A Qualitative Look into the “Black Box” of how Leaders and Services of Local Health Departments Impact Disparities

Background: Our previous quantitative research indicates that certain domains of local health department (LHD) services (e.g. maternal/child health) have differential relationships with changes in Black/White mortality disparities. We have also found significant relationships between the type of LHD leader (i.e. clinician, non-clinician) and reductions in Black/White mortality disparities. We subsequently conducted a qualitative investigation into the “black box” of how certain services and types of leaders may influence disparities. Methodology: Semi-structured interviews were conducted with 11 national public health leaders with experience as directors of LHDs. Questions elicited perceptions of how certain LHD services and workforce factors were associated with mortality disparities. We used inductive methods for analysis with a 3-person research team discussing independently coded transcripts, triangulating findings from multiple coders, and assuring inter-rater reliability. Results: Five primary ‘factors of influence' were found to explain our quantitative findings. (1) Public Health Leadership—past experiences, preferences, and clinical preparation impact how leaders address disparities; (2) Organizational Factors—resource capacity and local priorities impact decisions to adapt LHD services; (3) Shifting Trends—trends based on LHD priorities, national emphases, and/or new evidence impact programmatic decision-making; (4) Service Delivery Model(s)—tailoring services to specific populations and whether prevention is a focus impacts service outcomes; and (5) Service Utilization—Offering services which target specific populations impact the uptake of services and the magnitude of disparities. Conclusions: Training and experience in disparities among LHD leaders, as well as the targeting of services, influences the types of services provided and the impact of those services.