Over the past 20 years, there has been an increase in state health departments seeking to create comprehensive health improvement plans to guide quality improvement efforts and to achieve public health accreditation. Many of these plans use the US Department of Health and Human Services' Healthy People framework,1 including US state plans such as Healthiest Wisconsin 2020 and Healthy North Carolina 2020, international plans such as Healthy Ireland, Healthy Israel 2020, and the World Health Organization's Health21 and Health 2020 policy frameworks, among others. These initiatives are intended to provide long-term, systematic plans that set priorities, direct the use of resources, and develop and implement projects, programs, and policies.2 Despite the existence of these plans, many tribes and tribal nations are not well represented in the completed plans or included in statewide health improvement planning efforts.3
Alaska is a challenging environment in which to provide public health and health care services due to a geographically dispersed population, high transportation costs, and limited local public health infrastructure. The Alaska Department of Health and Social Services (AKDHSS) has a mission to promote and protect the health and well-being of all Alaskans. AKDHSS created the Healthy Alaskans initiative, with statewide targets in 2000 and 2010. The Healthy Alaskans initiative was intended to drive action by programs and organizations by providing a roadmap of the state's priorities and benchmarks for health outcomes for each decade.
Each iteration of Healthy Alaskans was different in its approach and implementation. When planning began for the Healthy Alaskans 2020 (HA2020) initiative, AKDHSS decided to expand beyond target setting and instead create a statewide health improvement plan with greater commitment to strategic action and promotion of health equity by collaborating with Alaska Native tribes and tribal organizations. The Alaska Native Tribal Health Consortium (ANTHC) is the largest tribal self-governance entity in the United States and is a nonprofit tribal health organization designed to meet the unique health needs of Alaska Native and American Indian people living in Alaska. It provides comprehensive medical services at the Alaska Native Medical Center and public health services throughout the state in partnership with regional tribal health organizations. Together, ANTHC and its regional partners are known as the Alaska Tribal Health System. Located within ANTHC, the Alaska Native Epidemiology Center is one of 12 national tribal epidemiology centers. The Alaska Native Epidemiology Center provides public health and epidemiologic services to the Alaska Tribal Health System and contributes to the wellness of Alaska Native people by monitoring and reporting on health data, providing technical assistance, and supporting initiatives that promote health.
In 2011, ANTHC and AKDHSS came together to cosponsor a state health improvement plan for 2020, building on the previous Healthy Alaskans initiatives. The decision was made early on to have the effort be a robust tribal-state collaboration, with representatives from both tribal and state systems involved in all aspects of the planning and goal-setting process. The vision, mission, and guiding principles were established early in the process to provide structure for the initiative. The vision of HA2020 is “Healthy Alaskans in Healthy Communities.” The goal of HA2020 is to identify health priorities of Alaskans, set targets, monitor progress, and support implementation of strategies for improvements during 2010-2020. In this article, we describe the development of the HA2020 partnership and the priority-setting process and outcomes and offer recommendations for other communities seeking to do similar work.
The formation of the HA2020 tribal-state partnership came during a window of opportunity in early 2011 with a combination of good timing, availability of funding, and solidified relationships among staff members at each organization. Around that time, both ANTHC and AKDHSS received funding from the Centers for Disease Control and Prevention (CDC) National Public Health Improvement Initiative (NPHII) made available through the Affordable Care Act Prevention and Public Health Fund. NPHII activities included completion of a statewide health assessment, a statewide health improvement plan, and an organizational self-assessment. In addition, the economic climate, the increased demands for accountability and efficiency, the presence of emerging and chronic health issues, and overall resources and capacity at each of the partnering organizations all contributed to the further development of this tribal-state partnership.
There was also a natural fit in that both ANTHC and AKDHSS are statewide organizations with similar missions and a shared goal of improving health outcomes. The health delivery system in Alaska relies on AKDHSS and ANTHC working closely with tribes, local health departments, and other organizations to function effectively. Top leadership from each organization provided commitment for the joint initiative and in 2012 the cosponsorship was formalized. A work plan was established to develop a statewide health improvement plan that included shared responsibilities and accountability.
The data reported here are available to the public and do not allow for the identification of individuals. Institutional review board approval was not needed as this was not research.
HA2020 adopted a collective impact model4 for creating social change that brought together a number of organizations committed to the shared goal of improving health for Alaskans. The HA2020 organizational structure included a Steering Committee, an Advisory Committee, a Core Team, and a Data Team. The Steering Committee comprised top leadership from both organizations who acted as vocal champions and ensured commitment for the initiative. The Advisory Committee included a range of stakeholders representing multiple sectors and was responsible for establishing the HA2020 vision and making recommendations on health indicators. The Core Team comprised staff members from both organizations and served as the backbone support. The Core Team provided the central infrastructure and created the project framework, managed the project, and acted as liaison between teams. A Data Team cochaired by the ANTHC Alaska Native Epidemiology Center staff and the AKDHSS Division of Public Health staff served as subject matter experts and provided data-related recommendations, reports, and continual data monitoring for the initiative.
After partnership formation, the first step was to conduct a statewide health assessment, which included completing a progress report on the Healthy Alaskans 2010 (HA2010) initiative. The report, Healthy Alaskans 2010 Health Status Progress Report on Leading Health Indicators,5 included data on leading health indicators from 2000 to 2010 and a scorecard on progress toward targets. The HA2010 report indicated minimal health target progress since 2000. The progress report also showed that there had been too many health indicators included in the HA2010 effort and that targets were unrealistically high. In addition, there was no committed effort across the state to track progress or coordinate efforts to effect change. Along with the report, 2 Web-based community opinion surveys were conducted to actively seek input from a broad range of people, including the general public, health professionals, and stakeholders from other sectors, to understand the health priorities of Alaskans and align health objectives with those concerns.
With the statewide health assessment and community input gathered, efforts focused on developing a framework and inventory of potential health indicators for consideration by the HA2020 Advisory Team. After careful review of several different frameworks, including the framework outlined in HA2010, CDC Healthy People 2020, and County Health Rankings (University of Wisconsin/Robert Wood Johnson Foundation, www.countyhealthrankings.org), the Data Team selected the County Health Rankings framework for use in the HA2020 initiative. This framework had the most potential to be understood by a broad audience, and it emphasized the importance of social determinants of health. This framework also provided a set of domains/topic areas that allowed for identifying a set of indicators to reflect a balance among a variety of determinants of health.
Healthy Alaskans 2020 leading health indicator selection
One of the guiding principles of HA2020 was to use the highest-quality data available during every step of planning and implementation. On the basis of lessons learned from HA2010 with having an unmanageable list of health indicators, the Core Team decided early on to focus the 2020 initiative on a much smaller set of leading health indicators.
Using the established framework, the Data Team began the task of populating each health topic with potential health indicators. As a starting point, the Data Team compiled a list of known and commonly used indicators from various health improvement initiatives. In addition, indicators were drawn from state-administered survey questions such as the Behavioral Risk Factor Surveillance Survey,6 Youth Risk Behavior Survey,7 Pregnancy Risk Assessment Monitoring System,8 as well as Alaska Native Epidemiology Center regional health profiles.9 Additional indicators came from other nontraditional sources such as law enforcement, education, and other sectors. The initial list of 467 indicators was winnowed down based on the following criteria: (1) an Alaska-specific data source; (2) a baseline data set; (3) a comparison measure (such as a national measure); and (4) be available across the life span and for different populations, particularly Alaska Native people. An informal scoring process was then used to prioritize indicators within a particular category based on a variety of data strength considerations including reliability and validity. This process narrowed the initial list down to 198 indicators, with a subset of 86 highly recommended by the Data Team using the established criteria. The Advisory Team made final recommendations using additional selection criteria such as usefulness, being actionable, and being measurable (see the Figure for selection process, and see Supplemental Digital Content, available at: http://links.lww.com/JPHMP/A585, for complete list of selection criteria).
The HA2020 state health improvement plan includes a set of leading health indicators and targets around priority health goals to improve health outcomes and promote health equity for all Alaskans. The final list of 25 leading health indicators covers a range of topics and is reflective of health concerns and challenges faced in Alaska (Table). The 25 leading health indicators include reducing the rates of cancer, suicide, obesity and overweight, injuries, Chlamydia infection, preventable hospitalizations, and interpersonal violence and sexual assault; increasing physical activity; decreasing alcohol, tobacco, and drug use; increasing disease prevention through vaccines; increasing access to care; increasing social support for adolescents; ensuring improved access to in-home water and wastewater services; reducing poor mental health; and addressing social determinants of health including educational attainment and poverty. The inclusion of Chlamydia trachomatis infection rates as a leading health indicator reflects the fact that Alaska had the highest rate of Chlamydia infection in the United States from 2010 to 2016.10 The inclusion of an indicator on the percentage of rural community housing units with water and sewer services reflects the ongoing challenge of access to water and sewer in some of Alaska's rural/remote communities.11 The leading health indicators prioritize Alaska youth, with 8 indicators focused specifically on youth, including a resiliency-based indicator measuring the percentage of adolescents with 3 or more adults from whom they feel comfortable seeking help. The 25 leading health indicators also reflect the results of the HA2020 community surveys, which asked Alaskans about their health concerns and priorities, and meaningful measures. The results of the first survey (n = 1542) showed that alcohol use, cost of health care, diet/exercise/obesity, other substance abuse, and violence were the topics of greatest concern.12 The results of the second survey (n = 1684) showed that alcohol and drugs, nutrition/exercise, health care, and abuse/violence were of highest priority. The most meaningful health measures for the community were related to suicide deaths, access to safe water/sewer, adult overweight/obesity, adolescent depression, and social support for adolescents.12
Once the 25 leading health indicators were approved by the Advisory Team, recommendations for a target for each indicator were developed by ad hoc target-setting teams composed of subject matter experts from a range of organizations including staff from ANTHC. Based on lessons learned from the HA2010 initiative, targets were set that would be achievable yet ambitious. Based on Healthy People 2020 methodology,1 which aimed for a general 10% improvement during the decade, 6% improvement for HA2020 was determined to be realistic within the given time frame. In addition, baseline data, health disparities, projections based on current trends, national goals, and other statewide goals were taken into consideration in selecting realistic targets.
ANTHC's Alaska Native Epidemiology Center and AKDHSS began conducting regular data monitoring and reporting on progress toward the 25 priority targets, beginning with the publication of baseline data for the 25 leading health indicators. The indicators are tracked continually and published using Alaska's Indicator Based Information Systems for Public Health (www.ibis.dhss.alaska.gov). Data are stratified for the Alaska Native population and are compared with the US or US white population. Scorecards summarizing progress for both the entire Alaska population and Alaska Native people are published annually for use by Alaska agencies and communities.13,14 In 2017, there was a request for more granular, substate-level data. As a result, there are now regional scorecards available that highlight progress on the 25 leading health indicators by the State of Alaska's Behavioral Health Systems Regions.
The most recent scorecards indicate that progress is being made on a number of indicators; however, only a small number of targets have been met as of 2018 (Table). Continued dedication to monitoring is crucial to track progress over time, keep stakeholders engaged in the process, and to initiate, direct, and sustain effective intervention efforts.
The establishment of an equal partnership between ANTHC and AKDHSS created a foundation for shared responsibility and commitment to addressing the identified health priorities of all Alaskans. The final 25 leading health indicators reflected a systematic and collaborative process between ANTHC and AKDHSS and participation from a range of organizations and individuals throughout the state.
The HA2020 initiative continues to promote efforts to reach the targets for the 25 priorities. A targeted implementation pilot was completed, with coordinating partners leading collaborative efforts focused on 8 leading health indicators related to suicide, socioeconomic status, tobacco use, and domestic violence. The implementation pilot revealed that HA2020 helped well-formed coalitions drive momentum and target their efforts around specific leading health indicators, with greater support from partners and other stakeholders. An implementation framework was developed that consists of 4 steps and 17 approaches that can be used by other community coalitions, partners, and organizations to align their work with HA2020 goals.
HA2020 has been used in a number of ways including for community health assessments, grant applications, program planning, strategic planning, and evaluation of programs. HA2020 has been integrated into a number of programs and local organizations, including by the regional Healthy Fairbanks 2020 project to develop a health improvement plan for the Fairbanks North Star Borough,15 by the MAPP (Mobilizing for Action through Planning and Partnerships) of the Southern Kenai Peninsula community coalition,12 and by the Alaska Statewide Violence and Injury Prevention Partnership statewide injury prevention plan.16
The success of HA2020 is linked to the formalized tribal-state partnership; organizational structure; the inclusion of the best available data on health status, health factors, and health priorities; and the inclusion of key elements of the collective impact approach including a common agenda, shared measurement, continuous communication, mutually reinforcing activities, and a centralized infrastructure/backbone support.4 Plans for Healthy Alaskans 2030 are already underway and will benefit from the foundational work accomplished during the HA2020 planning process. Recommendations for others seeking to undertake a similar initiative include ensuring buy-in and support from the highest levels of leadership from partnering organizations, having participation from supporting organizations in all stages and workgroups, having a multisector advisory committee that brings expertise and can advocate for the initiative to a range of stakeholders, and using both epidemiologic and community input data for priority setting.
There have been some challenges and limitations in the development of HA2020. The most significant of these was the late start of planning and implementation. The formal partnership was not signed until 2012, leaving only 8 years to plan and implement the initiative prior to the end of the decade. In addition, there were changes in data availability, staff turnover at both partnering organizations, changes in how data were collected, and changes in national guidelines, which impacted the targets. Some survey questions that provided data for tracking indicators changed, affecting the indicator and associated target. Setting targets that were both ambitious and achievable was challenging, especially since many of the priorities were associated with chronic disease, lifestyle factors, and social determinants of health. Review of the most recent scorecards indicates that only a few targets have been met or are on track to be met, suggesting that targets may still be too ambitious or that more targeted intervention efforts are needed for substantial improvement. Full-scale implementation has been a challenge because of the amount of effort required to coordinate partners around leading health indicators, especially for indicators where well-formed coalitions do not already exist.
To accomplish an initiative such as HA2020, there is a need for a strong backbone support system to assist with coordination, communication, technical assistance, and guidance. However, there were only a small number of staff members assigned specifically to HA2020, with resources provided in-kind by ANTHC and AKDHSS. While the organizational structure of a network of small teams was a major factor in the success of the initiative, it was also difficult to maintain momentum and champions over a long period of time. Finally, emerging public health issues, such as the opioid epidemic, are not reflected in HA2020, although they have now become high priorities for the state.
Despite these challenges, HA2020 is an important resource for state, local, and tribal health professionals within Alaska who use it as a shared framework for Alaska's collective health improvement priorities. Furthermore, the unique tribal-state partnership structure ensures that both tribal and nontribal perspectives are included in the plan, that monitoring of data and implementation efforts will continue, and that coordinated efforts will be sustained to support progress on Alaska's health improvement plan by the year 2020 and beyond.
Implications for Policy & Practice
- Establishing collaborative partnerships between tribal and nontribal entities provides a strong foundation for shared responsibility and commitment for health improvement efforts to ensure that both tribal and nontribal perspectives and priorities are included.
- Using not only the best available epidemiologic data, but also extensive community and subject matter expert input can help ensure that the priorities of the community are reflected and can help increase buy-in for health improvement activities.
- The use of a scorecard or other method to monitor community health improvement data can help promote continued momentum, particularly for long term efforts such as 10 year time period used in the Healthy People model.