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Research Projects

Examining the Influence of State and Federal Law on Public Health Preparedness

Public Health Ethics in Practice:
A Pilot Study of Day-to-Day Ethical Issues in Public Health Practice in Michigan

Measuring the Value of Public Health Services

The Sacramento County Driving Under the Influence of Alcohol (DUI)
Intervention Program for Second Offenders

Newborn Screening Implementation

The Legal and Ethical Aspects of Family History

Examining the Influence of State and Federal Law on Public Health Preparedness

Principal investigator:  Peter D. Jacobson
Co-Investigators:  Jeffrey Wasserman and Ben Berkman

Funded by CDC

The purpose of this project is to assess and evaluate how the law shapes the public health system’s preparedness activities and its response to public health threats, such as infectious disease outbreaks, pandemic flu, and all hazards (including bioterrorism preparedness). 

            Background.  The law is an important determinant of how the public health infrastructure is organized and how resources are allocated, but its effects on public health practice have not been studied systematically.  In particular, federal laws provide funds for specific activities, but also constrain how states and localities can spend the funds.  What actually gets funded at the local level (the primary locus for delivering public health services) is a function of numerous factors, including federal and state grant requirements, state laws (including the public health code), workforce capacity, and institutional structure.  It seems likely that there will be considerable variation across states in how public health officials interpret and act upon federal requirements. 

Objectives.  The specific objectives are to examine:  1) the link between law and public health preparedness activities; 2) the extent and scope of legal mandates on state and local public health systems and whether those mandates facilitate or impede public health preparedness efforts; 3) how variations in state laws affect the use of federal and state funding streams to meet public health preparedness objectives; 4) how public health practitioners interpret and respond to federal and state laws affecting public health preparedness; and 5) to translate the findings into concrete policy recommendations for public health officials and legislators to implement.

            Tasks.  To meet these objectives, the investigators will first examine federal laws regarding public health preparedness, such as bioterrorism and infectious disease threats (including an examination of funding streams and performance measures).  Then we will conduct a series of case studies of state and local public health systems to determine how state and federal law affects the public health system’s ability to respond more effectively to public health threats and other public health preparedness needs.

            Impact.  The project’s primary contribution will be to provide policymakers with the first systematic empirical information to understand how law shapes the public health system’s disease preparedness activities, and how public health officials are adjusting to the changing legal environment.  Another project goal is to bridge the gap between academic research and the issues public health practitioners face.  Translating the research findings to the practitioner community is an important element of our overall strategy, an aspect of the research that we view as both crucial to the project’s success and an important contribution of this effort.  Thus, we plan to recommend concrete strategies states and local health departments can use to address the implications of federal and state law and funding on their public health preparedness activities.

 Public Health Ethics in Practice:
A Pilot Study of Day-to-Day Ethical Issues in Public Health Practice in Michigan

Principal Investigator:  Peter D. Jacobson
Co-Investigators:  Nancy M. Baum and Sarah E. Gollust

Funded by The Greenwall Foundation

This project is the first major effort to assess public health ethics in practice in a systematic way.  The study will build the evidence base for the emerging field of public health ethics.  We expect that this pilot study will provide the foundation for a larger-scale, nationally representative survey of public health practitioners throughout the United States. 

Background:  Public health is a multidisciplinary, complex, and value-laden field.  In its core activities, public health practitioners must balance the moral imperative of improving and protecting population health with the need to respect individual liberties.  Public health practitioners operate within the context of resource constraints, a dynamic political environment, and emerging disease threats.  The notion that the distinct values of public health, in contrast to clinical medicine, warrant a novel ethical approach has been gaining traction in the scholarly literature.  Yet it remains unclear to what extent practitioners of public health consider ethics in decision-making within their daily practice. 

Objectives:  The objectives of the proposed work are two-fold:

  • To describe ethical issues experienced by public health practitioners in Michigan.
  • To assess the potential utility of ethical frameworks or ethics consultation for decision-making in local and state public health practice.

Tasks:  Through approximately 40 face-to-face interviews with public health practitioners throughout the State of Michigan, we will assess the types of ethical challenges practitioners confront on a daily basis, the approaches practitioners use to address and resolve ethical challenges, the types of ethical issues they encounter, their familiarity with ethics/ethics education, and the perceived desirability of ethical frameworks for decision-making or ethics consultations within public health practice environments.  We will select approximately 15 of 45 local health departments of different sizes and geographic location (urban vs. rural) in Michigan.  At each site, we will conduct two to three 60-minute semi-structured interviews with public health practitioners of varied occupations, from health officers and medical directors to public health nurses and other staff.  We will also conduct at least 5 interviews with employees at the Michigan Department of Public Health. 

Impact:  The analysis of the qualitative data will allow us to assess similarities and differences in the ethical issues encountered by practitioners across practice locations, type of occupation and training, and local- versus state-level employment.  We will present our findings to a Michigan public health conference and prepare manuscripts for submission to academic journals.  Finally, we will use the pilot data to develop a survey instrument to quantitatively assess the ethical issues practitioners experience and/or test the utility of ethical frameworks for decision-making.  

Publications relating to this project:

NM Baum, SE Gollust S Goold, and PD Jacobson, Ethical Issues in Public Health Practice in Michigan, American Journal of Public Health 2008 (forthcoming).

SE Gollust, NM Baum, and PD Jacobson, Politics and Public Health Ethics in Practice: Right and Left Meet Right and Wrong, Journal of Public Health Management and Practice 2008; 14:340-347.

NM Baum, S Gollust, SD Goold, and PD Jacobson, Looking Ahead: Assessing the Ethical Challenges on Public Health Practice, Journal of Law, Medicine, and Ethics 2007; 35:657-667

 Measuring the Value of Public Health Services

Principal Investigators:  Peter D. Jacobson and Peter J. Neumann

Funded by the Robert Wood Johnson Foundation’s Changes in Health Care Financing & Organization (HCFO) Program

This project will explore how the value of services provided by governmental public health systems (GPHS) can be defined and measured.  Subsidiary research questions include:  How do other public or quasi-public entities (e.g., port authorities, education systems) define and measure value?  What methodologies can be used to measure value?  What are the criteria for determining and measuring value?  How would measuring value affect other important dimensions of public health systems such as accountability?  The project is funded by the Robert Wood Johnson's Changes in Health Care Financing & Organization (HCFO) Program.

Background:  The reality of severe budgetary constraints and chronic underfunding of public health systems suggests that the public is unaware of the value of public health.  It is thus essential that GPHS allocate resources to those activities likely to achieve maximum value for improving the public's health. 

Tasks:  The research design consists of three integrated tasks.  First, we will conduct a critical synthesis of the literature.  We will examine other governmental structures that may offer alternative ways of addressing the value of public health services.  We will also review the methodological literature to examine how various methodologies have been applied to similar efforts (such as disease prevention) and to assess their general applicability to the public health system. 

In the second task, we will interview key national, state, and local public health practitioners, policymakers, and elected officials to ascertain participants’ views of how the public health system can define and measure value, as well as the feasibility of doing so.  The focus of the interviews will be to identify which specific public health system functions (e.g., screening, vaccination) and domains (e.g., social value for reducing health disparities) contribute to protecting the public's health.  In the third task, we will conduct an extensive search for and analysis of economic evaluations of GPHS activities.  We will focus the search on the Tufts-New England Medical Center’s registry of cost-effectiveness analyses, but will supplement the search with other databases. 

Impact:  Identifying the aspects of public health delivery that provide the most value will have an impact on several levels.  First, the research will inform and may lead to organizational or structural changes that would be more efficient and provide maximum return on the public health investment.  Second, the research will enable public health practitioners, policymakers, and elected officials to explain the overall benefits of GPHS to the public.  Third, as exploratory research, the proposed project will stimulate new ways of thinking about the goals and mission of GPHSs and lead to further empirical research to examine the value of public health. 

Publications relating to this project:

PJ Newman, PD Jacobson, and JA Palmer, Measuring The Value Of Public Health Systems: The Disconnect Between Health Economists and Public Health Practitioners, American Journal of Public Health 2008 (forthcoming).

Measuring the Value of Governmental Public Health Systems (PDF)
by Peter D. Jacobson, JD, MPH and
Peter J. Neumann, Sc.D.
June 18, 2007

The Sacramento County Driving Under the Influence of Alcohol (DUI)
Intervention Program for Second Offenders

Principal Investigators:  Peter D. Jacobson and Daniel Eisenberg

Funded by the Office of Traffic Safety, NHTSA

This project focuses on whether an inexpensive and brief intervention (BI) delivered in jail to adults (18 or older) after an arrest for driving under the influence of alcohol (DUI) can be effective in reducing DUI recidivism.  The research involves an onsite randomized trial in the Sacramento County jail.  A treatment group will receive the BI shortly before being released from jail; a control group will not.  The evaluation process will include an analysis of self-report data from a baseline questionnaire administered in the jail setting to both the treatment group and the control group and follow-up questionnaires at six and twelve months, and an analysis of administrative data gathered from county government sources that will indicate re-arrest for DUI within the research period.  The evaluation will also examine the effects of impounding the arrestee’s vehicle and a subsequent media campaign to reduce the incidence of DUI.

Newborn Screening Implementation

Principal Investigator:  Pamela McCann Clouser

Funded by the CLOSUP Program, Gerald R. Ford School of Public Policy, University of Michigan

This project examines the influence of institutional and organizational factors on the implementation of newborn screening policy.  Each year, 4 million babies undergo newborn screening in the United States.  This process is currently regulated by state statutes.  State self-reported data, interviews, archival data abstraction, and document reviews will be used to model the influence of bureaucratic autonomy, past policy changes, laboratory-type, and staffing on newborn screening policy implementation.

Background:  Recent scientific innovations in the understandings of human disease, infectious agents, and holistic approaches to population illness have offered new policy approaches to solving public health problems.  States have often been the site of numerous experiments for a variety of policies, particularly in the realm of public health.  In particular, the technology of newborn screening has rapidly advanced since its inception in the late 1960’s.  Consequently, state legislatures have repeatedly adapted their existing newborn screening statutes; 18 state Senate newborn screening bills and 20 state House of Representatives newborn screening bills were introduced in 2005 alone.  From January, 2004 to December, 2005 fifteen states enacted changes in their newborn screening policies. Since the creation of their newborn screening programs, states have changed their newborn screening statute an average of 6.5 times (range 2-14).  The lay public, policy experts, geneticists, and public health practitioners have cited separate concerns regarding the criteria for and impact of such policy changes. 

Tasks:  This project examines the influence of institutional and organizational characteristics on the actual implementation of newborn screening policy changes.  Specific research questions include:

  • To what extent does bureaucratic autonomy influence the speed of the implementation of policy changes at the state level?
  • Do states that experience more newborn screening policy changes over time have agencies that implement policy adaptations more quickly?
  • Does the type of laboratory that analyzes a state’s newborn screening samples shape the implementation of newborn screening policy changes?
  • Does the level of central accountability for newborn screening have an impact on how quickly newborn screening policy changes are realized at the agency-level?

Impact:  By focusing on institutional and organizational issues, we will develop a better understanding of internal barriers that increase the chances that a state will fail to implement policy changes.

The Legal and Ethical Aspects of Family History

Co-Principal Investigators:  Peter D. Jacobson and Toby Citrin

Funded by:  Centers for Disease Control

The Family History Law project is a collaboration between the Centers for Disease Control and Prevention’s (CDC) Office of Genomics and Disease Prevention and the University of Michigan School of Public Health, specifically the Michigan Center for Genomics and Public Health, and the Center for Law, Ethics and Health.

Background.  Family history could be considered the description of the genetic, medical, environmental, ancestral, and psychosocial relationships within a family.  Typically family history is referred to in reference to its association with both rare diseases, common and chronic diseases, and genetic disorders.  In fact, family history has been shown to be a strong independent risk factor for many diseases of great public health concern including coronary heart disease, asthma, and various forms of cancer.  Family history is also linked to rare single-gene Mendelian disorders, such as Cystic Fibrosis and Huntington’s Chorea.

Tasks.  The project is broken down into three (3) parts: 

  • The first part, which was completed over this past summer (May ’06 – Sep ’06), entailed a comprehensive literature review of clinical genomics, family history, genetic risk, and the ethical, legal, and social implications of family history.
  • Starting in Fall 2006, the information gathered and analyzed from the summer will be turned into two different guidebooks both of which will be made available on CDC’s web site.  The first guidebook is designed for primary care physicians and will include highlights from the ethical and legal family history analysis.  The second guidebook focuses on patients. 
  • During the Winter and Spring of 2006-2007, the project will short to generating a series of publications.  These papers will explore the legal and ethical aspects of family history in more depth.

Impact.  Despite the great promise of expanding the use of family histories in primary care using a tool such as this, there were still many unanswered questions about the clinical, ethical, and legal implications of family history, and clinical genomics more generally.  This project will address these issues and provide guidance to practitioners and policymakers for how to integrate family history into the physician-patient encounter.

Current Status.  We have completed our review of the literature involving the legal and ethical issues and have posted summaries on our internal website.  Based on the literature review, we presented our results at a conference at Michigan State University, and received very positive feedback.

We are now drafting two short guides--one for physicians and one for consumers--to facilitate the use of family history as part of the clinical encounter.  We plan to send the draft guides to the project officer within the next two weeks.  After that, we will begin to prepare manuscripts for submission to peer-reviewed journals.