The National Prevention Strategy Framework: Applause and Critique

By David A. Kindig, MD, PhD

Last week the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health Council met for the first time and discussed its draft National Prevention Strategy Framework.

This Council and Strategy represent an unprecedented opportunity. By emphasizing integration across federal departments, the Council creates the possibility for a Health-in-All possibilities approach to health improvement that embraces a robust population health framework. The Advisory Group is ably chaired by Jeff Levi, CEO of the Trust for America’s Health (TFAH). He and TFAH have been critically important in the efforts to promote prevention and public health in health reform and other federal budget efforts.

Given my outcomes focus, I am very pleased with the overall goal to “increase the number of Americans who are healthy at age 85” (defined as the percentage of those who reach age 85 and report being in good health). I am similarly pleased to see the elimination of health disparities as one of four main “pillars,” but note that no metrics or time frame have yet been identified. This will be a critical task for the Council and Advisory group in future work.

Population health advocates should applaud the Framework’s call for Healthy Environments as a “Cross-cutting Priority,” acknowledging that “good physical and mental health depend on affordable and secure housing; sustainable and economically vital neighborhoods that provide access to employment opportunities and public resources (e.g. efficient transportation, good schools, and effective policing).” With respect to the “Targeted Priorities,” however, advocates may be concerned by the focus (as framed by Healthy People 2020) on lifestyle and individual behavior. Improving health behaviors is important, but we can’t ignore the role that social and environmental factors play in tobacco use, diet and physical activity patterns, and other targeted behavioral priorities. This concept is reflected in the County Health Rankings model, which assigns greater value to social, economic, and environmental factors (50% total) than to health behaviors (30%).

 

It would be a shame for the Cross-cutting Priorities to get sidelined by interest group advocacy for the Targeted Priorities. To protect against this, care should be taken to develop and track specific measures to help the Cross-cutting Priorities maintain an elevated profile.

While the draft doesn’t specifically mention early childhood and prenatal environments, these deserve significant attention given their long term health impacts. Also, the draft adopts a somewhat narrow view of healthcare, which is only addressed through the Cross-cutting Priority of Clinical Preventive Services. While it might be argued that healthcare is getting sufficient attention via the Affordable Care Act, this Strategy Framework represents a key opportunity for integration (including linkage to health insurance and Community Benefit reform, as well as health care quality improvement). Finally, health care cost containment should be viewed as a community prevention opportunity strategy, as these growing expenditures necessarily limit broad population health investment opportunities.

Those concerned about population health improvement should celebrate the nature and scope of our emerging National Prevention Strategy, follow it closely, and seek out opportunities to support and strengthen it as it evolves.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Comments

[Helene Nelson]

Hi Dave -

What is the progress in knowing what % of health outcomes are attributable to the four broad domains representing the multiple determinants of health? What's the basis of the percentages you used in this blog post?

I agree with the principles and broad perspectives but am curious about the evolving science.

[David Kindig]

Helene, thank you for the thoughtful and important question. As you imply, the science is less than we would want, which is the reason for the commentary I wrote in JAMA last fall with John Mullahy calling for an expanded approach to comparative effectiveness research (http://jama.ama-assn.org/content/304/8/901.extract). For the County Health Rankings, we use a combination of existing evidence and expert opinion, this is summarized on the Rankings website in a working paper(http://www.countyhealthrankings.org/sites/default/files/differentPerspectivesForAssigningWeightsToDeterminantsOfHealth.pdf). With regard to behaviors and SES, the recent work of Paula Lantz and colleagues (http://www.improvingpopulationhealth.org/blog/2010/11/individual_responsibility.html) is about the best available.

Thanks for reading and please keep commenting!