Establishing an empowerment measure for Massachusetts boards of health and assessing impact of board empowerment on tobacco retail density: a mixed-methods study
Embargo Date
2027-08-22
OA Version
Citation
Abstract
BACKGROUND: Massachusetts local health boards (BoH) show considerable variability in leveraging their legal autonomy to enact policies that promote public health. This variability potentially introduces disparate health outcomes across communities. Currently, there is no measure of BoH empowerment. This research provides a validated index to fill this knowledge gap, enabling continuous measurement and improvement of BoH empowerment, policymaking, and health outcomes.
METHODS: First, demographic, economic, and municipal government secondary data from 314 Massachusetts municipalities were collected. Second, an empirical measure (empowerment index; “EI”) was created using five indicators of empowerment: number of codified BoH seats, method of attainment of BoH seat (elected or appointed), word count associated with BoH in municipality bylaws or city charter (enumeration), number of additional references to BoH/health department in other sections of municipality bylaws or city charter, and operating budget for municipality BoH/health department. Third, EI was validated as an indicative measure of BoH empowerment using multivariate regression modeling by assessing the effect of four potential socio-political determinants on EI: political conservatism (measured by the municipality’s percentage of Republican voters in the 2020 U.S. presidential election), race (measured by the percentage of the municipality identifying as White), Census population of the municipality, and the municipality's median income. Fourth, the predictive relationship between the EI and a municipality’s tobacco retail density (TDR) was assessed through multivariate regression modeling. Finally, qualitative research with a purposive sample representing 16 BoH assessed the usefulness and intent to implement the EI in public health practice.
RESULTS: Existing research shows that racially diverse populations can successfully influence policy change through participation and advocacy. Consequently, residents and leaders in more racially diverse communities may be more motivated than those in less diverse municipalities to influence policy change. This supports the hypothesis that more racially diverse communities should have more empowered health boards. As hypothesized, the regression validating the EI found the likelihood of having high BoH empowerment decreases by 61% as the percentage of Whites in the municipality increases (B = -0.9444, P = 0.072, OR = 0.389), with marginal significance. Larger populated municipalities are found in literature to have more empowered municipalities, as measured by greater governing autonomy and policymaking authority. It is hypothesized that larger populated municipalities, which have greater influence and success with state officials compared to less populated municipalities, may also have more empowered BoHs, reflecting similar increased influence with municipal leaders and the community. The regression demonstrated that as population increases, the odds a municipality will have a BoH with the highest empowerment score significantly increases by 233% (B = 1.2032, P < 0.0003, OR = 3.330). Associations have been found in existing research between population-based voting trends and public health, with the mean rate of adolescent HPV vaccination initiation and completion found to be significantly lower for “Red” states (voted Republican) compared to “Blue” states (voted Democrat). These trends were also seen in COVID-19 vaccination rates. This study hypothesized a similar negative influence of political conservatism on BoH empowerment across Massachusetts. As hypothesized, the regression showed that with each additional increase in political conservatism, the odds of having a most empowered BoH decreases by 39% (B = -0.4873; P = 0.291, OR = 0.614). The finding, while as hypothesized, is not statistically significant, suggesting trends for future research. It is anticipated that municipalities with greater median income levels can afford higher property taxes and consequently will contribute more property tax dollars toward municipal budgets, inclusive of BoHs. BoHs with greater empowerment are hypothesized to successfully obtain a consistent, or greater, amount of these larger municipal budgets in support of more policymaking and enforcement support, further expanding their authority and empowerment. The regression demonstrated that with each unit increase in median income, the odds of a BoH having the highest levels of empowerment increase by 77% (B = .5690, P = 0.10, OR = 1.77), approaching statistical significance. Regression analysis predicting tobacco retail density rate (TDR) found municipalities with the most empowered BoHs experience a significant 75% decrease in the odds of having a TDR above the state’s 3rd quartile (indicating high levels of municipal tobacco availability) compared to those with less empowered BoHs (B= -1.375, P < 0.046, 95% CI -2.825, -0.063, OR = 0.253). Qualitative study participants reported a lack of support from municipal governments negatively impacts a BoH’s ability to effectively develop and enforce public health regulations. Interviewees noted a general lack of awareness about the BoH’s legal authority among both BoH members and within the community. Municipal political dynamics were described as influencing the BoH, affecting the board’s functionality in deliberation and policymaking. Study participants found the EI useful for adopting new strategies and filling gaps in their knowledge and skills in advocating for BoH empowerment with municipal leaders and residents.
CONCLUSION: This research provides an understanding of the indicators that convey or enhance power to local BoHs, a new area of study. The development of the EI provides a tool for capacity building for more effective policymaking and enhanced collaboration within and between BoHs, municipal leaders and community stakeholders. Moreover, the EI demonstrates how variations in BoH policymaking across the state impact community health. Additionally, increased BoH empowerment can amplify health boards’ influence at the local government level in support of budget and resource allocation for public health programs and enforcement of regulations. The EI has been demonstrated to have utility and a viable path for implementation with BoHs in Massachusetts. More broadly, this dissertation's research offers other researchers studying BoHs a validated method to understand the implications of BoH empowerment on public health outcomes in their communities. Lastly, the EI can be used to assess hypothesized empowerment indicators in other contexts and to evaluate the influence of those indicators on other public health outcomes of interest.
Description
2025
License
Attribution-NonCommercial-NoDerivatives 4.0 International