Recent years have seen rising interest in initiatives that focus on public health improvement, often through efforts to strengthen public health department performance and advance the use of quality improvement.1–4 This includes field-based and national-level support for accreditation of public health departments, administered by the Public Health Accreditation Board (PHAB; www.phaboard.org). Public health accreditation involves measuring health department performance against 12 domains, which are based on the 10 Essential Public Health Services.5 For each domain, PHAB provides guidance on the meaning and associated standards. For all measures within each standard, PHAB provides the purpose, significance, and types of documentation required to demonstrate conformity. Health departments that meet the standards receive national recognition. Accreditation is intended to advance the quality and performance of health departments to improve and protect the public's health.5
Interest in public health improvement is also demonstrated by increasing expectations that health departments should use evidence-based programs, services, and policies (also called interventions).6–8 Health departments that implement evidence-based interventions are likely to make measurable progress toward achieving their public health goals, thus resulting in more efficient use of their often-scarce staff and financial resources.9 Interventions are considered to be evidence-based if the existing data about them—from research studies, program evaluation, or both—show that they are effective in achieving their intended outcomes.9 Systematic reviews are among the strongest types of evidence.6,9
One of the major sources of evidence-based community preventive programs, services, and policies is The Guide to Community Preventive Services (The Community Guide; www.thecommunityguide.org). The recommendations housed in The Community Guide are made by the Community Preventive Services Task Force (Task Force). The Task Force is a nonfederal, independent, uncompensated panel of public health and prevention experts appointed by the director of the Centers for Disease Control and Prevention, established in 1996, and mandated by Congress to provide recommendations for a wide range of US decision makers.10 The Task Force makes its recommendations based on systematic reviews of all available evidence (both research-tested and practice-based). These systematic reviews evaluate the effectiveness of each intervention and assess whether effectiveness changes in different settings or populations or across different ways of delivering the intervention. The reviews also assess the intervention's costs and cost-effectiveness.11 The Community Guide contains more than 220 Task Force findings and recommendations about interventions to address specific risk factors; diseases, conditions, or injuries; age groups; and settings.10
This project was initiated to explore the potential connections between Community Guide interventions and PHAB domains, standards, and measures. The intended output was a crosswalk (“the Crosswalk”) that could assist health departments in identifying evidence-based interventions from The Community Guide whose implementation may lead to documentation that demonstrates conformity with PHAB standards and measures.
Development of the Crosswalk was a collaborative and iterative process that involved staff from the National Association of County & City Health Officials (NACCHO) and the Centers for Disease Control and Prevention's Community Guide Branch and Office for State, Tribal, Local, and Territorial Support. The project was initiated in spring 2010, and a complete draft of the Crosswalk was finalized in spring 2013. All Task Force–recommended interventions were reviewed to determine whether they reflect the intent and requirements of PHAB standards and measures. This involved comparing Community Guide intervention definitions and Task Force recommendation statements with the text of the PHAB Standards and Measures Version 1.0—which includes language for domains, standards, measures, purpose statements, significance statements, required documentation, and documentation guidance.5
Three types of connections were defined through which specific Community Guide interventions could be relevant to the required documentation for a PHAB measure. The first is a direct relationship, which occurs when (1) the intent of the intervention, its components, and its related Task Force recommendation align with the intent of the PHAB domain, standard, and measure; and (2) the aims or main components of the intervention are mentioned in the purpose and guidance for the PHAB measure. Required documentation for PHAB will be obtained because either (a) it is a typical part of carrying out that intervention or (b) it provides one illustration of a broader series of required processes or practices being in place at the health department. For example, the Community Guide intervention “Restricting minors' access to tobacco products: community mobilization with additional interventions” relates directly to PHAB Measure 4.2.1 A: “Engage the community about policies and strategies that will promote the public's health.”5 This is because the Community Guide intervention requires the community engagement that is the subject of PHAB Measure 4.2.1 A. All direct connections were identified and included.
The second type of connection is an indirect relationship. It occurs when a Community Guide intervention is not fully aligned with a PHAB measure's purpose, but the intent of the PHAB measure may be addressed as part of carrying out the intervention. If this is the case in the way a particular health department delivers the intervention, then implementing that intervention could help the health department obtain the required PHAB documentation. For example, in addition to having a direct connection with a number of Community Guide interventions (as described earlier), PHAB Measure 4.2.1 A is also indirectly related to a number of Community Guide interventions. These include the Community Guide intervention “Reducing exposure to environmental tobacco smoke: smoking bans and restrictions,” as well as all of the other Community Guide interventions listed in the Crosswalk alongside PHAB Measure 5.1.3 A: “Inform governing entities, elected officials, and/or the public of potential health impacts, both intended and unintended, from current and/or proposed policies.”5 This is because although community engagement—the intent of Measure 4.2.1 A—is not a specific aim or main component of the Community Guide interventions listed for Measure 5.1.3 A, the community would likely be engaged to gain support for the Community Guide interventions listed for Measure 5.1.3 A. To avoid incorrect assumptions, it was decided to include in the Crosswalk only indirect connections likely to occur in most health departments. Indirect connections appear in the Crosswalk after direct connections.
The third type of connection relates to 4 PHAB measures for which it was determined that health departments should look broadly at all Community Guide interventions. Implementing any of these interventions may help the health department obtain the required PHAB documentation. The first 2 of these PHAB measures (10.1.1 A: “Identify and use applicable evidence-based and/or promising practices” and 5.2.2 State [S], Local [L]: “Produce a community health improvement plan”)5 specifically cite The Community Guide as a source of evidence-based interventions to be used in strategic planning and in intervention development and delivery. For the third (9.1.3 A: “Use a process to determine and report on achievement of goals, objectives, and measures set by the performance management system”)5 and the fourth (9.2.1 A: “Establish a quality improvement program based on organizational policies and direction”),5 outputs from all Community Guide reviews—including analytic frameworks showing how interventions relate to outcomes and the Community Guide's specification of the amount of impact (ie, the size of the effect) to be expected if an intervention is implemented—can help health departments set performance goals and measures and document processes.
This effort focused on developing a Crosswalk tool to support health department staff responsible for leading accreditation preparation efforts (eg, accreditation coordinator, accreditation team).12 The Crosswalk tool consists of 2 tables and instructions for use, and it is approximately 80 pages in length. The first table cross-references individual PHAB domains, standards, and measures with related interventions from The Community Guide that could help provide documentation. An illustrative excerpt from Table 1 can be found in Figure 1.
A second Crosswalk table was developed to help accreditation preparation staff engage with program staff who might not be as familiar with PHAB domains, standards, and measures. This second table is searchable by Community Guide topic area, identifying the PHAB measures that relate to each of the Community Guide interventions within that topic. An excerpt from Table 2 can be found in Figure 2.
Because of the ongoing need to update the Crosswalk on a regular basis to ensure that it consistently reflects new and updated Task Force findings as well as modifications to PHAB domains, standards, and measures, it was decided to develop the Crosswalk as an online (and printable) tool, accessible from The Community Guide Web site, with links from the NACCHO and Office for State, Tribal, Local and Territorial Support Web sites.
Connections between Community Guide interventions and PHAB standards and measures were found within 9 of the 12 PHAB domains—Domains 1-7, 9, and 10. The most extensive connections occurred in Domain 5: “Develop public health policies and plans,”5 Domain 9: “Evaluate and continuously improve health department processes, programs, and interventions,”5 and Domain 10: “Contribute to and apply the evidence base of public health,”5 since 1 or more measures within each of these domains (5.2.2 S, L; 9.1.3 A; 9.2.1 A; and 10.1.1 A) relate to all Community Guide interventions.
Domain 3: “Inform and educate about public health issues and functions”5 had the largest number of discrete connections between specific Community Guide interventions and specific PHAB measures (n = 72 direct connections between Community Guide interventions and PHAB Measures 3.1.1 A and 3.1.2 A).* A considerable number of discrete connections were also found within Domain 6: “Enforce public health laws”5 (n = 21 direct connections with 6.1.1 A and 6.2.3 A, and 19 indirect connections with 6.1.2 A) and Domain 7: “Promote strategies to improve access to health care services”5 (n = 19 direct connections with 7.2.2 A). All of these relate to intervention and program delivery. There are a substantial number of discrete connections with Domain 5 (n = 28 direct connections with 5.1.3 A) and Domain 4: “Engage with the community to identify and address health problems”5 (n = 5 direct connections and 56 indirect connections with 4.2.1 A and 4.2.2 A). These relate to engaging or mobilizing the community.
There are few connections between Community Guide interventions and Domain 1: “Conduct and disseminate assessments focused on population health status and public health issues facing the community”5 (1 direct connection each with 1.2.1 A, 1.3.1 A, and 1.4.1 A) and Domain 2: “Investigate health problems and environmental public health hazards to protect the community”5 (1 direct connection each with 2.2.1 A and 2.2.2A). Finally, Domain 8: “Maintain a competent public health workforce,”5 Domain 11: “Maintain administrative and management capacity,”5 and Domain 12: “Maintain capacity to engage the public health governing entity”5 focus on the capacities, workforce, and infrastructure that health departments need to have in place. No direct or indirect connections were found between the Community Guide interventions and these 3 domains.
Community Guide topics with the most individual connections to PHAB domains, standards, and measures are as follows: motor vehicle injury; tobacco; vaccination; cancer; physical activity; and HIV/AIDS, sexually transmitted infections, and pregnancy. Topics that have connections across the most PHAB domains are tobacco (Domains 3-7) and vaccination (Domains 1, 3, and 5-7). Eleven Community Guide interventions have 3 connections each with PHAB measures.
This article describes an effort to identify links between public health practice standards and evidence-based recommendations from The Community Guide. It identifies the process for creating a Crosswalk that is intended to be (a) comprehensive; (b) accurately and appropriately reflective of the intent of the accreditation process, specific PHAB measures, and specific Community Guide interventions; and (c) useful for a wide range of health departments. Achieving these ends is important since many health departments may be unfamiliar with either or both of PHAB and The Community Guide. This tool can therefore have great educational value. Closely reviewing both PHAB and Community Guide documents can help health departments ensure that they have clear understanding and select the most appropriate examples. The Crosswalk provides active hyperlinks to Community Guide intervention definitions and Task Force findings statements where this information can be found. If health departments determine that what they are doing is not congruent with the Community Guide intervention, the information available on The Community Guide Web site can help them see what modifications they could make to their programs, services, and policies to render them evidence-based.
Using the Crosswalk may help health departments identify Community Guide interventions that they can use in the short term to provide documentation in their accreditation application, and other interventions that they could implement in the future to help achieve their goals and that they could highlight when applying for funding that requires use of evidence-based approaches. Health departments can also contribute to the evidence base themselves by evaluating interventions with insufficient evidence findings and publishing the results. Through stimulating these actions, the Crosswalk helps reinforce public health improvement by identifying mutually reinforcing opportunities to advance practice.
After reviewing an early version of the Crosswalk, the NACCHO Accreditation Preparation and Quality Improvement Workgroup concluded that the Crosswalk could be very useful in supporting health department accreditation efforts, and an unpublished white paper—commissioned by the NACCHO—recommended that the Crosswalk be promoted as a resource to prepare for accreditation.
The Crosswalk provides insights into where the evidence base for public health practice—within the scope defined by PHAB standards and The Community Guide—currently exists. As expected given The Community Guide's mission and scope,10 Community Guide interventions are most plentiful among the domains (3-7, 9, and 10) that are heavily focused on programs, policies, activities, and services. Those domains (8, 11, and 12) that represent capacities—such as workforce development, administrative management and capacity, and governance—would not be expected to have strong association with most of the evidence-based programs, services, and policies included in the Community Guide. The Community Guide scope also leads to the limited number of Community Guide interventions associated with assessment, surveillance, and investigation (Domains 1 and 2). These findings highlight the need to gather the existing evidence for key capacities and for core public health activities in assessment, surveillance, and investigation, as well as the opportunity to build a stronger evidence base for all expectations placed upon health departments.
3. Public Health Quality Improvement Exchange. About PHQIX. http://www.phqix.org
. Accessed July 24, 2013.
4. Riley WJ, Moran JW, Corso LC, Beitsch LM, Bialek R, Cofsky A. Defining quality improvement in public health. J Public Health Manag Pract. 2010;16:5–7.
9. Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health. 2009;30:175–201.
11. Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based Guide to Community Preventive Services—methods. Am J Prev Med. 2000;18(1S):35–43.
* All discrete connections noted in the “Results” section represent what was found in the Crosswalk version finalized in spring 2013. Numbers will continue to change as the Crosswalk is updated over time. Cited Here...
evidence-based public health; performance management; public health accreditation; public health improvement; public health systems; quality improvement