Integrating Evidence-Based Clinical and Community Strategies to Improve Health
Judith K. Ockene, Ph.D., Med.;a Elizabeth A. Edgerton, M.D., M.P.H.;b Steven M. Teutsch, M.D., M.P.H.;c Lucy N. Marion, Ph.D., R.N., F.A.A.N.;d Therese Miller, Dr.P.H.;e Janice L. Genevro, Ph.D., M.S.W.;e Carol J. Loveland-Cherry, Ph.D., R.N., F.A.A.N.;f Jonathan E. Fielding, M.D., M.P.H., M.A., M.B.A.;g Peter A. Briss, M.D., M.P.H.h
The authors of this article are responsible for its contents, including any clinical or treatment recommendations. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention.
Address correspondence and reprint request to: Judith K. Ockene, Ph.D., Med.; Division of Preventive and Behavioral Medicine; University of Massachusetts Medical School; 55 Lake Avenue; North Worcester, MA 01655, E-mail: Judith.Ockene@umassmed.edu.
This was first published in the American Journal of Preventive Medicine. Select for copyright and source information.
Multiple and diverse preventive strategies in clinical and community settings are necessary to improve health. This paper:
- Introduces evidence-based recommendations from the U.S. Preventive Services Task Force (USPSTF) sponsored by AHRQ and the Community Task Force (CTF) sponsored by the Centers for Disease Control and Prevention.
- Examines, using a social-ecological model, the evidence-based strategies for use in clinical and community settings to address preventable health-related problems such as tobacco use and obesity.
- Advocates for prioritization and integration of clinical and community preventive strategies in the planning of programs and policy development, calling for additional research to develop the strategies and systems needed to integrate them.
Unhealthy lifestyle behaviors and risk factors, poor delivery of clinical and community* preventive services, and environments not conducive to health increase the risk of disease and injury and contribute to the leading causes of death (Table 1).1,2 Tobacco use, poor diet, and physical inactivity alone contribute to more than a third of the premature deaths in the United States.1,2
Disease and injury are not inevitable. A growing body of evidence-based preventive strategies is available to reduce the preventable burden of disease, that is, the amount of disease that could be averted if preventive and therapeutic services were universally delivered.3 Parts of the burden can be prevented through the delivery of appropriate clinical preventive services, through community-level interventions, and through appropriate treatment (Figure 1, lower bar). The remainder is currently unavoidable due to the limits of current knowledge and will require additional research.
Clinical, medical, and community interventions already have contributed to reducing the burden of illness; the impact of these interventions is illustrated in Figure 1 (top bar) as what has been prevented. The gap between what is avoidable through these interventions, and what we currently achieve represents the translation gap, that is, the failure to translate effective clinical and community-level services into practice. This information can be used to guide efforts to improve preventive care. The relative balance and prioritization of interventions should be based upon a clear understanding of what can be achieved; that is, the preventable burden attributable to each, and their relative value; that is, their cost effectiveness, along with important qualitative factors to assure successful implementation. Although Figure 1 portrays the clinical and community interventions as discrete, as we discuss below, they should be viewed as synergistic and integratable.4,5
Two established national expert panels, the United States Preventive Services Task Force (USPSTF) and the Community Task Force (CTF), specifically recommend evidence-based preventive strategies in clinical and community settings, respectively, in order to reduce the preventable burden of disease. Their recommendations are made on the basis of rigorous review of research-generated evidence and provide essential information for selecting and prioritizing effective preventive strategies. Members of both Task Forces are non-federal experts drawn from academia, state and local governments, and the private sector, and both Task Forces work closely with a range of Federal and non-Federal experts in science, program, and policy. The USPSTF and CTF are convened and supported by the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention, respectively.
This paper provides an overview of the work of the two Task Forces, discusses the complementary nature of their recommendations (Table 2), and notes the importance of prioritizing and integrating clinical and community efforts for achieving optimal disease prevention and control. A social-ecological framework7 (Figure 2) is used to include both perspectives and to organize examples of clinical and community evidence-based interventions. An example (tobacco) is provided where both clinical and community strategies have strong evidentiary support. Another example (obesity) is provided and the primary challenge is integration where there are given gaps in studies and syntheses, illustrating opportunities for improvement and research. Finally, some of the resources needed to address the challenges to integration and the need to address them are considered.
* We use the term "clinical" to include primary care in health care systems as well as solo practices and the term "community" to include a range of geopolitical units from small community inter-connected groups to entire countries, continents, and the globe.
Evidence-Based Recommendations for Preventive Services
The USPSTF and the CTF use evidence-based methodologies to assess the benefits and harms of preventive interventions. The USPSTF focuses on clinical preventive services primarily delivered at the level of the individual patient in primary care settings, while the CTF focuses on preventive services targeted to communities/populations (Table 2). Many high-burden high-interest health topics have been considered by both Task Forces including tobacco use, motor vehicle occupant injuries, physical activity, diabetes, and obesity. The USPSTF assesses the evidence for benefits and harms of screening, counseling, and preventive medication, and makes recommendations for services where evidence is sufficient to determine that benefits exceed harms. It also publishes clinical considerations that provide guidance for the delivery of recommended services. Current recommendations and clinical considerations are published annually as The Guide to Clinical Preventive Services. The current clinical guide and other clinical preventive services products can be accessed at http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/index.html. The findings are disseminated in both medical and public health journals.
The CTF assesses the evidence for preventive interventions targeted at the level of a community/population. Interventions include various types of service delivery, improvements in systems, education, policy, and environmental changes. Interventions considered in the Guide to Community Preventive Services (henceforth, Community Guide) can be targeted at health care systems including clinicians' offices as well as at schools, worksites, other organizations or the entire community. The CTF communicates recommendations in the Community Guide, journals, and other products that can be accessed at http://www.thecommunityguide.org.
The recommendations of both Task Forces are regularly used by organizations to support decisions about selecting and funding interventions and related research. The work also is used as a core set of recommendations that can then be tailored for particular audiences. Examples of use include the following:
- Recommendations made by the USPSTF form the core set of clinical preventive services that have been prioritized by the National Commission on Prevention. Priorities on the basis of their clinically preventable burden and cost effectiveness have been used by the National Committee for Quality Assurance (NCQA) in developing its Health Plan Employer Data and Information Set (HEDIS) measures, and by the National Business Group on Health in developing its "Employer's Guide to Health Improvement and Preventive Services" (https://www.businessgrouphealth.org/preventive/background.cfm), which provides practical advice to employers about structuring health benefits.
- Work of the CTF has been used by Institute of Medicine (IOM) committees to inform national efforts to achieve and maintain high levels of immunization coverage;8 and by public health programs (e.g., STEPS to a Healthier US)41 to inform ongoing public health activities.
- Work of both Task Forces has contributed to the effective state and national efforts to reduce tobacco use9 and is therefore considered fundamental to evidence-based cancer control. The latter has caused an IOM committee addressing strategies to fulfill the potential for cancer early detection and control10 to call for the U.S. Congress to provide sufficient appropriations to the U.S. Department of Health and Human Services for the USPSTF and the CTF to conduct timely assessments of the benefits, harms, and costs associated with screening tests and other preventive interventions.
Complementary Approaches to Prevention
Although some problems of ill-health may be addressed in clinical or community settings, many are likely to benefit from the complementary and coordinated efforts of clinical and community-based interventions to address fully the opportunities for prevention. The IOM has articulated the need to address major health threats and concerns from a multi-level perspective, building partnerships across health systems, communities, academia, business, and the media, in order to effectively improve the health of the population.7
Effective preventive services recommended by the USPSTF and the CTF can help to achieve national health goals (e.g., Healthy People 2010), as well as shape quality of care measurement (e.g., HEDIS, http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx), and public health programs (e.g., STEPS to a Healthier US).41 It is likely that integration of effective clinical and community services eventually will lead to greater gains than either type of service used by itself.
Integration of complementary preventive services into a comprehensive package is consistent with a social-ecological perspective that recognizes that behaviors and health are influenced by multiple levels from the individual to families to larger systems and groups and then to the broadest levels at its rim, the population and ecosystem.11 A framework (Figure 2) based on this perspective can serve as a guide or blueprint for intervention strategies needed to address specific clinical and public health challenges. The multiple levels of influence on behavior and health are categorized within this framework11 providing a structure for targeting strategies at the discrete but inter-related levels of influence on health and behavior.12 A strong evidence base demonstrates that there are effective intervention strategies available to target each level of the ecologic model.13,14 When intervention strategies are available at each level of influence, treatment access and support is provided for people at many different points (e.g. schools, clinics, worksites), thereby expanding their reach. In addition, by integrating them and creating a pathway from one level to another, resources can be leveraged making them more available and better utilized.15 There are reinforcing effects when a comprehensive coordinated approach is used, enhancing behavior change and influencing health.16,17
Levels of Intervention
Individual-level interventions involve one-to-one interactions between a patient and a provider, often within a clinical environment (clinician's office or clinic). However, clinical services can also extend to most proximal large systems (e.g., the family), and are well suited for addressing the health needs of the individual and the family. Social, family and community network interventions are oriented to close social groups and primarily target behavior change and social support. These mostly occur in community settings including "Y's", workplaces, schools, places of worship, and other venues. Interventions include strategies such as educational and skill building programs and workplace competitions. One-to-one interactions also can occur in programs based in the community such as in a workplace health program or tobacco quitlines. Community-level interventions influencing living and working conditions include interventions that target specific communities defined by geography, race, ethnicity, gender, illness, or other health conditions. Additionally these interventions target groups and systems that have a common interest including health or service agencies, organizations, workplaces, schools, health care or public health practitioners, or policy makers. They include environmental interventions such as water fluoridation, creation of walkable communities, and availability of nutritious foods and recreation facilities in neighborhoods.
The highest level of community-level interventions generally involves large geographic communities and include broad changes, especially at the policy level, in sectors such as the environment, criminal justice, health care regulation, agriculture, transportation, urban planning and fiscal policy. At this level there are policy interventions that restrict or support behavior through laws and regulations such as requirements to ensure clean indoor air, ensure patients' access rights to their personal health information and preclude driving legally with an excessive specific level of blood alcohol. Interventions targeting the family, social networks and community are needed for changing the context in which individuals live, and for supporting the behavioral changes that they make at the individual level.
Two examples are used to examine the evidence base and potential synthesis or integration of preventive strategies in clinical and community settings that are implemented at multiple levels of influence in the social-ecological model. In the first specific example, tobacco control, relevant information about effective clinical and community-level strategies is plentiful and interventions have been implemented at multiple levels contributing to improvements in important behavioral and possibly health outcomes. In the second example, obesity prevention and control, there are gaps in evidence regarding what works at each of the levels of influence and in the synthesis and integration of the evidence. This example is presented to highlight the need for additional evidence as well as possibilities that exist for strategic coordination of preventive strategies.
Coordinating Services on Multiple Levels. Tobacco use accounted for over 435,000 deaths per year in 2000 (Table 1).1,2 The current prevalence of tobacco use among adults in the US is 20.9%,18 reduced by more than one-half from 42.4% in 1965.19 Tobacco-cessation efforts demonstrate the importance of incorporating complementary activities at each level of influence in clinical and community settings.
Both the USPSTF and the CTF have considered the issue of reducing tobacco use and have issued recommendations for its prevention and treatment.20 Much of the same evidence was used by the Centers for Disease Control and Prevention for developing their recommendations noted in Best Practices for Comprehensive Tobacco Control Programs21 and by the Public Health Service (PHS) noted in Treating Tobacco Use and Dependence: Clinical Practice Guideline.9 Recommendations in each of these documents suggest the need for comprehensive tobacco treatment programs that identify smokers, advise them to quit, and provide brief counseling and a full range of treatment services including pharmaceutical aids, more intensive behavioral counseling, and follow-up visits. Optimal success in reducing tobacco use prevalence has occurred when, in addition to clinical services, community-level interventions such as mass media efforts and legislation raising the price of tobacco products and reducing exposure to environmental tobacco smoke have been used, and quitlines have been made accessible and available.14 The success of tobacco intervention has benefited from the dissemination of the evidence-based findings of clinical and community practice to all levels of the social-ecological model.
Clinical Preventive Services. In 2003, the USPSTF recommended that:
- Clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products.
- Clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke.
Community Preventive Services. In 2000/2001,20 the CTF recommended:
- Smoking bans and restrictions
- Increasing the unit price for tobacco
- Media campaigns with intervention
- Provider reminder systems
- Provider reminder systems with provider education
- Reducing patient costs for treatment
- Quitter telephone support with interventions
An example of a comprehensive coordinated tobacco treatment and control program is the statewide Massachusetts Tobacco Control Program (MTCP).16 Recognized by the CDC and others as a "best practice" program from its inception in 1993 through 2002, MTCP has incorporated clinical and community strategies, combining and connecting activities of clinical settings, the media, community agencies, academic institutions, and local and state policy makers. It included:
- An innovative media campaign to change public opinion and community norms around tobacco use.
- Community mobilization to change local laws and health regulations.
- Comprehensive tobacco treatment programs based in clinics and community settings modeled after CDC and PHS guidelines to reduce tobacco use.