Since 1979, the Healthy People initiative has served as a national framework for improving the health and well-being of the country.1 In August 2020, the US Department of Health and Human Services (HHS) launched Healthy People 2030, the fifth iteration of the initiative. The overarching goals of Healthy People 2030 are to achieve health equity, create healthy environments, and engage cross-sector stakeholders in designing strategies to improve health and well-being.1 Healthy People 2030 also strives to provide communities, states, and organizations with tools to facilitate their use of Healthy People, such as accessible data and evidence-based resources.
While Healthy People outlines a national framework for improving health, many states develop State Health Improvement Plans (SHIPs) to guide public health improvement within their states. SHIPs provide opportunities for state health agencies to collaborate with cross-sector stakeholders to identify public health gaps, assets, and strategies for improvement.2 In recent years, states have taken an increasing interest in developing SHIPs to fulfill health department accreditation requirements set by the Public Health Accreditation Board (PHAB).3 PHAB accreditation assesses the capabilities of health departments to function successfully and nationally recognizes health departments that uphold public health and evidence-based standards.4 Many health departments also associate PHAB accreditation with increased awareness of strengths and weaknesses and increased focus on quality improvement.5 By incorporating SHIP development into the PHAB Standards and Measures, PHAB reinforces SHIPs as a mechanism for public health collaboration, organizational accountability, and continuous health improvement.3 With this requirement as a primary driver, the number of states with SHIPs nearly doubled between 2010 and 2018, rising from 25 to 44.6
Healthy People can serve as a resource for state public health agencies as they develop their SHIPs. The Association of State and Territorial Health Officials (ASTHO) and PHAB direct states toward Healthy People materials for guidance on aligning national priorities, comparing data, and developing evidenced-based strategies.7 For example, with 355 measurable objectives, Healthy People 2030 offers abundant objectives for states to consider when developing statewide plans.1 The Healthy People 2030 initiative also aims to improve usability of Healthy People information with its dynamic Web site, which allows users to easily search national objectives, review evidence-based resources related to topic areas, and track data throughout the decade.8
In 2020, the Office of Disease Prevention and Health Promotion (ODPHP) at HHS contracted with NORC at the University of Chicago (NORC) to further explore how states and territories use Healthy People to develop their SHIPs. The purpose of this study was to understand the processes that states use to develop their SHIPs, how states align their SHIPs with Healthy People, challenges that states face using Healthy People, and how ODPHP might better support states in using Healthy People when developing their SHIPs.
NORC conducted semistructured interviews with 9 state health department staff members who were responsible for SHIPs. To identify potential respondents, NORC conducted a review of the status of SHIPs and health department contacts across all states and territories. This review identified 48 states that have developed SHIPs. Respondents were selected across the HHS designated geographic regions in an attempt to capture diversity in state geography and population size, with priority given to states that had recently updated SHIPs. Alternate states were also selected for each region in the instance that a respondent declined the interview. Respondents were recruited via e-mail to participate in a 45-minute telephone interview. Interviews were conducted between December 4, 2020, and January 28, 2021. At the time of the interviews, 7 respondents were from PHAB-accredited health departments, one respondent's health department was seeking PHAB accreditation, and one respondent's health department was not PHAB accredited. The respondents' responses were analyzed using qualitative thematic analysis. The NORC Institutional Review Board reviewed the study and determined it to be not human subjects research.
SHIP development processes
State health departments used similar approaches to develop their health improvement plans. Generally, states began the SHIP development process by performing community health assessments and then assembling diverse stakeholders to recommend key priority areas that should be addressed in the SHIP. States used a similar framework for their SHIPs, outlining priority areas, indicators, and targets. Typically, the SHIP development process took approximately 12 to 24 months.
Community health assessment
Most respondents began their SHIP development process by conducting a community health assessment to gather data on overall population health in their state. Respondents discussed collecting data on a variety of community health aspects, including health status, health factors, health concerns, and strengths. Some health departments collected data by acquiring reports from local agencies and aggregating the data to provide a statewide perspective, whereas others contracted with a partner organization to perform a statewide assessment.
Community engagement was a critical component of the preliminary assessment. In an effort to support equity and social determinants of health, all respondents sought input from diverse organizations and populations. Feedback was gathered from a wide variety of organizational sectors, including health care, economic development, social services, and advocacy groups. Respondents also discussed attempts to get feedback directly from community members, especially underrepresented and vulnerable populations, through forums, surveys, and listening sessions. Throughout this process, respondents mentioned that hundreds of stakeholders may provide input. One respondent reported participation from more than 25,000 individuals and 100 different organizations.
Selecting SHIP priorities
After completing a community health assessment, health departments assessed the data, literature, and stakeholder input to develop the content of the SHIP. Most respondents described a similar format for the SHIP, which usually included a variable number of health indicators grouped into a few health priority topic areas. Drawing from 1 or more data sources, health indicators were used to measure and track progress toward specific targets. For example, the rate of individuals without health insurance is a common health indicator, with the target reflecting a percentage improvement that is attainable by the end of the SHIP time period.
Cross-sector stakeholders played a key role in shaping the content of the SHIPs. Respondents discussed the involvement of professional stakeholders from traditional health sectors (eg, hospital associations, medical organizations, and advocacy groups) as well as partners from adjacent sectors (eg, economic development and transportation). Stakeholders were brought into the development process at different times depending on the health department. Some respondents reported that the health department decided on the health priorities and then recruited external stakeholders to topic area work groups to offer expertise on particular topic areas. One of the respondents noted that their health department intentionally created broad health priorities to increase the number of stakeholders that were involved in the process. Conversely, some respondents engaged stakeholders earlier in the process to serve on steering committees that made recommendations for the health priorities in the SHIP as well as the subsequent topic area indicators and strategies.
Prioritizing items for inclusion was a critical aspect of SHIP development. Respondents suggested that limiting the number of priorities and indicators helped keep the plan manageable and facilitated implementation. The prioritization process was largely influenced by stakeholder feedback, using methods such as dot voting or electronic ranking based on a selection criteria. Many respondents mentioned that stakeholders were often vocal about which items they believed should be included in the SHIP, which could lead to spirited discussions. One respondent described passionate “floor fights” where topic area work group members debated their recommendations for the group to vote on, which ultimately helped narrow down hundreds of indicators to less than 25.
Additional literature and resources offered guidance on organization, language, and strategies that could be incorporated into the SHIP. Respondents commonly reported looking to ASTHO, the National Association of County and City Health Officials (NACCHO), PHAB, the Community Guide, and the Robert Wood Johnson Foundation for resources on best practices and recommendations. In particular, respondents referenced the Collective Impact Model,9 the 10 Essential Public Health Services,10 the Mobilizing for Action through Planning and Partnerships (MAPP) strategic planning process,11 the National Prevention Strategy,12 the Centers for Disease Control and Prevention's (CDC's) Winnable Battles,13 and the County Health Rankings.14 Respondents reported that these resources helped structure their SHIPs, offered insights into how to engage stakeholders, and provided documentation for PHAB's accreditation process. One respondent indicated that there are opportunities for Healthy People to collaborate with other similar public health organizations to help states develop robust and actionable strategic plans.
Despite attempts to encourage diverse perspectives, inclusive participation and collaboration were often a challenge. On a community level, one of the respondents mentioned that despite heavily advertising community listening sessions across the state, they were not able to get the desired representation across the state. On a professional level, respondents discussed challenges related to engaging members during meetings. One respondent mentioned that meeting attendance decreased over the 9-month planning period. To help address these issues, one health department considered hiring an external meeting facilitator to manage the development process and ensure active participation from all. Another health department focused stakeholder engagement by organizing special sessions related to specific topic areas and strategic implementation. However, one respondent suggested that creating definitive topic areas reinforced silos between sectors and made it harder to have cross-sector conversations about how topics and activities are related.
The COVID-19 pandemic hindered some states' SHIP development, but health departments learned new skills as they adapted to the pandemic. The most commonly cited challenge was staff capacity and ability to prioritize SHIP activities. Several respondents mentioned that SHIP-related activities for 2020 were disrupted when many staff members were deployed to respond to the pandemic, which may delay the implementation of new state plans. Although some respondents had previous midyear processes in place, others highlighted that the pandemic led their departments to reinforce the flexibility of SHIP planning and implementation. For example, some respondents are incorporating COVID-19 recovery and resiliency strategies into their SHIPs. In addition, one respondent acknowledged opportunities to apply lessons learned from the pandemic response to future SHIP activities, such as using data visualization tools such as Microsoft Power BI15 and Tableau.16 One of the respondents reported that their health department had great success using data visualization tools during their COVID-19 response, and they anticipated that similar visualization techniques will be important to future iterations of their SHIP as they plan to shift toward a primarily Web-facing document.
Alignment with Healthy People
All respondents reported that they referenced Healthy People during the development of their SHIPs. Several respondents described their strategies for incorporating Healthy People resources into the SHIP development process. Respondents led several activities to bring awareness of Healthy People during SHIP development meetings, including sharing status updates about Healthy People and providing Healthy People materials for reference. Using these resources, stakeholders were able to utilize Healthy People for guidance on national health priorities, objectives, target setting methods, and best practices. Some respondents discussed exercises that helped steering committees align certain components of the SHIP, such as drawing connections from state priority issues to Healthy People priority topic areas.
States varied in the degree to which they used Healthy People as a resource or aligned their state plans with Healthy People. States also differed in terms of the aspects of Healthy People they found most useful when developing their SHIPs. Some states reported aligning their state plans with the Healthy People Framework, while others focused more on the specific Healthy People objectives or target setting guidance. Respondents reflected that the comprehensive nature of the Healthy People lends itself to selecting components that are most applicable to their state.
Healthy People Framework
Most respondents stated that they aligned their SHIPs with Healthy People's overall mission of improving health and well-being while promoting health equity. One respondent shared, “Part of the mission of Healthy People is to increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress, which is really what [our SHIP's] strategic approach has been.” Like Healthy People, many health departments were shifting toward a broader approach to health and attempting to address social factors that contribute to public health issues, such as transportation and economic development. One of the respondents mentioned that their health department worked closely with more than 30 sister agencies and conducted an environmental scan to determine what types of strategies were being implemented across the state. Moving forward, this health department planned to implement a new approach that engaged nongovernmental representatives from each sector (eg, transportation, housing, income, medical care) as strategic partners. Health equity was also a central theme shared across Healthy People and state health departments. Several respondents mentioned that their SHIP data collection processes considered demographics of underserved populations to identify disparities that may lie beyond statewide health averages. One respondent stated, “We are not just interested in the overall indicators, but we are really interested in digging down to see how [this is] impacting communities most affected by health inequities.” When addressing equity and social determinants in their SHIPs, respondents reported that Healthy People was a useful guide for specific language. For example, one of the respondents noted that their health department had already started to incorporate elements of racial equity into their SHIP but was glad to see that language appear in Healthy People for an additional reference.
Healthy People objectives and data
Some respondents found that Healthy People objectives were useful references when selecting state health indicators for a SHIP. Several respondents reported that the reduced number of objectives in Healthy People 2030 was more manageable for stakeholders to review and discuss during the SHIP development process. During planning meetings, some respondents directly engaged with Healthy People objectives to facilitate conversations about state-level indicators. For example, one of the respondents mentioned that their department would bring printouts of the Healthy People objectives to use as a menu of options when selecting its state health indicators. In some cases, states' SHIP development process coincided with the development of Healthy People 2030. One of the respondents shared that due to the timing of their SHIP, they were unable to reference the most updated federal guidance, as Healthy People 2030 was not yet released during their SHIP development.
State-level data were a primary driver in the SHIP indicator selection process. Although states referenced Healthy People objectives for guidance, health departments were ultimately limited in the indicators they could select on the basis of the data that were available for their state. Furthermore, many Healthy People objectives are tracked using national data sources, which may not lend itself to state-level application. One of the respondents noted that they were not intentionally diverging from Healthy People but rather the data in their state did not support the federal objectives. Instead, respondents often organized their indicators around the data available in their state and honed in on health disparities identified in the data. When using this methodology, some respondents still referenced Healthy People objectives afterwards for comparison.
Some respondents found that Healthy People offered valuable guidance on target setting and monitoring indicators. While Healthy People provides targets for national objectives, state objective targets may differ on the basis of individual state health characteristics. In instances where a national target was reasonable for a state goal, some respondents discussed using the same target that was used in Healthy People (ie, 10% improvement from the baseline over 10 years, or 5% improvement from the baseline over 5 years), especially when using an indicator that was similar to Healthy People. However, 3 respondents noted that their state had reached or surpassed at least some of the objective targets set by Healthy People. In that instance, one respondent was instead able to apply Healthy People target setting methodology alongside state-level trends, saying, “We didn't use the actual data from the national plan as much as the behind-the-scenes methodology that was available.” Some respondents also reported that steering committees deferred to Healthy People targets when state stakeholders had difficulty agreeing on a target.
Healthy People objectives and targets can be integrated into data visualization tools to help states track their progress. Two respondents discussed the application of the Indicator Based Information System for Public Health (IBIS-PH), which is a dashboard that allows states to house and share health indicator data. One respondent noted that the software had the Healthy People 2020 objectives built in for a profile comparison and anticipated a similar feature for the Healthy People 2030 objectives. Fifteen states and 2 tribal groups are currently using or exploring the IBIS-PH system.17 Similarly, some respondents discussed the use of scorecards to track indicators. For instance, some health departments had state scorecards that aligned with the Healthy People objectives, which was filled in with data compiled from the scorecards of county health departments and health systems.
Suggestions for improvement
ODPHP may be able to provide additional guidance to assist states as they develop their SHIPs. Six respondents conveyed that more guidance, either from ODPHP or peer learning from other states, would be helpful when developing SHIPs. Respondents suggested developing more opportunities for discussion on best practices, such as forums or webinars. One respondent mentioned that it would be beneficial for webinars to discuss strategies for implementation in low-resource settings in addition to featuring examples from health departments that are well resourced. The respondent stated, “I want to see examples and stories from states that struggle to do the work and do their best to do their job anyway.” Some respondents thought it would be useful to reestablish meetings with an ODPHP liaison to help determine which Healthy People strategies best fit their state's needs. One respondent found previous meetings with ODPHP very helpful, saying, “I feel more comfortable contacting someone who is designated to help me answer questions or give me some direction.”
Additional funding can help states translate the Healthy People initiative into actionable public health improvement efforts. Respondents conveyed that it was challenging to integrate SHIP activities into the state budget, especially when an investment was needed from stakeholders not directly involved in SHIP processes. Some respondents noted that their health departments previously had funding that supported Healthy People 2020 implementation, but that funding was no longer available. For example, respondents mentioned using CDC funding from the National Public Health Improvement Initiative (NPHII)18 toward SHIP development and other CDC funding toward the IBIS-PH data system, but both funding streams have since stalled. To fill this financial gap, some respondents suggested reinstating ways to link funding to Healthy People implementation activities, such as through CDC block grants.
Discussion and Conclusion
The SHIP development process provides opportunities for state health departments to assess their population's health needs, engage with a wide range of multidisciplinary stakeholders, and prioritize strategies for health improvement. Public health accreditation is likely a significant contributor to the increased focus on SHIP development among state health departments, as Standard 5.2 of the PHAB Standards and Measures is “Conduct a Comprehensive Planning Process Resulting in a Tribal/State/Community Health Improvement Plan.”3 Given that most of the responding health departments were PHAB accredited or seeking PHAB accreditation, it is unsurprising that their SHIP development processes were similar, often based on resources recommended in the PHAB Standards and Measures. The PHAB Standards and Measures also encourage state health departments to reference Healthy People during their SHIP development. PHAB cites Healthy People as “national state-of-the-art guidance” for several requirements, including development of measurable outcomes or indicators for health improvement, collaboration in community health improvement planning processes, and alignment with national priorities.3 As more states seek PHAB accreditation and progress toward reaccreditation, there are more opportunities for Healthy People to be used as a national model for strategic planning and public health improvement.
Healthy People can be a helpful resource for states as they develop public health improvement plans. While most states align with the mission of Healthy People, some struggled to apply the national framework to their specific state populations. As Healthy People enters a new decade, it includes several changes aimed to improve its utility and implementation for stakeholders. For example, the number of objectives has been greatly reduced, and the new online platform allows stakeholders to customize information based on their topic area interests. However, states may require additional resources and investment to ensure that implementation efforts are fully realized. Reinforcing relationships between state public health staff and ODPHP can help states better understand the role of Healthy People as well as encourage further dissemination of creative strategies and best practices.
Finally, public health agencies are expanding stakeholder engagement to promote inclusivity at both the state and federal levels. Both HHS and state public health agencies rely on input from stakeholders and cross-sector collaboration to ensure their initiatives reflect the diverse needs of their population. Stakeholder engagement is increasingly important as public health professionals are shifting toward a health equity approach that considers social determinants outside of the health care sector. Healthy People continues to strengthen this perspective by outlining national priorities on well-being while incorporating language around health equity issues. As this field continues to grow, Healthy People has an opportunity to provide additional guidance on how to operationalize equity-focused strategies.
Implications for Policy & Practice
- SHIPs help states identify public health priorities and outline strategies to improve the health of their state.
- Healthy People provides a national framework for states to reference and fosters alignment in health improvement plans across the nation.
- Engaging a diverse set of stakeholders is critical to the development of public health improvement initiatives.
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. Published December 5, 2016. Accessed July 13, 2021.
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