Funded by the Practice-Based Research Network of the Robert Wood Johnson Foundation

September 2014- August 2016

Project DIRECT aims to closely examine local public health systems in California and Alabama for variation in STD service provision. Specifically, we plan to examine variation in the differentiation, integration, and concentration of STD prevention, screening and treatment services as the local level in these two states. Quality of community and agency-level STD services, key outcome measures, and facilitator and barriers to implementing evidence-based STD interventions are all key features we plan to examine.



STDs continue to be a public health burden in the United States. Despite advances in disease surveillance and prevention methods, annual national STD incidence rates have not declined in recent decades and have increased for some conditions. Untreated STDs can have serious long-term health effects. Racial disparities in STD incidence are widening – both California and Alabama have large documented differences in STD incidence by race. STDs are among the largest non-Hispanic Black-White racial differences in health.

Local public health departments play a crucial role in controlling the spread of STDs, and used to be the “frontline” for STD screening and treatment. But in recent years a growing number of Local Health Departments (LHDs) are transitioning the direct provision of STD services from LHDs to community health centers (CHCs) and other community providers. Community partner organizations may play a bigger role in performing essential public health functions in communities as the ACA unfolds. New configurations of STD direct services at the local level may influence the reach and effectiveness of STD prevention, screening, and treatment programs.


Research Design

Our proposed project aims to clarify the relationship between LHD configuration and integration of evidence-based STD services using a mixed methodology with four approaches:

  • Stakeholder engagement and feedback of core structure, process, and outcome measures relevant to STD control. To ensure engagement of practice based partners, we will work closely with project advisory groups within each state composed of leaders and stakeholders from the practice community, such as the STD controllers in LHDs, State STD Program Controllers, as well as other experts. We will use our PBRN collaborative processes and advisory groups to finalize the criteria for defining “effectiveness,” to review the methodology, as well as identify optimum methods for feedback and interactions with LHDs, as well as dissemination of results. Importantly, the advisory groups will also provide critical feedback as to which process and outcome indicators can be considered valid measures of program effectiveness.


  • Survey of LHDs to clarify the use of evidence-based STD interventions and STD service organization. We propose to conduct a survey of Alabama and California STD programs at the local level in 68 and 61 jurisdictions, respectively, to assess the extent of differentiation, integration, and centralization of STD services. The specific services we assess in our proposed survey span STD prevention, screening, and treatment services and represent a range of evidence-based interventions and interventions with accumulating evidence.


  • Multiple stakeholder key informant interviews. To examine the facilitators and barriers of implementing evidence-based interventions, we will conduct key informant interviews in a subsample of LHD STD programs, CHCs, Planned Parenthood, major private providers and/or other community sexual health programs, and faith-based organizations.


  • Cost analyses. Using the data from the LHD survey, we plan to assess the cost of STD treatment services in LHD in a sub-sample of LHDs using a positive deviance approach.


Policy & Practice Implications

Prior work has assessed the relationship of county-level sociodemographic factors and STD rates. The local public health system organizational and financial arrangements specific to STD prevention, screening, and treatment services, however, have not been assessed among as diverse a set of jurisdictions as in this proposal.

Project DIRECT has potential to:

  • Identify effective financial and organizational arrangement to deliver recommended STD services across a community’s public health and clinical care settings


  • Identify methods which maximize LHD revenue opportunities to support population health improvement and reduce disparities


  • Clarify the most successful approaches for sharing STD prevention, screening, and treatment resources and services across local public health agencies and their partners


  • Define more holistically the relationship between LHD organization, prevention, and provision of services and STD incidence rates


  • Help agencies realize economies of scale in public health delivery