JtT

A walk through the Business section of any bookstore or a quick Internet search on the topic will reveal a seemingly endless supply of writings on leadership. Formal research literature is also teeming with volumes on the subject.

However, your own observation and experiences may suggest these theories are not always so easily found in practice. Not that the potential isn’t there; current evidence suggests that leadership factors such as emotional intelligence and transformational leadership behaviors, for example, can be highly effective for leading nurses and organizations.

Yet, how well are these theories put to practice? In this Discussion, you will examine formal leadership theories. You will compare these theories to behaviors you have observed firsthand and discuss their effectiveness in impacting your organization.

To Prepare:

Review the Resources and examine the leadership theories and behaviors introduced.

Identify two to three scholarly resources, in addition to this Module’s readings, that evaluate the impact of leadership behaviors in creating healthy work environments.

Reflect on the leadership behaviors presented in the three resources that you selected for review.

By Day 3 of Week 4

Post two key insights you had from the scholarly resources you selected. Describe a leader whom you have seen use such behaviors and skills, or a situation where you have seen these behaviors and skills used in practice. Be specific and provide examples. Then, explain to what extent these skills were effective and how their practice impacted the workplace.

Duggan et al. BMC Health Services Research (2015) 15:221
DOI 10.1186/s12913-015-0891-3

RESEARCH ARTICLE Open Access

Implementing administrative evidence
based practices: lessons from the field in
six local health departments across the
United States

Kathleen Duggan1*, Kristelle Aisaka1, Rachel G. Tabak1, Carson Smith1, Paul Erwin2 and Ross C. Brownson1,3

Abstract

Background

: Administrative evidence based practices (A-EBPs) are agency level structures and activities positively
associated with performance measures (e.g., achieving core public health functions, carrying out evidence-based
interventions). The objectives of this study were to examine the contextual conditions and explore differences in local
health department (LHD) characteristics that influence the implementation of A-EBPs.

Methods

: Qualitative case studies were conducted based on data from 35 practitioners in six LHDs across the United
States. The sample was chosen using an A-EBP score from our 2012 national survey and was linked to secondary data
from the National Public Health Performance Standards Program. Three LHDs that scored high and three LHDs that
scored low on both measures were selected as case study sites. The 37-question interview guide explored LHD use of an
evidence based decision making process, including A-EBPs and evidence-based programs and policies. Each interview
took 30–60 min. Standard qualitative methodology was used for data coding and analysis using NVivo software.

Results

: As might be expected, high-capacity LHDs were more likely to have strong leadership, partnerships, financial
flexibility, workforce development activities, and an organizational culture supportive of evidence based decision
making and implementation of A-EBPs. They were also more likely to describe having strong or important relationships
with universities and other educational resources, increasing their access to resources and allowing them to more easily
share knowledge and expertise.

Conclusion

s: Differences between high- and low-capacity LHDs in A-EBP domains highlight the importance of
investments in these areas and the potential those investments have to contribute to overall efficiency and performance.
Further research may identify avenues to enhance resources in these domains to create an organizational culture
supportive of A-EBPs.

Background
The tenets of evidence-based decision making (EBDM) in
public health have been formally developed over the past 15
years in several countries. Evidence-based decision making is
a process that involves the integration of the best available
research evidence, practitioner expertise, and the characteris-
tics, needs, and preferences of the community [1–9]. In local
health departments (LHDs), this process includes the imple-
mentation of administrative evidence based practices (A-

* Correspondence: kduggan@brownschool.wustl.edu
1Prevention Research Center, Brown School, Washington University, St. Louis,
MO, USA
Full list of author information is available at the end of the article

© 2015 Duggan et al. This is an Open Access
(http://creativecommons.org/licenses/by/4.0),
provided the original work is properly credited
creativecommons.org/publicdomain/zero/1.0/

EBPs) [9]. Administrative evidence based practices are
agency level structures and activities positively associ-
ated with performance measures (e.g., achieving core
public health functions, carrying out evidence-based in-
terventions) [10]. There are five broad domains of A-
EBPs: leadership, workforce development, partnerships,
financial processes, and organizational culture and cli-
mate (Table 1). These domains were previously devel-
oped from a literature review of evidence reviews that
aimed to identify administrative practices of varying pri-
ority, determined by the length of time needed to mod-
ify them or the strength of their research support [10].
The five broad domains, and their 11 subdomains, are

article distributed under the terms of the Creative Commons Attribution License
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. The Creative Commons Public Domain Dedication waiver (http://
) applies to the data made available in this article, unless otherwise stated.

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mailto:kduggan@brownschool.wustl.edu

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Table 1 Administrative evidence-based practices (A-EBPs)a in
local health departments

Domain EBP Description

Workforce
development

Training • In-service training in quality
improvement or evidence-
based decision making

• Skills-based training (e.g.,
organization and systems
change)

• Training in communicating and
collaborating with employees
from multiple disciplines

• Training aligned with essential
services and usual job
responsibilities

Access to
technical assistance

• Access and use of knowledge
brokersb

• Use of process improvement
activities (e.g., accreditation,
performance assessment)

• Face-to-face meetings to
share lessons, compare
experiences, and provide
updates

Leadership Skills and background
of leaders

• Leadership skill development

• Leadership experience

• Quality of leadership

• Leadership influence

• Manager competency to
manage change

Values and
expectations of
leaders

• Leadership support of quality
improvement, national
performance standards,
evidence-based decision
making, innovation,
accreditation

• Intend to hire well-educated,
experienced staff including
specialists (e.g., lab scientists,
epidemiologists, environmental
health professionals, financial
systems experts)

Participatory
decision-making

• Broad participation among
the management team

• Leaders and middle managers
seek and incorporate
employee input

• Non-hierarchical decision-
making

Organizational
climate & culture

Access & free flow
of information

• Communication flow

• Tailored messaging for
evidence-based decision
making

• 360 degree employee
performance reviews geared
to evidence-based practices
(with extensive feedback)

• Ready access to high-quality
information

Table 1 Administrative evidence-based practices (A-EBPs)a in
local health departments (Continued)

Support of innovation
& new methods

• Leadership/management and
employee training in evidence-
based decision making that
includes new methods

• Employees perceiving that
management supports
innovation

• Conscious creation of
environments conducive to
innovation

• Organizational capacity to be
in both business-as-usual
state and state of exploration/
innovation

Learning orientation • Shared employee perceptions
that supervisors value learning
and research evidence

• Project management teams
that encourage communication
& collaboration

• Presence of multidisciplinary,
diverse management teams

Relationships &
partnerships

Inter-organizational
relationships

• Build and/or enhance
partnerships with schools,
hospitals, community
organizations, social services,
private businesses, universities,
law enforcement

• Cooperative agreements with
state and/or local health
departments quality
improvement

Vision & mission of
partnerships

• Clear vision & aligned mission
of partnerships

• Capacity building over time
among partners

Financial

practices

Allocation &
expenditure of
resources

• Outcomes-based contracting

• Resources allocated for quality
improvement, evidence-based
decision making, innovation,
information access, training
and implementation

• Diverse funding sources
aAdapted from Brownson et al. [3]
bA knowledge broker is a masters-trained individual available for
technical assistance

Duggan et al. BMC Health Services Research (2015) 15:221 Page 2 of 9

described as both high-priority and locally modifiable in a
short to medium timeframe [10]. Use of A-EBPs in LHDs
is important because these practices have been shown to
be effective in boosting performance, contributing to ac-
creditation efforts, and may ultimately lead to improved
health of the population [9, 10]. In addition, the Public
Health Accreditation Board requires that LHDs use and
contribute to the evidence base, and likewise requires ef-
fective administrative practices – thus use of A-EBPs may
fulfill multiple domains within the LHD accreditation

Duggan et al. BMC Health Services Research (2015) 15:221 Page 3 of 9

process [11]. Since LHDs in the United States are using A-
EBPs to varying degrees [12, 13], it is important to examine
the contextual conditions that influence the implementa-
tion of A-EBPs. The purpose of this study, then, is to ex-
plore differences in LHD characteristics that may in part
explain the differences in implementation of A-EBPs. In
particular, this study will focus on contextual differences be-
tween high- and low-capacity LHDs, further defined below.

Methods
A mixed methods approach was utilized to expand upon
quantitative findings from the LEAD Public
Health National Survey (LEAD survey) and further
examine differences in LHD characteristics that influ-
ence the use of A-EBPs [12, 13]. Qualitative case studies
were conducted among a select number of LHDs, in
conjunction with a set of quantitative studies on the def-
inition and use of A-EBPs in LHDs [9, 10, 12, 14–17].
The case study sample was selected using an A-EBP
score from the LEAD survey (described elsewhere) [12]
and secondary data from the National Public Health Per-
formance Standards Program (NPHPSP). A set of A-EBP
scores were derived from thirteen 7-point Likert scale
questions from the LEAD survey and sum scores were
then ranked into quartiles. Secondary data from the
NPHPSP was linked to the LEAD survey; in concord-
ance with NPHPSP scoring methodology, an overall per-
formance score was computed as a simple average of the
10 Essential Public Health Services scores and then
ranked into quartiles. “High-capacity” was defined as A-
EBP scores in the top quartiles and “low-capacity” de-
fined as scores in the bottom quartiles for both the
LEAD survey and the NPHPSP.
Three LHDs that were in the top quartile and three

from the bottom quartile of both measures were used as
case study sites. The 6 sites were selected to provide a
variation in geographic dispersion, governance structure
and jurisdiction size. A goal of 6–8 interviews was used
to achieve content saturation. Previous research shows
that meaningful themes can be developed after 6 inter-
views and saturation is often present with 12 interviews
[18]. All of the LHDs that were selected and approached
agreed to participate in this research.

Case study guide development
The interview guide (see

Additional file

1) was devel-
oped based on previous literature [19–22], prior work by
members of the research team (both researchers and
practitioners) [23, 24], and research team input to ex-
plore LHD use of an EBDM process, including A-EBPs
and evidence-based programs and policies. Evidence-
based programs and policies include interventions, pro-
grams, and policies with evidence (based on published
research) of improving health. Interview guide questions

were developed to qualitatively supplement the data gaps
from the quantitative national survey [12, 15]. The guide
included the following topic areas: 1) biographical infor-
mation; 2) awareness of the existence of an EBDM
process; 3) administrative support for EBDM; 4) know-
ledge of the LHD accreditation process; 5) political cli-
mate and support for EBDM; 6) dissemination strategies
that would further EBDM; and 7) key networks and
partnerships to support EBDM.

Cognitive response testing
In May 2013, the case study guide underwent cognitive re-
sponse testing to elicit questions that were either unclear
or potentially difficult to answer. Cognitive response test-
ing is routinely used in refining questionnaires to improve
the quality of data collection [25–28]. These 45–60 min
phone interviews were conducted by the project manager
with directors of LHDs in two states not selected as case
study sites. The cognitive response testing sample (n = 6)
was purposively selected by members of the research
team. Upon verification of consent, all interviews were
audio recorded, and field notes were taken during the in-
terviews. Participants were instructed to provide feedback
on questions lacking clarity and items that could be
viewed as potentially difficult to answer. After the tester
verbalized each question, the participant was allowed time
to provide relevant feedback on each item. Information
from these interviews was used to modify items and for-
mulate the revised questionnaire for reliability testing. The
final interview guide included 37 questions in the seven
topic areas previously listed.

Case study interviews
Interviews were conducted with 35 practitioners (including
directors and assistant ant directors) from the six case study
sites in June-July of 2013, with an average of five interviews
per LHD. LHD directors and assistant directors selected a
variety of practitioners/professional staff for interviews
including program managers, clinic managers, and admin-
istrative or financial managers because these individuals
were likely to be knowledgeable about the LHD’s EBDM
practices. Each interview was conducted by two members
of the research team and took 30–60 min, depending on
the length of answers and knowledge of the practitioner.
All participants provided informed consent before the
interview began. This study received IRB approval from
Washington University in St. Louis.

Analysis
The interviews were tape recorded with the respon-
dent’s permission and transcribed verbatim. Standard
qualitative methodology was used for data coding using
NVivo software. Four team members were trained on
coding to ensure reliability among raters. A codebook

Duggan et al. BMC Health Services Research (2015) 15:221 Page 4 of 9

was complied with inductive codes, and both inductive
and deductive codes were used when coding the tran-
scripts. Coders were assigned transcripts to code inde-
pendently, after which the codebook was refined to
capture new themes and subcategories. Updated code-
books were distributed after each coding session. Cod-
ing pairs systematically coded three interviews using
NVivo noting any discrepancies and alternate coding.
Once these transcripts were coded and the codebook
refined, inter-rater reliability was evaluated using NVivo
with a final percent agreement among coders of 98 %.
Data from each LHD was summarized and combined
into high-capacity LHD and low-capacity LHD categor-
ies. Node reports were generated to explore common
themes in the high-capacity and low-capacity LHDs and
then summarized into thematic reports for each of the
five A-EBP domains.

Results
Of the three LHDs categorized as high-capacity, two
had local governance and one had shared governance
between the state and LHD. One LHD was in each of
these three jurisdiction sizes: 500,000+; 100,000–499,999;
and 25,000–49,999. Two of these LHDs were in the
Midwest census region and one in the South census re-
gion. The three LHDs categorized as low-capacity had
two state-governed health departments and one with
shared governance. Two of them had population juris-
diction sizes between 50,000–99,999 persons, and one
between 25,000–49,999 persons. There was one LHD in
each of the census regions of the South, Northeast, and
West.
From the thematic reports, the similarities and differ-

ences of high-capacity and low-capacity LHDs were com-
pared across the five A-EBP domains and organized into
an A-EBP table (Table 2). Based on the A-EBP table, spe-
cific themes and patterns were identified and explored.
The domain of relationships and partnerships was very
similar for both high- and low-capacity LHDs—both
groups reported that they value partnerships and often
share expertise and staff time with their partners. The only
difference that appeared was specific to internal relation-
ships within the LHD. Consequently, we have limited the
discussion of partnerships to the differences in internal re-
lationships that have been grouped under organizational
culture and climate. The domains of workforce develop-
ment, leadership, and organizational climate and culture
had the most dramatic differences between high and low
capacity LHDs.

Workforce development

High-capacity LHDs often mentioned training as an im-
portant aspect of their work; for example, employees
mentioned opportunities to attend state and national

conferences. Two of the high-capacity LHDs also men-
tioned using staff meetings to have on-site trainings
about the EBDM process, accreditation documentation,
or continuous quality improvement. One participant
from a high-capacity LHD described:

“there is a line item for education or continuing
education [for] our staff. So if people need a certain
type of training […] we have that and we provide that
to our employees to make sure they’re all certified.”

Staff at low-capacity LHDs expressed the desire to attend
trainings and conferences, but said funding constraints and
travel restrictions do not allow them to attend. One partici-
pant from a low-capacity LHD mentioned:

“We can go to [one specific] conference, but anything
else, we do on our own. It hasn’t always been like
that, but it has the last several years.”

Leadership

Leadership encompasses values and expectations of leaders
as well as participatory decision making at the LHD. Lead-
ership at both sets of LHDs expressed the knowledge that it
is desirable to use evidence-based programs and policies,
but employees at the high-capacity LHDs more often noted
behaviors of the leaders as being intentional for the purpose
of promoting the use of EBPs. Leaders at the high-capacity
LHDs were more likely to be fully supportive of EBPs, to
actively provide direction and training for staff in EBPs, and
to convey the expectation that the LHD would continu-
ously grow and change. When asked about decision mak-
ing, staff at high-capacity LHDs mentioned group decision
making, ideas generated by non-managerial staff, and all-
staff meeting time used for the purpose of gathering and
distributing ideas. One participant from a high-capacity
LHD commented,

“It’s important enough to administration that they
have the time to do the research and to attend the
academic classes or the trainings and things that they
need to keep us current on best practices.”

Staff at low-capacity LHDs, in contrast, had mixed
feelings about leaders’ support for EBPs; one mentioned
that

“I’ve found it from my director, but not necessarily
some of the other leaders.”

Additionally, lack of communication regarding expec-
tations for using EBPs, as well as how and when to use
them, emerged as a theme in low-capacity LHDs. Deci-
sion making at the low-capacity LHDs was often done

Table 2 Comparison of high and low capacity local health departments (LHDs) by A-EBP domain

AEBP High Low Both

Workforce development

Training – Budget line item for continuing
education

– No financial support to go to
trainings

– Recognize the need for trainings

– Try to send staff to all state and
some national conferences

– Very few if any attended – More are needed

– Use time during all staff meetings
to conduct trainings

– Potential areas of focus: accreditation,
webinars (as opposed to in-person training),
specific topic-related conferences

Leadership

Skills & background
of leadersa

– Physician/MPH/PhD – Masters in Management

– Bachelors in SW, MSW, completing
MPH

– Bachelors in nursing, certificate
of grad study in fundamentals
of public health

– Bach in science and education

Values & expectations
of leaders

– 100 % supportive of use of EBPs – Directors mostly supportive
of EBPs

– Supportive of EBPs

– Expect LHD to grow and change
including use of EBPs

– Not all upper management
were supportive of EBPs

– Know EBPs should be used

– Feel it is their job to provide direction
and training for their staff in EBPs

– Poor communication of EBPs
and expectations

– Want to provide quality service for the
clients

Participatory
decision-making

– Decisions often made by consensus – State makes many decisions – Subject matter experts at the LHD consulted

– Ideas come up from staff to
management and tested

– Decisions mostly made by
upper level management team

– State and regional HDs give directives

– All staff meetings once a month to
gather and distribute ideas

– Director makes decisions after
evaluating staff ability and
capacity for programs

– Involve community members and
stakeholders

Organizational climate
& culture

Access and free flow
of information

– University libraries – Very little access to online or
paper journals

– Internet access

– Attendance at conferences, in-person
and online trainings

– Information from state office

– Some academic journal subscriptions
through LHD

– National Association of County and City
Health Officials

Support of innovation
& new methods

– Supports and encourages new ideas – Many people in the LHD are
adverse to change

– Would like staff to be open to change more

– Uses QI to explore things that can be
changed to improve LHD

– No flexibility to try anything
new because many priorities are
mandated by the state

– Hires employees that are willing to
change with the LHD

– New ideas are not well-received

– “Global” instead of “Silo” approach to
programs

Learning orientation – Send staff to conferences and/or
conduct trainings at the LHD show
support of learning

– Do not necessarily emphasize
collaboration, especially
multidisciplinary

– Would like to send staff to more trainings
and conferences but can’t due to lack of
budget

– Many staff go back for MPH while
working

– More multidisciplinary collaboration
within the LHD

Relationships &
partnerships

Interorganizational
relationships

– Some sharing of funding between
partners including grants from the
community

– Funding is only shared within
the department

– Feel partners are essential to work of the
health department

Duggan et al. BMC Health Services Research (2015) 15:221 Page 5 of 9

Table 2 Comparison of high and low capacity local health departments (LHDs) by A-EBP domain (Continued)

– Share facilities – Looking to community
assessment to bring LHD and
community partners closer

– Share staff time and resources with partners

– Community partners have been
involved in trainings

Vision and mission
of partnerships

– Seems collaborative – Many partnerships seems to be
one working for the other i
nstead of collaborative

– Come together for the good of the citizens

Financial

Allocation and
expenditure
of resources

– State department provides funds to
the LHD to prepare for accreditation

– No funding that is not already
earmarked for specific programs

– Lack of finances is major roadblock to
implementing EBPs and EBDM Process

– Line item in the budget for trainings
and conferences

– Positions have been cut due to
budget cuts

– Lack of funding to pay high salaries can lead
to hiring of staff that has less experience
and/or less education

– Several staff felt their LHD has the
financial stability needed

– Financial situation makes even
mandated programs difficult to
implement

aSelf-reported by LHD leaders

Duggan et al. BMC Health Services Research (2015) 15:221 Page 6 of 9

by the management team or director. However, many
decisions were said to be made at the state or regional
level without input from anyone at the LHD.

Organizational climate and culture
Access to information, support of innovation, and learning
orientation are part of organizational culture and climate.
Overall, staff at high-capacity LHDs had better resources to
access more information; they described access to univer-
sity libraries, academic journal subscriptions, or trainings to
get information. In contrast, staff at the low-capacity LHDs
had little access to online or printed paper journals. Regard-
ing support of innovation, the culture at high-capacity
LHDs was described as encouraging to new ideas and open
to changes that would improve the overall LHD. One par-
ticipant from a high-capacity LHD commented that their
LHD encourages employees to:

“Always try to improve things, try new things, that’s
fine. And if you make a mistake doing that, you’re not
going to be fired for that, you’re not going to be
reprimanded for that; you’re going to try something
new, something different.”

They also mentioned more collaboration within their
LHD; one participant described that:

“one of the things that we have done an exceptional
job at doing is breaking down silos [….] we have more
of a global approach, an open approach, that allows us
to get things done and get things done fairly
efficiently.”

Low-capacity LHDs, on the other hand, were de-
scribed as having cultures that were averse to change
and without flexibility due to state mandated programs.

On the topic of new ideas and changes, one participant
from a low-capacity LHD described:

“There are some up and coming individuals who have
different ideas and different ways of doing things, but
I can’t say at this point that it’s extremely well-received.”

Related to the A-EBP domain of relationships and
partnerships, low-capacity LHDs overall were also less
likely to highlight multidisciplinary relationships, instead
only mentioning collaboration with specific individuals
or directors within their departments.

Financial practices
Differences between high- and low-capacity LHDs were
evident in the domain of financial practices as well. This
was most apparent when looking at the reported flexibil-
ity of funding within the department. Low-capacity
LHDs had little to no flexible funding and reported they
can only implement state mandated programs. Some of
these LHDs were experiencing staffing shortages and felt
they were unable to implement programs fully due to
this shortage and to budget constraints. One participant
from a low-capacity LHD mentioned:

“Because we do not have latitude in how we spend
money, I think … it probably impedes our ability to
think about solutions to problems that could be
affected had we been able to obtain and sustain
[funding for programs].”

High-capacity LHDs also reported that they would like
more funding, but had some flexible funding to use on
the programs they thought were best for their LHD.
They also seemed to be more optimistic about meeting
goals despite financial difficulties. One participant from
a high-capacity LHD pointed out:

Duggan et al. BMC Health Services Research (2015) 15:221 Page 7 of 9

“There’s always a gap [between what we would like to
have and what’s available]. As long as we’re on board
and we recognize those challenges, we do the best we
can to meet all those goals.”

Discussion

High-capacity LHDs were more likely to have the leader-
ship, organizational culture, and financial capacity to sup-
port workforce development activities, through sending
staff to trainings and conferences and/or using meetings
and training opportunities. In addition, high-capacity
LHDs mentioned that more supportive, communicative
leadership goes farther in building a department that is re-
silient to setbacks or problems that may arise. More spe-
cifically, they seemed to have more accepting, supportive
cultures that value innovation and encourage collaborative
communication compared to low-capacity LHDs. High-
capacity LHDs were also more likely to mention working
with a wider range of staff across their LHD, instead of
particular individuals or staff within their own work unit.
Financial constraints were a huge barrier for both high-
and low-capacity LHDs; however, high-capacity LHDs
seemed more flexible and open to making things work.
Low-capacity LHDs were more likely to describe limited
or insufficient funding as an insurmountable obstacle.
Lastly, high-capacity LHDs were more likely to describe
having strong or important relationships with universities
and other educational resources, which increases their ac-
cess to resources and allows them to more easily share
knowledge and expertise.

Relationship to findings from previous research
Workforce development emphasizes the importance of fo-
cusing on the core competencies for public health profes-
sionals, incorporating them into LHD missions, visions,
and goals. Providing trainings for employees in quality im-
provement or EBDM, leadership skills, multidisciplinary
approaches, and other areas increases growth and learn-
ing, enhancing the capacity and reach of a LHD [17, 29].
Workforce development has been linked to better per-
formance, which ultimately leads to better community
health outcomes [17, 29].
Enhancing leadership includes having competent leaders

that can effectively communicate missions and visions, and
are knowledgeable about and supportive of quality im-
provement, accreditation, national performance standards,
EBDM, participatory decision-making and non-hierarchical
collaboration [30]. It may also involve having leaders with
sufficient amounts of skill, experience, and influence, as
well as having a competent workforce that is able to take
on leadership positions within the LHD. Leadership is espe-
cially important in that it is the driving factor behind other
A-EBPs—leaders who understand the importance of EBDM

are more likely to prioritize workforce development and
emphasize a specific kind of organizational culture, effect-
ing further growth within their LHD [31].
An effective organizational culture has a learning orienta-

tion that encourages new thinking and adapting to new en-
vironmental conditions, rather than just doing what has
been done in the past. It also includes support and training
that incorporates innovation and new methods, valuing di-
versity and unique perspectives [17]. This is made possible
through access to high-quality information and feedback
from leaders about employee performance. Additionally,
prior research suggests that the introduction and use of
specific resources and tools across LHDs should be priori-
tized as an effective organizational strategy [32].
Allocating resources and actively promoting the use of

A-EBPs (e.g., supporting quality improvement, EBDM,
training) can improve health department performance and
community health overall [29]. Easily accessible tools and
resources can reduce time and cost barriers to EBDM
within LHDs, improving both effectiveness and efficiency
[32]. Additionally, obtaining funding from multiple, di-
verse places gives LHDs greater flexibility in spending and
lessens dependence on only a few core sources [33].
Finally, building and enhancing relationships with

multidisciplinary partners and being able to identify and
clarify a shared vision helps to increase rates of change,
sustainability, and capacity building over time [17, 29].

Implications
Low-capacity LHDs may benefit from identifying more cre-
ative, cost-efficient strategies for enhancing workforce de-
velopment. Research suggests that incorporating meetings
and trainings that are more interactive and problem-
specific, as well as emphasizing autonomy, prior knowledge,
and relevancy, will be more effective in developing a more
educated, competent workforce [34]. Workforce develop-
ment training that emphasizes leadership skills may also be
beneficial, as leaders can have a tremendous influence on
other areas of the LHD and overall productivity, especially
in terms of what kind of supportive communication and ac-
tion takes place [35].
Low-capacity LHDs could benefit from leaders who

emphasize and value A-EBPs through communication,
training opportunities, funding, and other means. In-
creased leadership support across various levels and
departments within the LHD could facilitate change in
organizational culture and climate, helping staff to be
more comfortable with EBPs and the process of EBDM
[36]. Also, high-capacity LHDs in this sample have
leadership who value innovation and create a culture
that supports risk taking by encouraging staff to try
new ideas. If a new idea doesn’t work, they learn from
it and try something else. This creates an environment

Duggan et al. BMC Health Services Research (2015) 15:221 Page 8 of 9

that is supportive of change and is not of afraid of
failure.
Lastly, research has suggested that partnerships be-

tween academia and LHDs are critical for addressing
public health needs and successfully improving a com-
munity’s overall health and well-being [37]. Thus, ex-
ploring avenues to enhance collaboration and resource
exchange between universities and LHDs may help to
lessen the gap between low- and high capacity LHDs.

Limitations
The main limitations of this study are that the data are
self-reported and the sample size was small, thus limit-
ing generalizability. In addition, practitioners interviewed
were selected by the director and this could introduce
selection bias. Finally, the LHDs in high and low cap-
acity categories differed in size, governance structure,
and geographic region – all of which may independently
impact or influence performance capacity. Specifically,
the group of high-capacity LHDs chosen by our ranking
method had larger jurisdiction sizes in comparison to
the group of low-capacity LHDs, which may have fac-
tored into their ability to address A-EBPs. A more in-
depth exploration of how high- and low-capacity LHD
performance differs based on size, governance structure
and geographic region is an area needing further study.

Conclusion
Differences between high- and low-capacity LHDs in A-
EBP domains highlight the importance of investments in
these areas and the potential those investments have to
contribute to overall LHD efficiency and performance.
Low-cost resources exist for low-capacity LHDs to better
their performance, including free A-EBP issue briefs that
give background information and specific resources re-
lated to each of the 5 A-EBP domains, a resource toolkit
about A- EBPs that lists online resources available to
LHDs [38], training courses to improve EBDM [39], and
the National Association of City and County Health Of-
ficials’ EBDM resource site for LHD practitioners [40].
Additionally, low-capacity LHDs might consider seeking
higher-capacity LHD mentors or partners, as well as in-
creasing cross-jurisdictional sharing of resources. Enhan-
cing access to resources and technical assistance to
improve A-EBP use in LHDs should be explored further.
Also, enhancing leadership skills to foster a more flexible
environment supportive of innovation may enhance cap-
acity in LHDs. Lastly, policy makers and researchers
should strive to offer easily accessible trainings to LHDs.
Investments in A-EBPs have the potential to increase
readiness for LHD accreditation, improve overall perform-
ance, and improve health outcomes in communities.

Additional file

Additional file 1: Case study Interview Guide.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

Conceptualization and design: RCB, KD, RT, CS, PE. Survey instrument
development: RCB, KD, RT, PE. Data collection: KD, CS, KA. Data management:
KD, CS, KA. Data analyses: KD, RT, CS, KA. Manuscript revisions: All. All authors
read and approved the final manuscript.

Acknowledgements

We would like to thank the members of our LEAD Research Team LEAD
including: Janet Canavese and Kathleen Wojciehowski, Missouri Institute for
Community Health; Dorothy Cilenti, University of North Carolina; Beth
Dodson, Amy Eyler, Robert Fields, and Jenine Harris, Mackenzie Staub, Brown
School, Washington University in St. Louis; Carolyn Leep, National Association
of City and County Health Officials; Rodrigo Reis, Federal University of Parana,
Curitiba, Brazil and School of Health and Biosciences, Pontifícia Universidade
Católica do Paraná, Curitiba, Parana, Brazil; and Katherine Stamatakis, College
for Public Health and Social Justice, Saint Louis University.
This study was supported by Robert Wood Johnson Foundation’s grant no.
69964 (Public Health Services and Systems Research) the National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK Grant Number
1P30DK092950). Additional support came from the Dissemination and
Implementation Research Core of Washington University in St. Louis’
Institute of Clinical and Translational Sciences (Grant Number 5U54CA155496-04).

Author details

1Prevention Research Center, Brown School, Washington University, St. Louis,
MO, USA. 2Department of Public Health, University of Tennessee, Knoxville,
TN, USA. 3Division of Public Health Sciences and Alvin J. Siteman Cancer
Center, Washington University, St. Louis School of Medicine, St. Louis, MO,
USA.

Received: 8 December 2014 Accepted: 26 May 2015

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Abstract
Background
Methods
Results
Conclusions
Background
Methods
A mixed methods approach was utilized to expand upon quantitative findings from the LEAD Public
Case study guide development
Cognitive response testing
Case study interviews
Analysis
Results
Workforce development
Leadership
Organizational climate and culture
Financial practices
Discussion
Relationship to findings from previous research
Implications
Limitations
Conclusion
Additional file
Competing interests
Authors’ contributions
Acknowledgements
Author details
References