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Background: Little is known about how local health departments (LHDs) are adapting STD control efforts to meet shifting demands as healthcare reform unfolds. We investigated changes in STD services and priorities in two states, California (CA) and Alabama (AL), with comparably large documented racial disparities in STD rates.
Methods: County STD staff were surveyed in CA (February-May 2015) and AL (May-August 2015) to assess scope of practice for STD control and clinic operations. Fifty-six LHDs in CA (92%) and 61 in AL (91%) participated. Key informant interviews were conducted with 5 high-performing LHDs in CA (September-December 2015) and 6 in AL (March-May 2016) to investigate changes in care delivery models and perceptions about county trends. Survey data was analyzed using cross tabulation in Stata. Using MaxQDA, a thematic analysis approach was used to identify themes among transcribed interview recordings that contextualized county activities reported in the surveys. Multiple coders identified themes both congruent and divergent between the two states; inter-coder reliability was assessed.
Results: Analysis revealed four themes: (1) Direct service provision through STD clinics are declining; smaller counties are integrating STD services with county primary care. (2) Respondents described universal access to STD care as an appropriate way to address racial disparities in STD rates within counties. (3) Prevention activities are more common in CA counties (72%) than AL (46%); condom distribution is the most widely available STD prevention service in both states (89% available CA; 70% AL). (4) Mobile applications are viewed as the best way to initiate partner notification services in light of shifting social norms.
Conclusions: Counties have varying degrees of agility to respond to increases in patient demand with sustained STD services. More research is needed to understand the decisional antecedents, benefits, and consequences of counties shifting to integrated models of care and its impact on access to services.