The National Institutes of Health (NIH) Office of Behavioral and Social Sciences Research (OBSSR) recently launched a web-based interactive anthology which will provide social and behavioral scientists (psychologists, sociologists, and economists, etc.) and other scientists with the latest research methods and tools to address emerging challenges in public health.   The free resource, known as e-Source (http://www.esourceresearch.org) was done in collaboration with the New England Research Institutes. OBSSR's mission is to stimulate behavioral and social science research throughout the NIH and to integrate these disciplines to improve the understanding, treatment, and prevention of disease.

The anthology is in response to the need for a central resource for current, high quality behavioral and social science research methods, given the fact that behavioral and social scientists come from widely varying disciplines from political science to social work research. It includes contributions from international experts and provides authoritative answers to methodological questions. Further, it sets quality stands for the research community. The interactive collection consists of 20 interactive chapters with new features including a discussion forum and enhanced note-taking capabilities.   The chapters cover a range of topics that are accessible to all users, including those with limited familiarity of concepts such as how to conduct a qualitative analysis.

According to OBSSR director Robert M. Kaplan, "The behavioral and social sciences research community has long needed an easily accessible, low-cost central resource for standardized methods." The program's goal is to demonstrate the potential of behavioral and social science research, focusing on applying research findings to public health activities and the potential to enhance biomedical research. It is also a useful training resource for biological scientists, providing them with a basic foundation for collaborations with behavioral and social scientists.

Five major categories relevant to behavioral and social sciences are included in the chapters:

1. Setting the Scene - major concepts in design and planning of social and behavioral science research;
2. Describing How - methodologies used to explain how something occurs;
3. Explaining Why - guidance on how qualitative methods appropriate for describing why something occurs;
4. What Works - research methods that can evaluate whether one treatment is better than another and whether there are cost differences;
5. Emerging Issues - addresses challenges in behavior and social science research.

The site has been developed with the expectation that it will provide a foundation of methods, but also evolve as new issues emerge. Future topics may include the effects of living in a particular neighborhood, the impact of differences in language and lifestyles, and the science of writing questions.

Data collection, reporting and action - including public policy and laws informed by data and quality metrics - are needed to support activities that will alter the physical and social environment for better health, according to a recently released Institute of Medicine (IOM) report, For the Public's Health: Investing in a Healthier Future. According to the report, it is to the detriment of society to fixate on clinical care and its delivery, which eclipses attention to population-based activities that offer efficient and effective approaches to improving the nation's health.

In 2009, the IOM Committee on Public Health Strategies to Improve Health was asked by the Robert Wood Johnson Foundation to examine three topics in relation to public health in the United States - measurement, law and policy, and funding - in context of the reform of the medical care system outlined in the Affordable Care Act (ACA).   Accordingly, the Committee was asked to prepare on each topic with actionable recommendations for public health agencies and other stakeholders.   For the Public's Health: Investing in a Healthier Future is the third and final report in the series.

In its first and second reports, For the Public's Health: the Role of Measurement in Action and Accountability and for the Public's Health: Revitalizing Law and Policy to Meet New Challenges, "the committee added its voice to a growing consensus that population health improvement depends on addressing the multiple determinants of health effectively." The Committee emphasized that "Much has been learned about the actual or distal (as opposed to proximal) causes of death and disease, including social and economic conditions that impair health and make it hard to avoid health risks. Therefore, it is no longer sufficient to expect that reforms in the medical care delivery system (for example, changes in payment, access and quality) alone will improve the public's health."

Viewing U.S. health problems through a funding lens, according to the report, reveals two issues: 1) insufficient funding for public health; and 2) dysfunction in how the public health infrastructure is funded. The Committee proposes solutions in the report to address both issues. It is noted that while the report focuses largely on the funding of governmental public health activities, the Committee recognizes that a far broader societal approach to improving population health is necessary.

Research and Evaluation

The Committee points out that research and evaluation are relevant to funding because they inform the continuum of public health practice, including decisions about what population-based interventions are funded, and the field's knowledge about what works best in public health financing, administration, and organization. It also outlined the "thin evidence base" that supports many areas of public health practice, the funding imbalances and the silo nature of health research and development and some specific needs.  

Acknowledging that the evidence base on effectiveness of health interventions is growing, the Committee stresses that it remains particularly sparse with respect to population-based interventions. Efforts to improve population health are hampered by the many uncertainties and evidence gaps regarding how to promote health and prevent disease and disability on a population-wide basis. Public health leaders have few research-tested guidelines, protocols, and decision supports to inform choices about funding, staffing, and managing public health activities. Accordingly, the dearth of evidence promotes wide variation in public health practices among communities, creating missed opportunities for improving population health, waste and inefficiencies in resource use, and inequities in health protection. Expanded investments in the applied fields of research are needed to produce information with which policy officials and public health professionals can drive improvements in the nation's public health system (recommendation number 6).

The Committee highlights the meager funding available for public health research.   Therefore, substantial research investments are needed to help public health agencies be more operationally efficient and programmatically effective. It also points out that the nation's health research enterprise is segmented into silos that focus on specific disease processes and biomedical pathways, reducing opportunities for research that examines cross-cutting social and environmental pathways and for research on prevention opportunities outside clinical care settings. One way to begin to break those silos, according to the report, would be to include population-based research in comparative effectiveness research (most of which is clinically oriented). The report also points out that the Affordable Care Act provisions that established the Patient-Centered Outcomes Research Institute (PCORI) excluded population-based prevention interventions from the institute's purview.

The discovery of new and better prevention strategies and delivery system approaches requires a continuum of research activities, including:

The Committee stresses that a strong infrastructure is needed to support each part of the research continuum described above, including: robust data collection at state and community levels; methods for constructing meaningful indicator sets - valid, reliable, sensitive, specific, and actionable; infrastructure for accessing and linking new and diverse sources of data relevant to population health, including electronic health data, place-based data sources, and commercial data on purchasing, consumption, travel, work and recreational behavior; research on analytic methods and a variety of techniques, including complex system modeling, structural equation modeling, and qualitative methods to shed light on causal mechanisms and the effectiveness of interventions; and training and development for the public health research workforce.

According to the Committee, solving the challenges identified in the report will empower public health to "bend the curve" on health risks, contributing to decreases in the volume of people who require medical care for preventable conditions, and in a broader sense, leading to improved population health outcomes. Steps to renew the public health enterprise include using public health knowledge to reform the delivery of clinical care quality with an emphasis on efficiency, appropriateness, and integration with population-based efforts.

Recommendations

The Committee recommended:

1. The Secretary of the Department of Health and Human Services (HHS) should adopt an interim explicit life expectancy target, establish data systems for a permanent health-adjusted life expectancy target, and establish a specific per capita health expenditure target to be achieved by 2030. To address the lackluster health outcomes and unsustainable health care expenditures of the U.S., a critical first step is to focus national efforts by setting a national target for health system performance on the two key measures of longevity and per capita health spending.

2. To ensure better use of funds needed to support the functioning of public health departments, the committee recommends that (a) the Department of Health and Human Services (HHS) (and other departments or agencies as appropriate) enable greater state and local flexibility in the use of grant funds to achieve state and local population health goals; (b) Congress adopt legislative changes, where necessary, to allow HHS and other agencies, such as the Department of Agriculture, the necessary funding authorities to provide that flexibility; and (c) Federal agencies design and implement funding opportunities in ways that incentivize coordination among public health system stakeholders.

3. The public health agencies at all levels of government, the national public health professional associations, policymakers, and other stakeholders should endorse the need for a minimum package of public health services.

4. As clinical care provisions in a community no longer require financing by public health departments, these should work with other public and private providers to develop adequate alternative capacity in a community clinical care delivery system.

5. A technical expert panel should be established through collaboration among government agencies and organizations that have pertinent expertise to develop a model chart of accounts for use by public health agencies at all levels to enable better tracking of funding related to programmatic outputs and outcomes across agencies.   The Affordable Care Act authorized a program of research (Section 4301, Research on Optimizing the Delivery of Public Health Services) related to many of the issues raised in the report. Funding and infrastructure development for the program, however, is not yet available. The Committee recommends steps to achieve a strengthened research infrastructure, including dedicated funding of up to 15 percent of total public health funding.

6. Congress direct HHS to develop a robust research infrastructure for establishing the effectiveness and value of public health and prevention strategies, mechanisms for effective implementation of these strategies, the health and economic outcomes derived from this investment, and the comparative effectiveness and impact of this investment. According to the Committee, the infrastructure should include: a dedicated stream of funding for research and evaluation; a national research agenda; development of data systems and measures to capture research-quality information on key elements of public health delivery, including program implementation costs; and development and validation of methods for comparing the benefits and costs of strategies to improve population health.   The research infrastructure would be shared among three HHS agencies: the National Institutes of Health, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention.   The national agenda would need to include a prioritized list of topics to be addressed by the research.  

7. Expert panels should be convened by the National Prevention, Health Promotion, and Public Health Council to determine: the components and cost of the minimum package of public health services at local and state and the cost of main federal functions; and the proportions of federal health spending that need to be invested in the medical care and public health systems. The information developed by the panels should be included in the council's annual report to Congress.

8. To enable the delivery of the minimum package of public health services in every community across the nation, the committee recommends that Congress double the current federal appropriation for public health, and make the minimum package of public health services. The Committee notes that as coverage for health care is extended to the entire population in the course of implementing health care reform, public health departments need to retain for their population-health mission general state and local resources that were previously used to cover clinical care.

9. State and local public health funding currently used to pay for clinical care that becomes reimbursable by Medicaid or state health insurance exchanges under Affordable Care Act provisions be reallocated by state and local governments to population-based prevention and health promotion activities conducted by the public health department.

10. Congress should authorize a dedicated, stable, and long-term financing structure to generate the enhanced federal revenue required to deliver the minimum package of public health services in every community.

An Institute of Medicine panel has identified degrees of integration for primary care and public health which share a goal of promoting the health and well-being of all people. The two disciplines historically have operated independently of one another. But new opportunities are emerging for bringing the sectors together in ways that will yield substantial and lasting improvements in the health of individuals, communities, and populations, according to the IOM in its report, Primary Care and Public Health: Exploring Integration to Improve Population Health.   The Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) requested the study. Paul J. Wallace, The Lewin Group, served as the Committee's chair.

The Committee's charge was to: 1) identify the best examples of effective primary care and public health integration and the factors that promote and sustain these efforts; 2) examine ways by which HRSA and CDC can use provisions in the Affordable Care Act (ACA) to promote integration of primary care and public health; and 3) discuss how HRSA-supported primary care can effectively integrate and coordinate around specific topics. The report offers the most detailed picture yet of the current landscape for integrating primary care and public health.

The Committee, as part of its study, identified and analyzed past and current efforts to integrate primary care and public health.   Primary care is defined as focusing on providing medical services to individual patients with immediate health needs. Public health is defined as focusing on offering a broader array of services across communities and populations that collectively will help people to be healthy. Given that the types of interaction between the two sectors are so varied and dependent on local circumstances, the Committee opted to identify a set of core principle derived from successful integration efforts.

The core principles include a common goal of improving population health, as well as involving the community in addressing its needs; strong leadership that works to bridge disciplines, programs, and jurisdictions; sustainability; and the collaborative use of data and analysis. The Committee concluded that integration can start with any of the principles.

The Committee emphasized that the time is right for action. Research findings continue to clarify the importance of social and environmental determinants of health and the effect of primary prevention. An unprecedented wealth of health data is providing new means to understand and address community-level health concerns.   Similarly, the ACA provides new opportunities to encourage integration to occur, changing the way the nation improves health. Committee recommendations included:

 1)    To link staff, funds and data at the regional, state and local levels, HRSA and CDC should: 

2)    To create common research and learning networks to foster and support the integration of primary care and public health to improve population health, HRSA and CDC should:

• Support the evaluation of existing and the development of new local and regional models of primary care and public health integration including by working the Centers for Medicaid and Medicare Services (CMS) Innovation Center (CMMI) on joint evaluations of integration involving Medicare and Medicaid beneficiaries;
• Work with the Agency for Healthcare and Research Quality's (AHRQ) Action Networks on the diffusion of best practices related to the integration of primary care and public health; and
• Convene stakeholders at the national and regional levels to share best practices in the integration of primary care and public health.

3)    To develop the workforce needed to support the integration of primary care and public health: 

• HRSA and CDC should work with CMS to identify regulatory options for graduate medical education funding that give priority to provider training in primary care and public health settings and specifically support programs that integrate primary care with public health.
• HRSA and CDC should work together to develop training grants and teaching tools that can prepare the next generation of health professionals for more integrated clinical and public health functions in practice.   These tools, which should include a focus on cultural outreach, health education, and nutrition, can be used in the training programs supported by HRSA and CDC, as well as distributed more broadly.

4)    To improve the integration of primary care and public health through existing HHS programs, as well as newly legislated initiatives, the Secretary of HHS should direct: 

• The National Institutes of Health to use the Clinical and Translational Science Awards to encourage the development and diffusion of research advances to applications in the community through primary and public health;
• The National Committee on Vital and Health Statistics to advise the Secretary on integrating policy and incentives of the capture of data that would promote the integration of clinical and public health information;
• The Office of the National Coordinator to consider the development of population measures that would support the integration of community-level clinical and public health data; and
• AHRQ to encourage its Primary Care Extension Program to create linkages between primary care providers and their local health departments.

5)    The Secretary of HHS should work with all agencies within the department as a first step in the development of a national strategy and investment plan for the creation of a primary care and public health infrastructure strong enough and appropriately integrated to enable the agencies to play their appropriate roles in furthering the nation's population health goals.