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Using PBRNs to Identify Delivery, Quality and Cost of Nuisance Inspection and Abatement Services in Ohio Scott Frank, MD, MS Director, Case Western Reserve University Master of Public Health Program Director, Shaker Heights Health Department Jason Orcena, MA Health Commissioner, Union County Health Department Slide 2 Faculty Disclosure No Conflict of Interest to Disclose. Funding from the Robert Wood Johnson Foundation Delivery and Cost Studies (DACS) grant Slide 3 Nuisance Abatement Habits of transgression formed from repeated petty misdeeds can ripple up to bad effect in a polity. o Plato (788b-c) Slide 4 Purpose Examine the process, cost, and value of mandated local health department nuisance inspection and abatement Slide 5 Objectives Describe the nature and content of nuisance inspection and abatement in LHDs quantified through Direct Observation of Nuisance Abatement (DONA) Identify time and cost in total and in component dedicated to nuisance inspection and abatement Discuss perceptions of the value of nuisance inspection and abatement Slide 6 Background Nuisance inspection and abatement is a mandated, unfunded, essential public health service Often represents the face of the local health department (LHD) to the community Most likely interaction of environmental public health with other governmental departments Slide 7 What is a Public Health Nuisance? A condition or activity involving that amounts to an unreasonable interference with community: Health Safety Morals Comfort Prevent uninhabitable conditions and to control the spread of disease Conditions that may cause sickness, disease and filth Slide 8 Steps in Nuisance Enforcement Nuisance identified Investigate Declare a Nuisance Abate a Nuisance Develop policy to control a range of actual or potential nuisances Civil rather than criminal consequences Slide 9 Broken Window Theory An unfixed broken window leads to decay and disorder, which in turn leads to social disorganization, increased criminality and impaired health and safety Those that live in a broken neighborhood tend to leave it broken, therefore leading to greater levels of crime and civic disinvestment If a broken window is unrepaired, all the windows will soon be broken Wilson and Kelling, 1982 Take care of the little things and the big things will take care of themselves Slide 10 Broken Window Theory Social Disorganization Theory: Physical and social environment are primarily responsible for the behavioral choices people make Social norms change or are set based on the level disorganization High broken windows index (litter, graffiti, abandoned cars, and blighted housing) independently predicted neighborhood gonorrhea rates Root Causes Matter Cohen D, Spear S, Scribner R, Kissinger P, Mason K, Wildgen J. 2000. Broken windows and the risk of gonorrhea. Am J Public Health 90(2):230 236. Slide 11 DONA Methods Comparative case study Mixed methods approach including interview, direct observation of service delivery, abstraction of nuisance inspection and abatement reports Time studies were conducted to measure the delivery of services Slide 12 DONA Methods Seven trained student observers were partnered with 27 environmental health specialists across 6 LHDs Each LHD provided access to student observers during all steps of 167 nuisance inspection and abatement procedures Abstraction of 509 Nuisance inspection reports conducted in the past 12 months Development of an observational protocol through focus group and DELPHI process Inter-rater reliability was demonstrated in previous research Slide 13 Analyzing and Interpreting Results Comparative Case Study includes the use of direct observation, data abstraction, surveys & interviews with EHS Mixed Methods used to analyze the structured direct observations and data collected from field notes and abstraction forms Slide 14 LHD Sites Slide 15 Methods In 2010, the median salary for public health environmental health technicians $41,380 (mphonline.org) Environmental health worker benchmark 1 per 25,000 population or 4.35 per 100,000 population (NACCHO 2011) Slide 16 Time spent with nuisance inspection and abatement 56% male Average 15 years working in environmental health 70% have conducted 10 or more nuisance inspections in the past 2 months 26% have conducted more than 60 10% of time spent conducting nuisance inspections 37% of time at desk involved with paperwork or communication regarding nuisance abatement Slide 17 Top Nuisance Complaints* 1.Property32% 2.Animal29% 3.Garbage or Solid Waste28% 4.Water16% 5.Air15% 6.Insect14% 7.Sewage13% 8.Other 11% 9.Toxic (hazardous)5% *combined observation and abstraction (n=676) Slide 18 Slide 19 Actuals Musty, moldy smell throughout hotel and bedbugs infestation in room where complainant spent the night Rancid smell of dog feces, and dog feces run-off observed on sidewalk after rain. Mosquitos breeding on back patio of property because there are kiddie pools and buckets collecting water. Overwhelming odor in laundry room of apartment complex. Smells like old meat and because the compacting room shares a vent with the laundry room, the entire floor smells. Vacant home with neighbors complaining of pool breeding mosquitoes. Abandoned refrigerator next to house (no doors on refrigerator) but prescription drugs viewable. Severe waste in and outside of a trailer, neglected animals locked into cages, and strong odors. Septic tank rusted and discharging into river. Slide 20 Source and Object of Complaints* Resident re: other private property28% Unknown/Anonymous22% Resident re: own property13% Re: commercial property11% Renter re: rental property11% Government employee re: residential7% Re: public property2% *observation only (n=167) Slide 21 Mechanism of Contact* Phone 73% Email/online15% Other12% In person (6) Mayors office (3) Complaint form (4) Hospital fax (5) Effort made to contact complainant prior to visit 33% *observation only Slide 22 Activities during Inspection Squat/Bend/kneel48% Look under or behind46% Take notes or drawings45% Environmental education39% Offer advice36% Take pictures15% Inspection related phone calls13% Slide 23 Closing the Inspection Offers clear feedback 91% Discuss improvement plan88% Environmental health education 62% Slide 24 Informant/Complainant Response Knowledge questioned13% Judgement questioned 11% Fairness questioned 15% Authority questioned 15% Informant with conflict or argument 16% Informant raises voice in anger 13% Slide 25 Outcome of Inspection Process* Nuisance remediated/didnt require 58% Nuisance partially/not remediated 42% Require further discussion23% EHS had special concerns19% EHS threatened punitive action 11% *observation only Slide 26 Nuisance Inspection Outcomes Resulted in citation15% Resulted in written orders18% Resulted in verbal warning11% Slide 27 Direct Observation Results 61 contacts with other governmental departments in resolution of complaint Government Departments Most Involved Housing 10.8% Public Works/Service 6.0% Police 4.2% Slide 28 Follow-Up Needed with (n=361) Complainant 18.8% Other Departments16.5% Person on site 12.8% Prosecutor 3.7% Slide 29 Time During Inspection* Time invested prior to inspection 16.4 minutes Travel time: mean 19.6 minute (round trip) Inspection time 69.2 minutes Total time expended 105.2 minutes (1.75 hours) Mean hourly salary of EHS $20.69= $36.21 per complaint Does not include follow-up time *Includes first inspection and re-inspection Slide 30 Investment of Time after Inspection Require further inspection 28% .28 x 36.21= $10.14 + 36.3= $39.19 3.7 times more time spent on paperwork and communication than on inspection 39.19 x 3.7= $145.00 personnel time/inspection Shaker Heights Health Department (28,840 population) 95 nuisance inspections/year= $19,211 Slide 31 Non-Personnel Related Expenses Vehicle Fuel Office overhead (space, equipment, supplies) Inspection equipment Flashlight Hardware tools Personal protective equipment Measuring tape Contact with other personnel Slide 32 Perception of Value 45% of EHS believe that most nuisance complaints do not impact health and/or safety 55% of EHS believe that most nuisance complaints do impact health and/or safety Importance of Health Department to consulting governmental departments: 9.1 mean (scale of 1 to 10; n=13) Emphasis on health often preempts conflict Slide 33 Benefit of Inspection to Community (n=509) No community benefit 51.7% (263) Remediated blight19.3% (98) Removed infestation17.1% (87) Removed safety hazard13.0% (66) Removed infectious disease9.0% (46) Slide 34 Who Received Benefit? (n=509) Respondent 8.8% (45) Complainant 35.8% (182) Immediate neighbors25.3% (129) Neighborhood18.7% (95) Children, seniors, special needs3.7% (19) Entire community8.8% (45) Community and beyond3.7% (19) Slide 35 Key Findings Top nuisance complaints involve property, animals, and garbage/solid waste Lodged by residents by phone regarding other peoples property Most (58%) are resolved at the time of the inspection About 1/3 resulted in citation or written orders Significant number of contacts with other governmental departments Slide 36 Key Findings A small but meaningful number of inspections generate tension Significant personnel cost related to conduct and follow up of nuisance complaints The real value of nuisance inspection is difficult to discern Remains an unfunded mandate Slide 37 Limitations Convenience sample of 6 diverse LHDs Limited number of EHS (n=27) Dont know the number of inspections done per year No direct measure of inter-rater reliability Slide 38 Strengths Novel observational methodology Trained student observers Direct observation decrease error variation Retrospective abstraction component Mixed methods Slide 39 Thank You! Its a tough job, but someones got to do it Questions or Comments