A framework to evaluate the development and implementation of a comprehensive public health strategy

Abstract

Recent estimates released by the Centers for Disease Control and Prevention (CDC) indicate that 34% of the US population is obese, with the prevalence projected to increase to 42% by 2030 if government and non-governmental stakeholders do not take action.1 Media attention surrounding these estimates highlighted the population-based approaches proposed by various stakeholders.2 The Institute of Medicine (IOM) released a report suggesting interventions to stem the obesity epidemic in the US that could comprise a comprehensive national obesity prevention strategy.3 Decision makers at the federal, state, and local levels face the task of selecting from these and other guidelines to address obesity and other public health issues. As a product of this work, they often develop a public health strategy, defined in this context as a set of policies or programs aimed at changing chronic disease risk factors and disease outcomes. There is no single bullet solution for the leading global risk factors for disease and disability such as obesity, tobacco, and HIV/AIDS; they require multipronged comprehensive approaches. Those tasked with defining a national or state-level public health strategy face numerous recommended programs and policy instruments for each risk factor or disease area, and can select from already prioritized lists of interventions to reduce non-communicable diseases, some based on the cost-effectiveness of available options.4–6 In addition, priority setting tools, such as the one proposed by Magnusson (2011), as well as those discussed in a recent IOM workshop, are available for decision makers to use in selecting legal and regulatory approaches to address the burden of chronic disease.7,8 An intervention's inclusion in a strategy document is not a guarantee that the health department or other responsible agency will implement the strategy in its entirety if they face barriers, such as inadequate funding or pressure from interest groups. In general, the evaluation of comprehensive strategies has focused on a set of interventions contained within the strategy with little emphasis on the processes used by decision-makers to formulate, staff, and fund the final strategy for a given jurisdiction. Further, the literature has not explored the extent to which these processes, such as using a priority-setting tool, influence strategy implementation and its impact on health outcomes. The extent to which the aspects of the strategy development process, such as the degree of stakeholder involvement or the availability of resources, influence the strategy as it appears on paper, and also the extent to which responsible implementing agencies carry out the strategy as originally envisioned are not known. When faced with a menu of evidence-based interventions for inclusion in a strategy – how, why, and with what support are the interventions selected and implemented?