With recent policy and funding changes, the public health enterprise is increasingly shifting toward value-driven practices based on data and evidence. Now, more than ever, public health looks for innovative ways to maximize the effectiveness of resources to best meet the needs of priority populations. Understanding public health needs is increasingly challenging at a national level, given the vast variety of public health issues associated with regional areas, populations, and the complexity of public health agency structures across the nation. Even with this challenge, a growing number of public health system partners are searching for data sources that showcase the key issues health agencies are tackling within their jurisdictions and the strategies they are using to address them. The Association for State and Territorial Health Officials (ASTHO), a national nonprofit organization representing public health agencies, set out to strengthen understanding of public health agency needs across the nation by conducting an analysis of State Health Improvement Plans (SHIPs). This article highlights key initial findings from ASTHO's analysis and the potential value the information can bring to the public health field at large.
A SHIP has a wealth of agency-specific information and is defined as a long-term systematic plan to address issues identified in the state health assessment.
The purpose of the SHIP is to describe how the health department and the community it serves will work together to improve the health of the population of the jurisdiction. Together, the community, stakeholders, and partners set priorities, direct the use of resources, and develop and implement projects, programs, and policies. The plan is comprehensive, including the roles and responsibilities of a broad set of community stakeholders and partners, along with the health department. The plan reflects the results of a collaborative planning process with significant involvement by a variety of community sectors.1
SHIP development is routinely led by the health agency and involves identifying and engaging stakeholders, practicing in visioning and systems thinking, collecting and analyzing health assessment data, and communicating and vetting priorities. A defined process is used to identify issues and set priorities, develop objectives, determine strategies and performance metrics, and implement an action plan. Furthermore, monitoring, evaluating, and consistently updating the plan are critical to adapting to the jurisdictions' changing environment.2 The process and resources to develop and implement a SHIP can be time- and resource-intensive, but the outcome is a plan and commitment from the state health agency (SHA) to pursue and prioritize health issues facing the community, placing emphasis on community buy-in and engagement, multisector collaboration, continuous quality improvement, accountability, data-driven decisions, and transparency.
In January 2018, with funding support from the Centers for Disease Control and Prevention Office of State, Tribal, Local and Territorial Support, ASTHO conducted an environmental scan of existing SHIPs across all 50 states and the District of Columbia (n = 51). The scan involved a search of SHA Web sites for publicly available SHIPs, followed by direct outreach to agency staff when an electronic Web-based plan could not be found. The scan identified 44 states with existing SHIPs, up from 25 with completed or in-progress SHIPs when ASTHO conducted a similar comprehensive search in 2010.3 This upward trend, an almost doubling of SHIPs in 8 years, demonstrates an increase in perceived value by SHAs of the collaborative SHIP process. There are many potential drivers for this, including guidance from the Public Health Accreditation Board (PHAB); a SHIP is a key required document during the health agency accreditation process. While 31 plans identified in this search are from accredited SHAs, 13 nonaccredited agencies had a SHIP that followed PHAB's defined process. This suggests that the emphasis on data and collaboration has positively impacted states' public health improvement planning. SHAs are seeing the value in involving various sectors in their planning, whether accredited or not.
After collecting all 44 SHIPs, ASTHO reviewed and analyzed the public health priorities in each plan and grouped them into 10 most prevalent themes (Figure). The top 5 priority areas that states included in their SHIPs were as follows: (1) tobacco, (2) chronic disease, (3) health disparities/health equity, (4) behavioral health, and (5) access to care. Health disparities/health equity and access to care were 2 crosscutting priorities that stood alone but were often integrated within several of the other priorities. Subtopics were identified within each priority area, for example, tobacco control in youths, tobacco control in individuals with chronic conditions, and tobacco control in individuals with nicotine dependency.
While the data revealed high-level themes and trends, each SHIP also offered details on the agency's specific strategies, measures, and objectives related to each priority issue. An example of this is from the Wisconsin State Health Assessment and Health Improvement Plan (Table).4 Many SHIPs also included the intended target population(s), state-specific programs or interventions to be implemented, and community stakeholders and partners that will contribute to the health agency's efforts. The SHIPs serve as a roadmap to addressing the most pressing public health issues within each state.
This analysis offers an opportunity to generate increased energy at the national level to improve population health in priority areas. While the SHIP analysis offers a broad snapshot into the public health priorities of SHAs, the value is in the application of data to inform health policy, identify evidence-based public health practices and pockets of innovation, and recognize regional and national public health trends. Each of these strategies bolsters the collective impact of the national public health system and strengthens the effectiveness of interventions, policies, and practices.
Public health policy and law are critical tools for protecting and promoting the health of the public. Many of public health's greatest successes, including high childhood immunization rates, improved motor vehicle safety, safer workplaces, and reduced tooth decay, have relied heavily on law and policy, and public health law continues to play an important role in addressing emerging public health threats such as childhood obesity, healthcare-associated infections, motor vehicle injuries, and prescription drug overdoses.5
The priorities identified in this SHIP analysis are informed by the health status of millions of people and should guide the policy agenda of governmental health agencies and partners dedicated to improving health. Organizations can and should leverage resources to advance effective laws and policies in these top priority areas.
“Widespread adoption of evidence-based strategies is recommended to achieve state and national objectives for improved population health. Public health practitioners should work towards incorporating scientific evidence in selecting and implementing programs, developing policies, and evaluating progress.”6 (p176) As the field of public health continues to embrace evidence-based public health (EBPH) to design and implement programs and interventions, many SHIPs highlight which EBPH practices will be replicated and identify the collaborators and community assets that support that work. Broad dissemination of EBPH through SHIPs contributes to the repository on which public health practitioners can model their work and engage with a network of peers to discuss implementation, outcomes, and impact.
Yet, our evidence base is often limited and continuously evolving. Many funders and organizations, such as the Robert Wood Johnson Foundation and the Public Health National Center for Innovations, have placed emphasis on the value and importance of “empowering health departments to drive change and improve health through innovation,”7 thereby adding to our knowledge base of effective programs and policies.
As public health departments adapt to meet the growing and changing needs of their communities, experts note the need for strategic coordination to help incubate and share innovative ideas. To meet the needs of the 21st century, we need innovative public health practices that build on the work of non-health sectors to transform the health of the population.8
The robust strategies and implementation plans included in the SHIPs can help identify pockets of innovative interventions that are working within communities with unique needs and characteristics. While EBPH is viewed as the gold standard, further examining how communities use innovation to approach an issue through the lens of their population is a meaningful use of the SHIP data by public health practitioners and the field.
The SHIP analysis highlights regional and national trends. Access to these trends can heighten the public health system's ability to connect information and create a larger picture of population health. Through this lens, the public health system can better align federal funding with top priorities, conduct research in the areas with higher need, implement interventions, and target public health workforce and service placement in geographic regions where they are needed the most. National trends in SHIP priorities can also promote a more proactive approach to addressing public health issues. National epidemics associated with a pandemic disease outbreak, the opioid crisis, and even childhood obesity did not occur overnight or in a vacuum. Rather, they began as smaller-scale issues that grew in severity over time. By monitoring emerging public health issues through comprehensive review of state health agencies' priorities, the public health system can get in front of issues to help lessen their impact on populations and communities.
Examining public health assessments and improvement planning through a collective and national perspective is a new endeavor. In a short amount of time, state public health has increased its capacity and dedication to routinely collect and make these data available. As a national organization with a mission to “support, equip, and advocate for state and territorial health officials in their work of advancing the public's health and well-being,”9 having a firm understanding of state public health priorities positions ASTHO to support public health leaders and drive improvement. ASTHO is currently using this information to guide advocacy efforts and align its work with the issues that matter the most to leaders, and more analysis is ahead. More analysis on EBPH and interventions contained in the SHIPs is planned, as well as review and analyses of other key SHA plans, including strategic plans, workforce development plans, and quality improvement plans, to identify national trends in public health infrastructure and organizational planning, capacity-building, and service and policy implementation. By working with public health partners, this information can be used to make a collective impact on population health.