An Integrated Framework for Assessing the Value of

Community-Based Prevention

Institute of MedicineCommittee on Valuing Community-Based,

Non-Clinical Prevention Policies and Wellness Strategies

Robert S. Lawrence, M.D., Chair

Kirsten Bibbins-Domingo, Ph.D., M.D.

Laura K. Brennan, Ph.D., M.P.H.

Norman Daniels, Ph.D.

Darrell J. Gaskin, Ph.D.

Lawrence W. Green, Dr.P.H., M.P.H.

Robert Haveman, Ph.D.

Jennifer Jenson, M.P.H., M.P.P.

F. Javier Nieto, M.D., Ph.D., M.P.H.

Daniel Polsky, Ph.D.

Louise Potvin, Ph.D.

Nicolaas P. Pronk, Ph.D.

Louise B. Russell, Ph.D.

Steven M. Teutsch, M.D., M.P.H.

Chapin White, Ph.D., M.P.P.

Committee Charge

The Institute of Medicine will appoint an expert committee to develop a framework for assessing the value of community-based, non-clinical prevention policies and wellness strategies, especially those targeting the prevention of long-term, chronic diseases.

Committee Charge continued

Specifically, the committee will:• Define “community-based, non-clinical prevention policy and

wellness strategies;”• Define “value” for community-based, non-clinical prevention policy

and wellness strategies;• Analyze current frameworks used to assess the value of community-

based, non-clinical prevention policies and wellness strategies, including:– The methodologies and measures used and– The short and long-term impacts of such prevention policy and

wellness strategies on communities including healthcare spending and public health;

Committee Charge continued

• If warranted, propose a new framework or frameworks that capture the breadth and complexity of community-based, non-clinical prevention policies and wellness strategies including interventions that target specific behaviors and health outcomes.

The framework should:• Consider the sources of data that are needed and available;• Consider the concepts of generalization, scaling up, and

sustainability of programs, and• Address national and state policy implications associated with

implementing the framework.

Definitions

Community-based, non-clinical prevention policy and wellness strategies was shortened for purpose of this report to community-based prevention.

Definitions

• Community-based prevention interventions are population-based interventions that are aimed at preventing the onset of disease, stopping or slowing the progress of diseases, reducing or eliminating the negative consequences of disease, increasing healthful behaviors that result in improvements in health and well-being, or decreasing disparities that result in an inequitable distribution of health.

Definitions

Community-based prevention interventions focus on population health and often address changes in the social and physical environment, involve intersectoral action, highlight community participation and empowerment, emphasize context, or include a systems approach.

Definitions

• Community is defined as any group of people who share geographic space, interests, goals, or history.

• The value of an intervention is defined as its benefits minus its harms and costs.

• A framework for assessing value is a structure for gathering and processing information to aid intelligent decision making and, more specifically, to help decide whether an activity or intervention is worthwhile.

Domains of Value

Because of the way in which community-based prevention interventions are designed and developed, they can have an impact beyond health.

Domains of Value

The committee concluded that the following three distinct but interrelated categories of outcomes, or domains of value, may result from community-based prevention interventions:•health,•community well-being, and•community process.

Domain Elements

It is important to note that the list of elements in the next few slides are illustrative of the elements to be found in each domain. The actual elements selected for valuing will depend on the intervention of interest and on its implementation.

The committee has identified one element—equity—which crosses all domains.

Health (Physical and Mental) Domain

Includes reductions in the incidence and prevalence of disease, declines in mortality, and increases in health-related-quality of life.

While health is a component of community well-being, it has been identified as a separate domain because it is an outcome of particular interest.

Elements in the Health Domain

Physical health includes mortality, morbidity, and functional capability.

Mental health includes cognition, individual resilience or emotional reserves, mortality from such causes as suicide, morbidity (e.g., depression), and socio-emotional health-related quality of life.

Community Well-Being Domain

Includes social norms, how people relate to each other and to their surroundings, and how much investment they are willing to make in themselves and in the people around them.

Elements of Community Well-Being

Elements of community well-being include wealth and income, education, employment, crime, transportation, housing, worksites, food, social support and social networks, and health care.

Community Process Domain

Community processes refer to several elements that have a distinctive influence on community participation in the decision-making as well as the design and implementation associated with community-based prevention interventions.

Elements of Community Process

Includes civic engagement, local leadership development, community participation, trust, skill-building, transparency, and inclusiveness.

Criteria for a Framework for Valuing

1. The framework should account for benefits and harms in the three domains of health, community well-being, and community process.

2. The framework should consider the resources used and compare benefits and harms with those resources.

3. The framework needs to be sensitive to differences among communities and to take them into account in the valuing process.

Existing Frameworks

The committee analyzed 8 existing frameworks to determine whether they were sufficient for valuing community-based prevention interventions.

1.Benefit-cost analysis

2.Congressional Budget Office scoring

3.Cost-effectiveness analysis

4.The PRECEDE-PROCEED framework

5.The RE-AIM framework

6.The Health Impact Assessment framework

7.The Community Preventive Services Task Force guidelines

8.The Canadian Health services Research Foundation (Lomas) model

Existing Frameworks

The committee concluded that none of the existing 8 frameworks met all of the criteria for a valuing framework. Therefore, a new framework was needed to assess the value of community-based prevention interventions.

Goals of a New Framework

1. Incorporate the full scope of benefits (health, community well-being, and community process) into the valuing process.

2. Emphasize that value requires a comparison of the benefits and harms of an intervention in relation to the resources used.

3. Allow the specific characteristics and context of individual communities to be reflected in the valuing process

Goals of a New Framework continued

4. Promote the quantification of value in terms of projected or actual changes due to the intervention.

5. Promote the development of evidence to make understanding the effects of interventions easier and more reliable.

A New Framework

Recommendation 1

The committee recommends that those seeking to assign value to community-based prevention interventions take a comprehensive view that includes the benefits, harms, and resource use of such interventions in 3 major areas: health, community well-being, and community process.

Data Sources

1. Data on health exist (including surveys, cohort studies, registries, health services data, and vital statistics).

2. There are many limitations when attempting to use these data for local, community-based measurement.

3. Identifying measures and sources of data for community well-being and community process elements is even more challenging.

Recommendation 2

• The committee recommends that the CDC:– Develop an expanded inventory of data

sources and needs for community-based prevention,

– Identify information gaps, and– Develop information to fill those gaps.

Indicators

• The committee proposes four indicators to assess the value of community-based prevention:– Changes in health– Changes in community well-being– Changes in community process– Resources used

Indicators

• Quality-adjusted life years or health-adjusted life expectancy can be used as an indicator for the health domain.

• Single metrics for the community well-being and community process domains do not exist

Recommendation 3

The committee recommends that the National Prevention, Health Promotion, and Public Health Council and other public and private sponsors support research aimed at developing:– A single metric for appraising a community’s well-being,– A single metric for appraising community processes, and– A single metric for combining indicators of community well-being

and community process with health into a single indicator of community benefit that can be considered in the context of costs and used to determine the value of a community-based prevention intervention.

• 

Assessing change

The value of a community-based prevention intervention reflects its impacts in relation to what would have happened in its absence or in relation to an alternative community-based prevention intervention.

Recommendation 4

The committee recommends that those assessing value should include in their assessments the expected or demonstrated changes, both positive and negative, that result from the intervention.

Who Should be Involved in Valuing?

Consultation with the community and other stakeholders is critical in determining the value of community-based prevention interventions since different groups will have different preferences that need to be considered when making decisions about which interventions to support.

Recommendation 5

The committee recommends that those involved in decision making ensure that the elements included in valuing community-based prevention interventions reflect the preferences of an inclusive range of stakeholders.

Decision Making

• Reasonable disagreement about how to value a community-based prevention intervention may persist.

• Such disagreement may pose legitimacy problems for decision makers.

• Providing the rationale for how decisions are made should enhance legitimacy.

Recommendation 6

The committee recommends that, to assure transparency:– Analysts make publicly available the evidence

used for valuation and provide estimates of the uncertainty of their results, and

– Decision makers make publicly available the rationale for their decisions.

Implications for State and National Policy

• The committee’s framework is in its very early stages, so its near-term impact on policy is likely limited.

• Expanding its influence requires building consensus that the domains—health, community well-being, and community process—are all of value in community-based prevention.

Implications for State and National Policy

• As the framework is used, communities and decision makers will have the opportunity to refine it and expand the underlying evidence base.

• A future role could be a requirement that legislative or grant proposals perform an objective impact assessment based on the framework.

Conclusion

Though there remains much to be learned, the framework presents the first step to realizing the long-term goal of valuing community-based prevention appropriately and comprehensively.