title: The future of urban health: needs, barriers, opportunities, and policy advancement at large urban health departments.
abstract: BACKGROUND
  More than 2800 local health departments (LHDs) provide public health services to more than 300 million individuals in the United States. This study focuses on departments serving the most populous districts in the nation, including the members of the Big Cities Health Coalition (BCHC) in 2013.
  
  
  OBJECTIVE
  To systematically gather leadership perspectives on the most pressing issues facing large, urban health departments. In addition, to quantify variation in policy involvement between BCHC LHDs and other LHDs.
  
  
  METHODS
  We used a parallel mixed-methods approach, including interviews with 45 leaders from the BCHC departments, together with secondary data analysis of the National Association of County & City Health Officials' (NACCHO) 2013 Profile data.
  
  
  METHODS
  Forty-five local health officials, chiefs of policy, and chief science/medical officers from 16 BCHC LHDs.
  
  
  RESULTS
  The BCHC departments are more actively involved in policy at the state and federal levels than are other LHDs. All BCHC members participated in at least 1 of the 5 policy areas that NACCHO tracks at the local level, 89% at the state level, and 74% at the federal level. Comparatively, overall 81% of all LHDs participated in any of the 5 areas at the local level, 57% at the state level, and 15% at the federal level. The BCHC leaders identified barriers they face in their work, including insufficient funding, political challenges, bureaucracy, lack of understanding of issues by key decision makers, and workforce competency.
  
  
  CONCLUSIONS
  As more people in the United States are living in metropolitan areas, large, urban health departments are playing increasingly important roles in protecting and promoting public health. The BCHC LHDs are active in policy change to improve health, but are limited by insufficient funding, governmental bureaucracy, and workforce development challenges.
authors.affiliation: National Association of County & City Health Officials, Washington, District of Columbia (Dr Hearne and Ms Bass); de Beaumont Foundation, Bethesda, Maryland (Mr Castrucci and Dr Leider); and Robert Wood Johnson Foundation, Princeton, New Jersey (Dr Russo).
authors.forename: Shelley
authors.initials: S
authors.lastname: Hearne
authors.forename: Brian C
authors.initials: BC
authors.lastname: Castrucci
authors.forename: Jonathon P
authors.initials: JP
authors.lastname: Leider
authors.forename: Elizabeth K
authors.initials: EK
authors.lastname: Rhoades
authors.forename: Pamela
authors.initials: P
authors.lastname: Russo
authors.forename: Vicky
authors.initials: V
authors.lastname: Bass
mesh_terms: D003299:Cooperative Behavior; D006291:Health Policy; D006801:Humans; D007857:Leadership; D009111:Local Government; D011635:Public Health Administration / Q000379:methods*; D014481:United States; D014505:Urban Population / Q000639:trends*