US Communities Need More Accessible Data to Improve Health, Not Less

In this AJPH issue, Phillips et al. (p. 1865) raise a major concern about discontinuation of the Community Health Status Indicators (CHSI) tool in 2017 without a similar replacement. CHSIs are standardized health outcomes and key social, economic, and physical environmental determinants of health for US counties with peer comparisons. These data were also easily accessible to the public as a data set. As health equity researchers who search for and use publicly available data to improve community health through community engagement, we are also concerned that to date there is still no replacement tool for informing community stakeholders’ advocacy and action as described in the Morehouse model for effective community engagement.¹

Although the measurement unit is the county, CHSIs are important sources of data. The CHSI tool is also a platform to stimulate data collection at smaller geographic areas such as city, zip code, census track, or census blocks. These are the local areas in which community- and faith-based organizations, civic organizations, social services, local public health agencies, and community leaders and advocates are increasingly engaged to improve the health of local residents.² Smaller geographic areas are often those most affected by the determinants of health, which the CHSI tool helps to explicate. Smaller geographic areas are also those where many health disparities are often observed and areas that stimulate the most significant community involvement and strategic action by local communities to find local solutions to improve health and well-being.²

Although Phillips et al. point out many very important uses of the CHSI, most communities and local public health agencies interested in relevant and needed data do not have the ability to access and analyze the data for meaningful, action-oriented decision making and intervention planning. We also agree that having needed data that are more detailed does not diminish the importance of CHSIs; it points out the need for more, not less data. Past and current work have clearly shown the importance of county-level and peer-comparison data in highlighting and directing resources to areas of need in improving community health.^3,4 The need for CHSIs might be clearer if they were more tightly aligned with such national efforts as the Action Plan to Reduce Racial and Ethnic Health Disparities or other efforts, such as the Eliminating Health Disparities Act of 2017, to allow a state to establish a Health Disparities Elimination Program, through which the state could develop community-based interventions to reduce health disparities.⁵

We ask the following: What national, regional, or state-level initiatives could the reintroduction of the CHSIs be aligned with?

IMPROVING COMMUNITY HEALTH

In 2013, a pivotal report of the National Research Council and the Institute of Medicine (now the National Academy of Medicine), US Health in International Perspective: Shorter Lives, Poorer Health, comprehensively and clearly outlined the health differences and reasons for these differences between the United States and its peer high-income countries, including 16 democracies.⁶ Sadly, US health ranking was near the bottom as measured by life expectancy, which had improved but not as fast as in peer countries. The smaller gains in US life expectancy were actually reversed before the COVID-19 pandemic, from a peak of 78.84 years in 2014 to 78.54 years through 2018.⁷ And during the pandemic, the US media has shone a bright light on the US health disadvantage by highlighting greater COVID-19–associated mortality in the United States than reported in peer countries.⁸

In the wake of the National Research Council and Institute of Medicine report, the American Public Health Association began an initiative to become the healthiest nation in a generation (by 2030), which included a strategy to promote the building of safe and healthy communities because the average life span across the nation is rooted in the health of communities.⁹ If data on community health outcomes and determinants are not widely accessible to communities, gaps in knowledge will remain about current community health and any health progress.

As the US public health system transforms to improve overall health through full implementation of the Affordable Care Act,¹⁰ by meeting goals and objectives of Healthy People 2030,¹¹ by meeting Public Health Accreditation Board Standards, and by implementing other national, local, and community initiatives to eliminate health disparities and achieve health equity,¹² communities need more, not less, essential data to actually improve the health of every member. Although many communities in the United States are strong, resilient, and capable of meeting the health needs of its residents, many communities are underresourced, have limited social supports and preventive and primary care health care services, and are not well enough organized to address the many environmental, social, behavioral, health care, and structural needs of its residents.¹³

Many communities require more and more varied interventions informed by data to provide the conditions for a healthy environment that leads to the optimal health of all residents. Stakeholder knowledge of current health outcomes and determinants of health enables science-based action to improve community health. Furthermore, the National Prevention Strategy also steers communities to implement evidence-based recommendations strategically to create healthy and safe community environments, integrate clinical and community preventive services locally, empower people, and eliminate health disparities in priority activities of tobacco-free living, preventing drug abuse and excessive alcohol use, healthy eating, active living, injury and violence-free living, and promotion of reproductive and sexual health and mental health and emotional well-being.¹⁴

Similarly, Healthy People 2020, and now Healthy People 2030, also calls for communities to use their goals and objectives to set local priorities.¹¹ Setting effective community target objectives will depend on current knowledge of health outcomes and health determinants at the level of community action as well as accessible data for surveillance and monitoring of the targets.

ACCESSIBLE HEALTH DATA

Although other sources of county-level data are available through the Robert Wood Johnson Foundation, PolicyLink, and other organizations, these resources provide aggregate data and allow some comparisons of key essential data between counties but do not provide all the essential data on health outcomes and health determinants in one data set that the CHSI tool made accessible to the public. We concur with the authors that there is still a need for CHSI-type data that are easily accessed by the public and expand indicators to also measure emotional well-being and better community health, particularly if they are combined in one accessible data set for smaller geographic areas, as the Federal Data Strategy presents an opportunity to build on lessons from the use of CHSIs.

CONCLUSIONS

Although national initiatives, such as the Federal Data Strategy and the National Committee on Vital Health Statistics, identify key health indicators to move the entire health status of the nation forward, local communities often need additional data, including smaller geographic areas of data for community health planning, interventions, programs, evaluation, and monitoring ultimately for advocacy and public health action. Creating a complete set of essential data as suggested by Phillips et al., which also addresses the gaps identified by the Federal Data Strategy and the National Committee on Vital Health Statistics, could arm communities with the needed science to effectively improve community health and achieve health equity. Only then can we realize the aphorism from a wise epidemiologist that “what gets measured gets done.”