Essential Case Studies in Public Health:

Putting Public Health into Practice

Katherine L. Hunting and Brenda L. Gleason

Editors

PartialFacilitator Guide for Case 16

Beyond Measurement?Evaluating Environmental Public Health:Assessing the Effectiveness of Food Safety Programs

Lindsey Realmuto and SuriliSutaria

SYNOPSIS

Since 2007, each level of government – federal, state, and local – has been affected by the economic decline. Budget cuts imposed by state legislatures have jeopardized the substantial gains that state health agencies have made in the past decade.1Some state health agencies have made programmatic cuts across the board, while others targeted specific programs. Some state health departments reduced services or eliminated activities altogether, such as food safety inspections. In addition, state health agencies have reduced their workforces by reducing staffing levels and eliminating positions. Many staff have been laid off of furloughed. According to a study on the impacts of budget cuts on states conducted by the Association of State and Territorial Health Officials, 87% of all state health agencies have experienced job losses since July of 2008.1

To inform prioritization of programs and activities in the face of budget threats, it is critical that a program can demonstrate measureable success. Although the services provided under state environmental health programs are among the oldest and most traditional, they are not hot topics, such as CDC’s Six Winnable Battles: healthcare associated infections, HIV, motor vehicle injuries, obesity/nutrition/physical activity, teen pregnancy, and tobacco control.2Nor are environmental health services tied to emergency preparedness activities mandated by the Pandemic and All-Hazards Preparedness Act of 2006, which outlines responsibilities by several entities to improve the public’s health and medical preparedness and response capabilities for emergencies, whether intentional, accidental, or natural.3The activities that fall under this statue are mandated by Congress, and funding will always be available to the health agencies for implementation. Nevertheless, activities such as food safety inspections are a vital as a first line of defense against food-borne outbreaks.

In a climate of competing priorities and scarce resources, the evaluation of public health activities provides more evidentiary support for difficult funding decisions. This case follows the decision-making process of a state environmental health program director whose food safety program is threatened by budget cuts. The crux of the case is whether he can demonstrate that his food safety inspection program enhances population health – or perhaps more to the point – whether cutting such services will likely have adverse health impacts. Students will be afforded the opportunity to think critically about program evaluation, and about the impact of food safety programs on the public’s health.

CASE OBJECTIVES AND USE

This case could be an effective teaching resource in a number of different public health courses at the undergraduate or graduate level, including:

  • Introductory public health
  • Environmental health
  • Public health practice
  • Program evaluation
  • Food safety
  • Health policy

In addition, outside of public health, courses focusing on government or public policy – especially at the state or local level – might also use this case.

LEARNING OBJECTIVES

At the conclusion of this case, students should be able to:

  • Interpret study results and translate the findings in order to influence policy-makers;
  • Use critical thinking to design a program assessment plan;
  • Discuss the role of local and state environmental public health professionals in protecting public health;
  • Describe the problem of food-borne illness in the U.S., the role of retail food inspections, and the Hazard Analysis Critical Control Point framework, which was adopted and disseminated by the U.S. Food and Drug Administration;
  • Discuss public health managerial challenges in an economically strained atmosphere.

TEACHING SUGGESTIONS

This case is designed to be read and discussed in sequential sections.The first round questions (1-3) focus on problem formulation/information needs, as well as the role of food safety professionals.The second set of questions (4-6) concerns more technical content regarding food safety and food-borne illnesses.The last set of questions focuses on interpreting existing research, conceptualizing a program evaluation based on available data, and program management implications of decisions about resources.The case could be discussed in 2 to 4 hours.If multiple class sessions are used, the third round questions (7-10) could be discussed on the second day.

Depending on class focus, you may wish to emphasize some parts of this case more than others.For example, questions 4-6 might be discussed in detail in courses on environmental health or food safety, but they could be discussed more briefly in other courses.Program evaluation courses might want to focus most extensively on information needs in the first round questions and on program evaluation ideas in questions 7-10.

You may want to ask students to read the entire case study ahead of class.Alternatively, since the case is relatively short, you may wish to have them read the case one section at a time and discuss in class.The first and second rounds of questions are suitable for a whole-class discussion, although it would also be effective to have students break into groups of 4-6 to brainstorm Question 2.The last set of questions (7-10) is ideal for small group discussion.

IDEAS FOR WRITTEN ASSIGNMENTS

  • Ask students to do pre-class research on one to two outbreaks that they can share with the class. To look at outbreaks in a particular state, check the state department of health website for recent outbreak information. For national outbreaks, use CDC’s Multistate Outbreak website. This site has links to each outbreak with information on the responsible pathogen and the number of people who reported illness.
  • Ask students to identify at least two important information needs for Question 2, part I, along with the type of data that would address the information need.Be sure to emphasize that they should identify measureable information.
  • Ask students to write up a program evaluation methodology, as outlined in Question 3, part III.This could be 1-3 pages, depending on degree of detail desired.

FURTHER INFORMATION

Selected State Environmental Health Resources:

  • Louisiana Office of Public Health: Center for Environmental Health
  • Florida Department Health: Division of Environmental Health
  • California Department of Public Health: Center for Environmental Health

Other Federal and National Association Environmental Health/Food Safety Resources:

  • CDC National Center for Environmental Health
  • U.S. Food and Drug Administration
  • Association of State and Territorial Health Officials
  • National Association of City and County Health Officials
  • International Food Protection Training Institute

Centers for Disease Control and Prevention:

  • Frequently Asked Questions about Foodborne Illness: How does food become contaminated? Available at:
  • CDC’s Multistate Outbreak website describes national outbreaks by year.Available at

KEY QUESTIONS AND ANSWERS

First Round Questions – State Health Department Faces Budget Threats

Below are the “big picture” questions raised by this case.You may want to start the discussion by recapping these questions, and asking students to keep these in mind as they discuss the case.

  • How do restaurant inspections impact the public’s health?
  • How can his staff measure the impact to public health if it does exist?
  • How much does the food safety program cost to implement?
  • What is the estimated cost of food-borne illness in the state, from both direct medical expenditures and lost school and work days?

Before starting with the first round of questions, perform a simple yes or no poll with the class on whether they think John Smith should make an automatic cut to his program or continue with the evaluation. Perform a similar poll before each subsequent round of questions to gauge how the information learned has been interpreted by the class. Ask one to two representatives from each side to provide reasoning for their decision.

  1. What sort of roles and responsibilities do environmental health professionals have regarding food safety?
  • The goal of the question is to allow students to brainstorm about the environmental health profession. Environmental health professionals are sometimes referred to as the “unseen” profession because they do a lot of their work behind the scenes.

There are 10 discussion questions posed in the case; the facilitator’s guide discusses key points for each of these. The Q&A has been redacted for this partial facilitator guide example.

EPILOGUE

The Epilogue has been redacted for this partial facilitator guide example.

LINKAGE TO ASPH/MPH COMPETENCIES

Students will practice the following ASPH/MPH core competencies by working through this case study:

B.Environmental Health Sciences

B1 – Describe the direct and indirect human, ecological and safety of major environmental and occupational agents.

B3 – Describe federal and state regulatory programs, guidelines and authorities that control environmental health issues.

B4 – Specify current environmental risk assessment methods.

D.Health Policy and Management

D5 – Apply the principles of program planning, development, budgeting, management and evaluation in organizational and community initiatives.

In addition, the case study touches on numerous cross-cutting interdisciplinary competencies, most particularly the following:

F.Communication and Informatics

F10 – Use informatics and communication methods to advocate for community public health programs and policies.

J.Professionalism

J3 – Apply evidence-based principles and the scientific knowledge base to critical evaluation and decision-making in public health.

J4 – Apply the core functions of assessment, policy development, and assurance in the analysis of public health problems and their solutions.

K.Program Planning

K3 – Explain how the findings of a program evaluation can be used.

L.Systems Thinking

L2 – Identify unintended consequences produced by changes made to a public health system.

L7 – Illustrate how changes in public health systems (including input, processes, and output) can be measured.

LINKAGE TO ESSENTIAL PUBLIC HEALTH SERVICES

This case study relates most closely to the following essential public health services:

  • Assure a competent public health and personal health care workforce.
  • Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

In addition, it touches upon the following:

  • Enforce laws and regulations that protect health and ensure safety.

REFERENCES

  1. Association of State and Territorial Health Officials. “Impact of Budget Cuts on State Public Health.” Available at: Accessed: January 19, 2010.
  2. Center for Disease Control and Prevention. CDC’s Winnable Battles. December 1, 2010. Available at: Accessed: January 19, 2010.
  3. Pandemic and All-Hazards Preparedness Act of 2006, Pub. L. No. 109-417, 120 Stat. 2831 (2006). Available at: Accessed: January 19, 2010.