The Community Guide—A National Health Success Story

What works to improve the health of populations? This is a fundamental question asked by public health leaders, other elected and appointed government officials and staff, and private and not-for-profit organizations whose decisions affect the health of populations. In the United States, myriad interventions claim to enhance health and well-being, but which ones actually work?

The Community Guide: Your online guide of what works to promote healthy communities by Community Guide Staff and the Community Preventive Services Task Force http://www.thecommunityguide.org

A GUIDE TO IMPROVING POPULATION HEALTH

The US Guide to Community Preventive Services (the Community Guide) was created to reduce the confusion and highlight effective options based on the highest quality scientific evidence. For each intervention, the evidence base is rigorously assessed by Centers for Disease Control and Prevention (CDC) Community Guide staff employing methods developed collaboratively with the Community Preventive Services Task Force (CPSTF). This expert group was established in 1996 to help decision makers select evidence-based interventions that improve health and safety and prevent disease.

During its 23 years of existence, the CPSTF has been part of monumental changes occurring in public health, making a difference for Americans at all stages of life. When the first CPSTF meeting occurred in August 1996, the idea that prevention at the population level was an opportunity to improve health was not yet widely embraced. At that time, the US Preventive Services Task Force (USPSTF), established in 1984, focused on developing recommendations for what “prudent clinicians should provide their patients as part of routine clinical care.”^1(piii)

Important as that guidance was and is, it did not address the effectiveness of preventive approaches aimed at populations in communities, states, or nationally, or defined by gender, risk factors, or health status. Nor did the guidance address interventions that target patients as a group. It became clear that what makes the greatest difference in people’s health happens outside clinical settings—in schools, worksites, homes, neighborhoods, and communities. Thus, the CDC launched the CPSTF as a population-targeted complement to the USPSTF. Interventions assessed include policies, programs, and system changes that can improve the health, well-being, safety, and preparedness of communities by addressing key determinants. All findings, recommendations, and references are at thecommunityguide.org.

At the start, an argument against launching the Community Guide was that we would find scant evidence for most topics. This has not been our experience. However, a great dividend from our reviews has been the identification of key knowledge gaps for research funders, including the National Institutes of Health (NIH), the CDC, and the Health Resources and Services Administration, to facilitate prioritizing their research targets.

The CPSTF and the Community Guide staff have proven their worth. Because their mission is critical and ongoing, they should be a permanent part of our public health infrastructure. Much like information technology and preparedness, their infrastructure requires regular monetary infusions to upgrade, update, and expand commensurate with the growing research base. Just as we can’t be satisfied with static information technology, we must improve methods and throughput for finding the worthiest investments for the health, safety, and well-being of populations.

Several developments have influenced how the CPSTF conceptualizes and pursues its mission. One is recognition of the large contribution of social determinants such as education, job opportunities, housing stock, and income and assets to health, disease, injury, and well-being. Concerns have also grown around the glaring health inequities arising in part from discrimination and structural racism. Both of these issues are now systematically considered in the CPSTF’s choice of interventions to review.

We started to address social determinants by reviewing education interventions that could improve both health and health equity. Reviewed interventions that have led to recommendations include early childhood education, school-based health centers, full-day kindergarten, and high-school completion programs. The Community Guide is now also addressing housing policies and programs, with early reviews of mixed-income housing developments, tenant-based rental assistance program, and interventions aimed at reducing homelessness.

Grave concerns about health inequities also led to important changes in CPSTF methods. Prioritization of topics for review explicitly considers the extent of health inequities. Furthermore, every Community Guide literature review explicitly examines the degree to which that intervention affects health equity.

The CPSTF recognized that it was essential to systematically include economic literature reviews to elucidate costs and cost effectiveness. For the past two decades, Community Guide staff economists have reviewed every topic and generated economic findings, although such findings are often limited.

A CRITICAL PART OF US PUBLIC HEALTH

There are many Community Guide success stories. For example, the CPSTF has made an important contribution to the health of infants and toddlers by identifying and recommending the most effective ways to boost community immunization rates. Community Guide recommendations, based on rigorous systematic literature reviews, have also provided the basis for child safety seat laws and smoke-free policies that reduce exposure to secondhand smoke.

Our findings related to alcohol use and impaired driving have also provided the basis for state laws limiting hours of alcohol sale and the Department of Transportation’s 2001 Appropriations Act, which incentivized states to implement 0.08 blood alcohol content laws. Additionally, the United States has seen great reductions in tobacco use following implementation of CPSTF-recommended programs and policies.

Now comprising nearly 250 evidence-based findings and recommendations across 21 topic areas, the Community Guide has been the work of 47 CPSTF members volunteering more than 55 000 hours over 23 years, along with untold time by CDC Community Guide staff and 32 liaisons representing state and local health departments, the US Armed Forces, other federal agencies, health care professionals, and other interested organizations. To date, the Community Guide includes 160 economic reviews among its 335 publications because economic merit factors into decisions among alternative interventions.

The unsung heroes of the Community Guide are superb staff who have drafted new methods, conducted reviews, drafted findings and recommendation for CPSTF deliberation, and served with enormous dedication. I will do injustice to the many by mentioning a few, but I must cite Steven Teutsch and Alan Hinman, who pushed within CDC for the establishment of the CPSTF; David Satcher, a CDC director who authorized its implementation; the first three staff members who transformed a suspect idea into a national program, Marguerite Pappaioannou, Peter Briss, and Stephanie Zaza; and two long-serving staff leaders who both advanced the science and helped the Community Guide survive perilous times, Shawna Mercer and Randy Elder. With Ned Calonge as the new chair, I know the CPSTF is in strong, capable hands. Special thanks belong to the current CDC director, Robert Redfield, a strong supporter of our work.

Everyone interested in improving population health is indebted to CDC leadership for consistent support of the Community Guide, including when its very existence was in doubt. I hope the CDC, under whose auspices all our work has occurred, can both increase its support and obtain contributions from other federal agencies that benefit from the Community Guide, starting with the Centers for Medicare & Medicaid Services and the NIH.

Additional funds are essential to cover unaddressed priority review topics and to rereview all topics at a frequency that ensures that recommendations are comprehensive and current. With greater monetary support, the enormous benefits garnered from our pioneering work can be multiplied and make all Americans healthier and safer. In short, the Community Guide should be recognized and funded for what is has become: a fundamental pillar of our nation’s public health infrastructure.

In its third decade and beyond, I urge the CPSTF to continue pushing the boundaries of research on social determinants of health, so critical to improving the public’s health and reducing our nation’s blatant health inequities. Community Guide topics are given in the box on page 13.

Box 1— Topics Covered by the Community Guide: Your Online Guide of What Works to Promote Healthy Communities.

Adolescent health

Asthma

Cancer

Cardiovascular disease

Diabetes

Emergency preparedness

Excessive alcohol consumption

Health communication and health information technology

Health equity

HIV/AIDS, other sexually transmitted diseases, and pregnancy

Mental health

Motor vehicle injury

Nutrition

Obesity

Oral health

Physical activity

Pregnancy health

Tobacco

Vaccination

Violence

Worksite health

Source. http://www.thecommunityguide.org.