Essential Case Studies in Public Health:
Putting Public Health into Practice
Katherine L. Hunting and Brenda L. Gleason
Editors
Partial Facilitator Guide for Case 16
Beyond Measurement? Evaluating Environmental Public
Health: Assessing the Effectiveness of Food Safety Programs
Lindsey Realmuto and Surili Sutaria
© 2012 Jones & Bartlett Learning, LLC
1
Case 16 Facilitator Guide. Beyond Measurement? Evaluating Environmental Public Health: Assessing the
Effectiveness of Food Safety Programs
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.1 Some 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.2 Nor 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.3 The 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:
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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.
Essential Case Studies in Public Health: Putting Public Health into Practice
© 2012 Jones & Bartlett Learning, LLC
2
Case 16 Facilitator Guide. Beyond Measurement? Evaluating Environmental Public Health: Assessing the
Effectiveness of Food Safety Programs
LEARNING OBJECTIVES
At the conclusion of this case, students should be able to:
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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.
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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 (710) is ideal for small group discussion.
IDEAS FOR WRITTEN ASSIGNMENTS
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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.
Essential Case Studies in Public Health: Putting Public Health into Practice
© 2012 Jones & Bartlett Learning, LLC
3
Case 16 Facilitator Guide. Beyond Measurement? Evaluating Environmental Public Health: Assessing the
Effectiveness of Food Safety Programs
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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:
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Louisiana Office of Public Health: Center for Environmental Health
http://www.dhh.louisiana.gov/offices/?ID=242
Florida Department Health: Division of Environmental Health
http://www.myfloridaeh.com/about/index.html
California Department of Public Health: Center for Environmental Health
http://www.cdph.ca.gov/programs/Pages/CenterEnvironmentalHealth.aspx
Other Federal and National Association Environmental Health/Food Safety Resources:
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CDC National Center for Environmental Health
http://www.cdc.gov/nceh/
U.S. Food and Drug Administration
http://www.fda.gov/
Association of State and Territorial Health Officials
http://www.astho.org/Programs/Environmental-Health/
National Association of City and County Health Officials
http://www.naccho.org/topics/environmental/
International Food Protection Training Institute
http://www.ifpti.org/about
Centers for Disease Control and Prevention:
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Frequently Asked Questions about Foodborne Illness: How does food become contaminated?
Available at: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/foodborne_illness_FAQ.pdf
CDC’s Multistate Outbreak website describes national outbreaks by year. Available at
http://www.cdc.gov/outbreaknet/outbreaks.html
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.
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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?
Essential Case Studies in Public Health: Putting Public Health into Practice
© 2012 Jones & Bartlett Learning, LLC
4
Case 16 Facilitator Guide. Beyond Measurement? Evaluating Environmental Public Health: Assessing the
Effectiveness of Food Safety Programs
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?
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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.
Essential Case Studies in Public Health: Putting Public Health into Practice
© 2012 Jones & Bartlett Learning, LLC
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Case 16 Facilitator Guide. Beyond Measurement? Evaluating Environmental Public Health: Assessing the
Effectiveness of Food Safety Programs
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:
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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:
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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: http://www.astho.org/Display/AssetDisplay.aspx?id=4818. Accessed: January 19,
2010.
2. Center for Disease Control and Prevention. CDC’s Winnable Battles. December 1, 2010.
Available at: http://www.cdc.gov/about/winnablebattles.htm. Accessed: January 19, 2010.
3. Pandemic and All-Hazards Preparedness Act of 2006, Pub. L. No. 109-417, 120 Stat. 2831
(2006). Available at: http://www.gpo.gov/fdsys/pkg/PLAW-109publ417/pdf/PLAW-109publ417.pdf.
Accessed: January 19, 2010.
Essential Case Studies in Public Health: Putting Public Health into Practice
© 2012 Jones & Bartlett Learning, LLC