it because that’s the right thing to do, and that’s what’s gonna save lives, and I don’t care.’” (LHD-12)	Identifying and imploring shared goals of keeping the community safe and sharing personal stories of the pandemic’s impact
Economic authority involves providing monetary resources and creating other economic incentives	Working with businesses to implement safety protocols to minimize economic impact: “How can we support you to make sure that they can continue to get that paycheck that they can continue to stay well. That you continue your services with as much recognizing that there would be some interruption . . . Some changes . . . Some major, in some instances modification. But how can we . . . Let’s be realistic, there’s going to be an impact. How can we minimize that impact?” (LHD-02)	Distributing funding/grants to organizations (and associated frustration with the limited funds available for this): “[Economic authority] was hard at the beginning because we had no money. We’d have these collaborative conversations with the community. Yep, they wanted us to do something. Yep, we wanted to do something. And we really didn’t have much to do it with.” (LHD-08)	Appealing to local elected leaders using economic rationale: “I think for the purposes of general community messaging, we did have some local government officials that did come on board and say, yeah, let me help with this messaging to say, ‘Let’s protect our community.’ But it was always raised with the economic portion as well. So even if there was a little bit of moral authority, it was always rounded out with because of the economy.” (LHD-13)	Enforcing safety protocols to keep businesses open (thus minimizing economic impact), distributing funding to organizations (grants) and individuals (vaccine incentives), and supplying organizations with personal protective equipment.
Scientific authority involves generating and sharing evidence and data	Technical assistance—less of a regulator, more of a consultant/educator “But the 80% [of businesses who followed scientific guidance] really stood up and gave us a lot of kudos and sort of stood by the health department to say, ‘No, they’re really giving good advice. It’s really helpful. They’ll give you time.’” (LHD-16)	Technical assistance and using CBOs as messengers of scientific information “Honestly, it took a lot of groundwork from all of our staff members answering calls at any time of the day to build that relationship with these leaders in the community, so that they could look to us and trust us, when we said, here’s a resource, please use it. And they would actually share it out. And I think that’s . . . You really can’t create something like that without putting in the work, you know, over time for that trust to be built.” (LHD-13)	Sharing scientific information to inform decisions (level of authority circumscribed by governance structure): “Because misinformation or disinformation would be interjected into board discussions and meetings by board members or members of the public that they invited to the board meetings to provide comments. So I feel like that was an area that we were often, maybe not even in agreement with our board in trying to not. . . I guess, to try to correct that wrong information and really to try to stick to what we knew to be true at the time.” (LHD-04)	Communicating higher level guidance, generating and distributing local data, placing national pandemic trends into local context, and working with organizations to operationalize mandated and best practice safety protocols
Logistical authority involves overseeing operations and coordinating stakeholder involvement	Coordinated testing and vaccine clinics at businesses and distributed signage and PPE to facilitate businesses operating safely: “So, I think some of the things that we were able to do is partnering with our local chambers that represent a lot of our businesses for PPE distribution, providing a lot of technical assistance . . . to make sure that they can keep a healthy workforce as well as do what they need to do.” (LHD-09)	Partnered with CBOs for testing and vaccine clinics, COVID-19 messaging, and delivering social services: “At the end of the day, we’re a pretty small health department for the number of individuals that we are responsible for. And so we tend to use our partners pretty heavily in planning large operations. So, going back to the vaccination, we did a lot of it, but we drew very heavily on all of our partners in the community to make that successful.” (LHD-18)	Incident command structure facilitated coordination across local government agencies: “Normally we’re just one partner amongst many in activities, and so that piece of having that incident command in place, having the Health Director and then the other members of the Health Department, woven in with police, fire, the Mayor’s office, all of those other sort of things. So it’s one piece for. . . That’s a practical component of all of this.” (LHD-11)	Convening and coordinating stakeholders (“public health is a mutual convener” [LHD-01]), planning mass testing and vaccination events and coordinating access to such events, and allocating resources (medical supplies, personal protective equipment, vaccines, and tests) in the community
Political authority involves informing decisions of elected officials and regulating the enforcement of mandated safety protocols	Regulatory authority used as last resort with businesses: “But our one goal was and we were very successful at this, we were never gonna go out to a business and have to prosecute them. We were going to work with them. We’re gonna educate them. We’re gonna get them into compliance. It took a lot of work, but it happened.” (LHD-06)	Less commonly used—government affiliation influencing relationships with CBOs: “. . . because we are a government entity and work for a board . . . there’s probably political authority . . . so it carries weight when we work in relationships sometimes.” (LHD-04)	Informing decisions of local elected leaders: “[Local elected officials] reach out to me when they have questions, and I can reach out with them and say, ‘Hey, you know what would be nice? This, this would really help us.’ So you need to keep the. . . And I also have. . . Some I don’t have a good relationship with because they don’t like factual information and they think that everything that we’re doing is a communist pinko, lefty, whatever. But we still have to keep, we still have to keep doing it. That’s our role.” (LHD-12)	Regulatory authority to enforce isolation, quarantine, and mandated safety protocols; threatening to close organizations not following safety protocols (as a last resort); as well as communicating with elected officials to inform policy decisions

Source: The data used to create this table strictly come from interviewee commentary gathered for this study.

Note. CBO = community-based organization; LHD = local health department.

Across all sectors, scientific authority was referenced most commonly, followed closely by moral and logistical authority. In contrast, political and economic authorities were used less often, with some interviewees making a point to distance themselves from the use of political authority: “Well, one I can say that doesn’t work at all is political authority, so we try not to fall on that at all, unless it’s the last resort” (LHD-18).

Influence of Governance Structure on Organizational Authorities

The range of authority available to LHDs was notably influenced by the governance structure within and surrounding the LHD. Different structures had noted tradeoffs. Interviewees from centralized state public health systems discussed how leaders at the state level (i.e., surgeon general, governor) often took the “fall” for negative criticism of public health policies, providing LHDs “a ton of protection” (LHD-18) against criticism at the local level. However, when state leadership did not approve of public health restrictions, these interviewees could not implement desired policies at the local level. Communication to the public was also stifled in centralized systems as LHDs had to align their messaging to what were sometimes perceived as limited “talking points that we were provided” (LHD-10). This alignment frustrated local media and community members as it both slowed down LHD communications and made their messaging less transparent.

Tradeoffs were also noted in LHD health districts (as opposed to single county or city jurisdictions). As a semiautonomous unit of government separate from county-specific affairs, districts were able to be a “center of the wheel . . . more of a neutral place” (LHD-12) when convening agencies. However, their geographic reach also created confusion, as community members “lump[ed] us in with the county complex” (LHD-19) when expressing their frustrations (similar tensions occurred in overlapping jurisdictions between city and county health departments). In addition, it was harder for health districts to coordinate with single-county agencies.

Across all governance structures, interviewees expressed frustration over how elected officials and community members misunderstood LHD policy-making authorities. These groups would either wish the LHD could do something that it did not have the power to do, or they would wish the LHD did not have the power to do what they did: “I think our community wondered from time to time, why is the Health Officer not making this decision?” (LHD-01). This misunderstanding was especially pronounced with mask and vaccine mandates. In response, LHD leaders had to refer to state statutes to defend their authorities (e.g., their power to issue and enforce mask mandates).

Strategic Use of Organizational Authorities

Depending on the values of other sectors, LHDs tailored their organizational authority across sectors and for different audiences within sectors. Although scientific authority was used consistently, LHDs leaned on other types of authority, particularly moral, with those that were more skeptical of science:

. . . science kind of became a bad word here too, so I really felt like [we] needed to pull at people’s emotions . . . I always saw myself as that little nagging angel or devil on the mayor’s shoulder, just constantly nagging him behind the scenes about what’s right, that these are lives that we’re talking about . . . just saying we need to do what’s right for the community. (LHD-15)

At times, several LHDs mentioned leveraging their partner’s authority (often CBOs) if it would be more effective to advance the LHD’s values:

Our role was data and evidence, but we had to be very careful about how we shared that and with whom we shared it, so that others could really push the message and not us . . . because we didn’t have a lot of that gravitas. (LHD-19)

LHDs strategically related their use of authorities in the context of COVID-19 to their use of similar authorities prior to the pandemic, when their work was less public and, in some cases, less stigmatized. Logistical authority was more consistently respected by the community. “We’ve been . . . orchestrating events like this for years at a smaller level . . . we’re really trusted on the logistical part of pulling people together . . .” (LHD-06). LHDs related their regulatory (or political) authority to restaurant health and safety inspections. “You expect public health to make sure that the people in the restaurant cook the food appropriately, that places [have] proper hygiene and sanitation . . .” (LHD-02).

Influence of LHD Values on Their Use of Organizational Authorities

LHD values strongly guided cross-sector work through their exercise of each organizational authority. Shared values, particularly professionalism and trust, were foundational to the successful use of all authorities. Trust was relied upon for effective data and evidence sharing (scientific authority), partnerships with community organizations (logistical authority), and communication with elected officials (political authority): “I think what went well is that [local public officials] trust us” (LHD-14). Furthermore, trust was critical to exercising moral authority, in which LHDs implored a shared value system: “. . . where you build moral authority is when you have a history of collaborating. . .‘We’ve worked with them. We trust them . . . Okay. We’ll give that [moral authority] to them’” (LHD-08). Furthermore, in describing moral authority, interviewees conveyed a sense of moral obligation to protect the health and safety of the community, despite challenges to their scientific authority:

I took a lot of risks based on what I believed was the public health moral authority . . . when we were starting to really absorb . . . how many people were dying . . . it really pushed us that much more to stay on track and not get distracted. (LHD-16)

Health justice and equity manifested as a moral obligation to protect all members of the community. To this end, LHDs exercised their logistical authority to ensure access to resources (e.g., testing, vaccination), particularly for community members with marginalized identities. “. . . we were really focusing on who had access to testing, who had access to vaccines . . . how we were building relationships where people could trust us . . . knowing that there’s historical distrust there” (LHD-11). Within funding constraints, LHDs also exercised economic authority by funneling funding and grants to CBOs that were more embedded in the community than LHDs could be: “We’re giving money to those [community-based] organizations . . . because we can’t do that [vaccine outreach] work. We need them to do that work” (LHD-03). Partnerships with a wide range of community members illustrated the value placed on inclusivity and engagement: “So, it was just an ongoing bringing the partners to the table, so we were the convener, we were the educator, we’d try to be a collaborative equal partner and not tell them what to do . . .” (LHD-17).

Whereas interdependence and solidarity were not emphasized as frequently when interviewees discussed their LHD’s values, it was foundational to their use of moral authority. Interviewees implored organizations and community members to follow recommended safety protocols for the collective good. “. . . our efforts will be successful together, or we will not be successful together . . . I think subconsciously part of it was to make people realize that, honestly, we are all interconnected” (LHD-02). In contrast to this notion of interdependence and solidarity, an underlying emphasis on human rights and civil liberties surfaced in interviewees’ discussion of their scientific authority. Rather than mandating behavior, interviewees largely viewed their scientific authority as providing clear scientific information to the public and organizations to inform their own decisions in accordance with their own value system: “We are here in a catalyst facilitator type of mode, we’re telling you what the facts are, we’re here to answer your questions, we’re here to be transparent, but ultimately [the] decision is up to you” (LHD-02).

Discussion

COVID-19 has highlighted the role of LHDs in working with organizations in other sectors to collectively improve community health. By interviewing leadership from metropolitan LHDs across the United States, this study highlights how public health values and authorities were operationalized for cross-sector work. Although each authority and value we explored was present across all interviewees, how each shaped action varied. Internally, LHDs emphasized certain authorities more than others to the degree that they more closely aligned with prioritized core values. Externally, values and the implementation of authorities were influenced by surrounding political and governance contexts.

Given how COVID-19 has demonstrated and exacerbated long-standing health inequities by race, ethnicity, income, disability, immigration status, “essential” worker status, and geography (Lopez et al., 2021), our interviewees expressed the heightened priority of “health justice and equity” as a core public health value guiding their pandemic response. To actualize this value, interviewees developed diverse partnerships and served in distinct roles in those partnerships. This finding aligns with Public Health 3.0’s (PH3.0) recommendation that “public health departments should engage with community stakeholders—from both the public and private sectors—to form vibrant, structured, cross-sector partnerships” (DeSalvo et al., 2017). Failing to work with sectors beyond health care will only exacerbate inequities driven by social and economic factors (Dalsania et al., 2022). PH3.0 clearly outlines the need for LHDs to work cross-sector to advance health equity, whereas our findings illustrate how LHDs have done this during the greatest public health crisis in the past century. Particular emphasis was given to the importance of value alignment—including the ability to articulate both the values of public health and those of other sectors, and creatively seek opportunities to find synergy between these value systems whenever possible. While health equity may be the prevailing goal, working cross-sector requires LHDs to become fluent in discussing the importance and operationalization of other values, too. LHD leaders also emphasized the nuance with which organizational authorities are leveraged in cross-sector work, demonstrated by an active consideration for which authority best fits the context and ultimately suggesting a “multiple hats” approach depending on the sector of interest. Further training should be developed to assist LHD leaders in both identifying the range of these roles and knowing which “hat” is most appropriate, given specific cross-sector objectives.

When discussing cross-sector partnerships to advance health equity, the authors of PH3.0 acknowledge that “the basic foundational structure of local governmental public health may itself be a barrier to efficient and cost-effective coordination at the local level.” Our findings confirm and clarify the tradeoffs between alternative governance structures on the ability for LHDs to effectively work cross-sector. To minimize both confusion (at best) and unwarranted threats (at worst), public health practitioners must communicate with the public and elected leaders on how governance shapes the authorities they have in the community. Another core dimension of governance, as documented by our interviewees, concerns the proximity of LHD decision-making to elected officials. Different arrangements provide degrees of structural separation between an LHD’s decision-making and political pressures. More research is needed to understand how alternative governance arrangements influence the ability for LHDs to navigate the dichotomy between political involvement and administrative neutrality; in turn, additional training should be developed to assist LHD leaders and their elected officials with this navigation. Similarly, policies should be considered to limit governance models in which there is a disproportionate influence of politics on public health decision-making.

This study has limitations. Our interviewees worked within midsize, metropolitan LHDs. It is unclear whether the strategies and challenges they expressed translate to the experiences of smaller LHDs, especially those in rural communities. In addition, the specific values and authorities we explored may have distracted from other relevant values and authorities not included in our interview guide. For instance, it is unknown whether values outlined in the APHA Code of Ethics have been formally adopted by LHDs across the country, including the LHDs in our sample. Similarly, organizational authorities outlined in our interview guide were assembled by members of the research team based on their own review of cross-sector activity within public health. Additional research should assess whether our list represents an exhaustive characterization of public health authorities, including whether the authorities utilized by LHDs align with public administration scholarship on policy tools available to government agencies. Finally, our interview guide did not explicitly define a list of organizations from the local government, business, and CBO sectors, leaving room for slightly different interpretations among interviewees as to what these sectors constituted.

Collectively, our findings highlight the need for LHD leadership to effectively communicate public health values and the unique authorities by which health-supporting work can be facilitated, including how this message must be adapted depending on the specific sectors with which the LHD needs to partner and the governance arrangement in which the LHD is situated.

Supplemental Material

sj-docx-1-hpp-10.1177_15248399231192989 – Supplemental material for Local Health Department Values and Organizational Authorities Guiding Cross-Sector Work During COVID-19

Supplemental material, sj-docx-1-hpp-10.1177_15248399231192989 for Local Health Department Values and Organizational Authorities Guiding Cross-Sector Work During COVID-19 by Karl Johnson, Caitlin B. Biddell, Katherine Gora Combs, John Wiesman, Monica Valdes Lupi and Kristen Hassmiller Lich in Health Promotion Practice

Footnotes

Authors’ Note:

This research was supported in part by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), through Grant Award No. UL1TR002489 and by Cooperative Agreement No. NU38OT000297 from the Council of State and Territorial Epidemiologists (CSTE), and the Centers for Disease Control and Prevention (CDC). C.B.B. was additionally supported by an NCI Cancer Care Quality Training Program grant, University of North Carolina at Chapel Hill (UNC-CH), Grant No. T32-CA-116339. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, CSTE, CDC, or the universities employing the researchers. One of the authors in this study, M.V.L., currently works for the Kresge Foundation. However, her work with the Kresge Foundation did not have any bearing on the individuals we were referred to nor her assistance with data analysis. This analysis was NOT an evaluation of the Emerging Leaders in Public Health Initiative (ELPH), which is supported by the Kresge Foundation. Interviewees were NOT asked about their experience participating in ELPH. Our sample of interviewees consisted of local health departments (LHDs) that had participated in ELPH, but recruitment was done with assistance from members of the National Program Office for ELPH, which is not located within the Kresge Foundation and is not staffed by Kresge Foundation employees. M.V.L. was recruited to assist with this article strictly based on her experience serving previously as a local public health director prior to her joining the Kresge Foundation. For the remaining authors, no funding sources or potential conflicts of interest were declared.

Supplemental Material

Supplemental material for this article is available at .

ORCID iD

Karl Johnson

References

Acciai

Capano

. (2021). Policy instruments at work: A meta-analysis of their applications. Public Administration, 99(1), 118–136. https://doi.org/10.1111/padm.12673

American Public Health Association. (2019). Public health code of ethics. APHA Code of Ethics (pp. 1–34). https://www.apha.org/-/media/files/pdf/membergroups/ethics/code_of_ethics.ashx

Angeli

Camporesi

Dal Fabbro

. (2021). The COVID-19 wicked problem in public health ethics: Conflicting evidence, or incommensurable values? Humanities and Social Sciences Communications, 8(1), 1–8. https://doi.org/10.1057/s41599-021-00839-1

Blomqvist

. (2016). Soft and hard governing tools. In Ansell

Torfing

(Eds.), Handbook on theories of governance (pp. 285–296). Edward Elgar.

Brownson

R. C.

Burke

T. A.

Colditz

G. A.

Samet

J. M

. (2020). Reimagining public health in the aftermath of a pandemic. American Journal of Public Health, 110(11), 1605–1610. https://doi.org/10.2105/AJPH.2020.305861

Burwell-Naney

Mortiboy

Zitta

J. P.

Stevens

Patterson

Salter

J. C.

Easterling

Bock

L. B.

Wood

Rayner

Jenkins

. (2021). Local government approaches to combating COVID-19 inequities: A Durham county department of public health perspective. International Journal of Environmental Research and Public Health, 18(12), 6544. https://doi.org/10.3390/ijerph18126544

Capano

Howlett

. (2020). The knowns and unknowns of policy instrument analysis: Policy tools and the current research agenda on policy mixes. SAGE Open, 10(1). https://doi.org/10.1177/2158244019900568

Castañer

Oliveira

. (2020). Collaboration, coordination, and cooperation among organizations: Establishing the distinctive meanings of these terms through a systematic literature review. Journal of Management, 46(6), 965–1001. https://doi.org/10.1177/0149206320901565

Dalsania

A. K.

Fastiggi

M. J.

Kahlam

Shah

Patel

Shiau

Rokicki

DallaPiazza

. (2022). The relationship between social determinants of health and racial disparities in COVID-19 mortality. Journal of Racial and Ethnic Health Disparities, 9(1), 288–295. https://doi.org/10.1007/s40615-020-00952-y

10.

DeBruin

Leider

J. P

. (2020). COVID-19: The shift from clinical to public health ethics. Journal of Public Health Management and Practice, 26(4), 306–309. https://doi.org/10.1097/PHH.0000000000001204

11.

de Montigny

J. G.

Desjardins

Bouchard

. (2019). The fundamentals of cross-sector collaboration for social change to promote population health. Global Health Promotion, 26(2), 41–50. https://doi.org/10.1177/1757975917714036

12.

DeSalvo

K. B.

Claire Wang

Harris

Auerbach

Koo

O’Carroll

. (2017). Public health 3.0: A call to action for public health to meet the challenges of the 21st century. Preventing Chronic Disease, 14(9), 1–9. https://doi.org/10.5888/pcd14.170017

13.

Gostin

L. O.

Wiley

L. F

. (2020). Governmental public health powers during the COVID-19 pandemic: Stay-at-home orders, business closures, and travel restrictions. JAMA—Journal of the American Medical Association, 323(21), 2137–2138. https://doi.org/10.1001/jama.2020.5460

14.

Halverson

P. K.

Yeager

V. A.

Menachemi

Fraser

M. R.

Freeman

L. T

. (2021). Public health officials and COVID-19: Leadership, politics, and the pandemic. Journal of Public Health Management and Practice, 27, S11–S13. https://doi.org/10.1097/PHH.0000000000001281

15.

Holt

C. M.

Fawcett

S. B.

Hassaballa-Muhammad

Partridge

Jordan

. (2021). Participatory monitoring and evaluation of the COVID-19 response in a local public health system. Health Promotion Practice, 22(6), 750–757. https://doi.org/10.1177/15248399211041085

16.

Howlett

Fraser

. (2009). Government communication as a policy tool a framework for analysis. Canadian Science Review, 3(June), 23–37.

17.

Hsieh

H. F.

Shannon

S. E

. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. https://doi.org/10.1177/1049732305276687

18.

Juliano

Castrucci

Fraser

M. R

. (2021). COVID-19 and public health: Looking back, moving forward. Journal of Public Health Management and Practice, 27, S1–S4. https://doi.org/10.1097/PHH.0000000000001300

19.

Landers

G. M.

Minyard

K. J.

Lanford

Heishman

. (2020). A theory of change for aligning health care, public health, and social services in the time of COVID-19. American Journal of Public Health, 110, S178–S180. https://doi.org/10.2105/AJPH.2020.305821

20.

Lopez

Hart

L. H.

Katz

M. H

. (2021). Racial and ethnic health disparities related to COVID-19. JAMA—Journal of the American Medical Association, 325(8), 719–720. https://doi.org/10.1001/jama.2020.26443

21.

McHugh

M. L

. (2012). Lessons in biostatistics interrater reliability: The kappa statistic. Biochemica Medica, 22(3), 276–282. https://hrcak.srce.hr/89395

22.

Meit

Sellers

Kronstadt

Lawhorn

Brown

Liss-Levinson

Pearsol

Jarris

P. E

. (2012). Governance typology: A consensus classification of state-local health department relationships. Journal of Public Health Management and Practice, 18(6), 520–528. https://doi.org/10.1097/PHH.0b013e31825ce90b

23.

Miller-Stevens

Taylor

J. A.

Morris

J. C

. (2014). Are we really on the same page? An empirical examination of value congruence between public sector and nonprofit sector managers. Voluntas, 26(6), 2424–2446. https://doi.org/10.1007/s11266-014-9514-6

24.

Ravenhall

Levy

N. A.

Simpson

Fleming

Arana

Dimanno

Grijalva

Murrman

M. K

. (2021). New York State Local Health Department preparedness for and response to the COVID-19 pandemic: An in-progress review. Journal of Public Health Management and Practice, 27(3), 240–245. https://doi.org/10.1097/PHH.0000000000001340

25.

Weber

Barry-Jester

. (2021). Over half of states have rolled back public health powers in pandemic. Kaiser Health News, 1–14. https://khn.org/news/article/over-half-of-states-have-rolled-back-public-health-powers-in-pandemic/

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.24 MB