Now that the planning process has launched, the next step is to review and organize relevant public health data that provides a clear picture of the impact of diabetes or chronic disease in the state. The data will then be shared in a meeting or series of meetings of the planning group, in order to (1) define the problem and (2) create a shared vision and goals for how to address the problem through the state plan. State department of health staff play an important role throughout this process.
Module 3 discusses several types of data that should be analyzed and ways to present data to partners. Just as you would gather information on the weather and soil conditions in your area before planting a garden, you need to gather information on the burden of diabetes or chronic disease in your area before taking action.
An Introduction to Public Health Planning
Learning the basics of gardening
Working Collaboratively with Partners, Pre-Planning and Launching the Planning Process with an Initial Meeting
Identifying what resources you have and what tools you need
Presenting the Data and Defining the Problem
Gathering information on weather and soil conditions in your area
Upon completion of this module, you should be able to:
It should take approximately 75 minutes to complete this module.
According to the public health approach described in Module 1, data is the foundation – and driver – of health planning and decision making.
Using data as the foundation of the state planning process ensures that the plan is based on an accurate understanding of the causes of public health problems and what interventions are effective in addressing them. Using data to drive the process of creating a state plan helps to:
There are three main types of data that will need to be analyzed and discussed to create an effective state plan:
As you prepare to gather and present data to your partners, it is important that you have a clear understanding of each of these types of data, including where the data come from, what the data tell you, and limitations of the data. The rest of this section discusses each main type of data in detail.
The first of the three main types of data to be collected is epidemiological and surveillance data.
Epidemiology is the study of the distribution and determinants of disease and injuries in specified populations. Epidemiologists use a variety of research methods to examine the differences between people with a particular disease and health condition and those without it. Epidemiological research can be used to determine an association between individual and population characteristics and a disease. Epidemiologists focus on collecting data that indicates the number of new cases of a particular disease (incidence) as well as the total number of cases of a particular disease (prevalence) at a particular period of time.
Surveillance is the on-going systematic collection, analysis and interpretation of health data essential to planning, implementation, and evaluation of public health practice. Surveillance is a type of epidemiological study that focuses on what is happening to the distribution of disease in the population over time. The same set of data elements are collected year after year, so trends in the pattern of disease can be described.
Epidemiologic and surveillance data help demonstrate the impact chronic disease has in your state and which populations are most affected. These data can also illustrate what modifiable personal and social factors exist that may contribute to the problem. Taken together, this information shows you where, how, and with which target populations you should intervene to decrease chronic disease-related problems. These data also provide a baseline to compare peer communities and future progress.
Types of information systems that routinely provide data for public health surveillance of chronic disease are discussed next.
Vital statistics reflect information collected at the time of birth (birth certificates) and death (death certificates), and are usually maintained by local and state health departments. Death certificates are used more often than birth certificates for chronic disease surveillance. The usefulness of both types of records depends on how accurately and completely information is recorded. Click here for more information about birth and death certificates.
Health surveys use structured interviews to collect information from a randomly selected sample of the population at the local, state, or national level. Health surveys can be administered in person, on the telephone, or online. Health surveys ask questions about sociodemographic (age, race/ethnicity, gender, education level, income level, access to health insurance) and geographic data, so that the characteristics of the sample can be matched against the characteristics of the population from which the sample is drawn.
Several different health surveys and epidemiological resources are supported nationally and in states by the Centers for Disease Control and Prevention (CDC). Described in detail in the next few slides, these surveys and resources include:
Surveillance Data Sources: Health Surveys
Behavioral Risk Factor Surveillance System (BRFSS)
The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based system of health surveys that collects information on health risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury. More than 350,000 adults are interviewed each year, making the BRFSS the largest telephone health survey in the world.
Click here for more information about the BRFSS.
Surveillance Data Sources: Health Surveys
Other state-specific epidemiological surveys
Some states with sufficient fiscal and personnel resources also conduct their own epidemiological surveys using traditional survey methods (such as telephone interviews and stratified random samples) to examine topics of particular interest. These surveys may be done once to collect data to be used in planning or to answer specific questions, or they may be done repeatedly over time to determine trends.
The National Health Interview Survey (NHIS) is the nation’s largest household health survey, conducted annually by the National Center for Health Statistics (NCHS). It provides information on the health status of the U.S. civilian non-institutionalized population using a national sample to conduct confidential, in-person interviews of all adult members of selected households.
Click here for more information about the NHIS.
Surveillance Data Sources: Health Surveys
The National Health and Nutrition Examination Survey (NHANES)
The National Health and Nutrition Examination Survey (NHANES) is NCHS' most in-depth and logistically complex survey, designed to assess the health and nutritional status of Americans. This comprehensive survey combines personal interviews with standardized physical examinations, diagnostic procedures, and lab tests on approximately 5,000 persons each year.
Click here for more information about the NHANES.
Surveillance Data Sources: Health Surveys
The CDC’s National Diabetes Surveillance System
National burden data, along with Healthy People 2020 Objectives, can provide states with a starting point in setting reasonable targets for their state-specific goals and objectives.For the example of diabetes, the CDC’s Division of Diabetes Translation (DDT) and its partners provide several resources through the Diabetes Data & Trends website, including the National Diabetes Fact Sheet, National Diabetes Surveillance System data, and county-level estimates of diagnosed diabetes and selected risk factors.
The National Diabetes Fact Sheet summarizes the latest national level estimates of Americans with diagnosed and undiagnosed diabetes. It presents data on health complications, mortality, and costs associated with diabetes, as well as information on differences by age and racial/ethnic groups. The information presented in the fact sheet can be used to compare state rates to national rates and also as a reference for what information to include in state diabetes burden reports.
The National Diabetes Surveillance System monitors several trends in diabetes and its complications including hospitalization, preventive care practices, risk factors for complications, health status and disability.
County-Level Estimates provide maps of diagnosed diabetes, obesity, and physical activity, generated from BRFSS and Census data. The maps rely on estimates and statistical modeling techniques, so caution should be exercised when making comparisons based on these maps.
The ultimate source of demographic data used in the United States for epidemiologic purposes is the United States Census. The U.S. Census, conducted every ten years, is an enumeration of the total population of the United States.
Standard epidemiological analyses of health status by age, gender, race/ethnicity, geographic region, education, and income levels are dependent on the demographic information collected through the Census. Comparison of rates measured across different population segments show whether or not any particular subgroup is disparately affected by a disease or condition.
Click here for more information about the U.S. Census.
Since the BRFSS and other epidemiological data sources gather information about individuals’ places of residence, data obtained through these surveys can be mapped to Census data. The Geographic Information System, or GIS, uses Census information tied to the geographic coordinates for each Census district to map factors that influence health and disease, such as:
Using State Surveillance Data to Describe the Burden
The results of the annual BRFSS and additional epidemiological surveys provide the basic data for each state’s chronic disease burden reports. These reports examine the distribution of diseases and their related risk factors in the population by person, place, and time.
Person, place and time trend analyses may be done for specific subgroups in addition to the general population. These analyses are critical in identifying health disparities, modifiable and non-modifiable risk factors, target populations for interventions, and geographic variation within the same racial/ethnic group.
The term “Social Determinants of Health” (SDOHs) describes how our health is affected by political, economic, and social forces. These forces create variations in health among segments of the population differentiated by race/ethnicity, place of residence, education, employment, insurance, and income. Segments that bear a disproportionate share of the burden of chronic disease are referred to as “disparate populations.”
Analyzing and understanding the social determinants of health and the resulting health disparities allows you to target your efforts to the populations that are most affected by diabetes or chronic disease and determine appropriate intervention strategies.
Most information about the social determinants of health is derived from the U.S. Census and other economic surveys conducted by the U.S. government. A research-based list of twelve major social determinants of health indicators is presented in the National Association of Chronic Disease Directors’ Diabetes Council Guidance Document Effective Use of Indicators for Exploring the Social Determinants of Health. This document also contains a table showing the recommended sources of data, data analysis plans, and limitations to consider when using these indicators. It is a good resource to use when considering how to access, interpret, and use SDOHs data in the planning process.
Social Determinants of Health Indicators
The second type of data to be used in defining the burden of chronic disease is health care system data. Sources of health care system data, which are generated by health care organizations and agencies, include:
Not all state public health departments have access to administrative health care system databases. Some states have laws that guarantee public health access to certain health care administrative systems, such as hospital discharge databases and state Medicaid databases.Access to other health care systems, such as HMOs, federally qualified health centers (FQHCs), and individual providers, is usually based on the relationship between the state department of health and the specific health care system.
Several states have participated in health care quality improvement (QI) initiatives. The participating health care system facilities collect, track, and report data on the delivery of preventive care and treatment services and patient health status outcomes. This data is recorded in patient registries and in electronic health records.
Health care system data can provide information regarding:
These data will help you document not only morbidity and mortality, but also the scarcity or sufficiency of resources to treat those with chronic disease. Factors like the distribution, accessibility, and affordability of these resources will influence which interventions are ultimately selected for the state plan.
Health care system data are not generalizable to the population at large. They are collected from a specific subset of the population, health care system users, and are not a random sample of the total population.
While a useful source of information, there are important limitations to consider when using health care system data:
The third and final type of data to be used during the planning process is environmental scan data. Environmental scans may be conducted regularly, or before beginning a state planning process. In public health, an environmental scan is a form of needs assessment that focuses on:
The health care and social services systems and how they interact to meet the needs of particular populations with or at risk for a particular disease
Environmental scans used in state planning describe the programs and services provided through the chronic disease health system. The health system is comprised of organizations and agencies that offer varying services and programs that span many different sectors. Environmental scans should include details about these organizations, their programs and services, and the populations they target.
There are several types of key organizations that should be described in the environmental scan, as listed below. Hover over the organization type for more information specific to the example of diabetes:
Public health environmental scans rely on quantitative and qualitative data collection methodologies. Partners in the coalition and individuals representing different stakeholders in the system can be used as sources of information for the scan. Increasingly, environmental scans also utilize health databases, such as hospital information systems and government population health registries.
Once all of the information about the chronic disease health system in your state has been gathered for the environmental scan, it should be organized and analyzed using the following components:
Taken together, these environmental scan components outline the resources, programs, and services available to those with or at risk for chronic disease; provide insight into the capacity of the chronic disease health system; and identify areas where improvement or new interventions may be needed.
Section I described three main types of data that will be used during the planning process, including sources of these data types, the ways the data can be used, and limitations to using them.
Now, think about how these concepts apply to your state planning process. Watch the video below featuring the Kentucky DPCP epidemiologist. Then, answer the discussion questions that follow. Click here for a worksheet to record your answers.
The next section of Module 3 will discuss how to present the data to the planning group.
Once the relevant data has been collected, the data will need to be organized and shared in a meeting or series of meetings of the planning group. Sharing data will help the planning group understand the burden of diabetes or chronic disease in the state, the extent of existing programs and services, and gaps where interventions are needed to address the problem.State Health Department staff play an important role in this process.
Since many members of the planning group may be unfamiliar with epidemiological data, this section will describe ways that data can be presented to partners and tips on how to make these presentations easy to understand.
One of the ways to present data to partners is through the state chronic disease burden report. Most state departments of health publish a chronic disease burden report every three to five years.
As the primary method of disseminating data, the burden report is an important source of information that should be shared with all planning group members. However, the burden report is a comprehensive technical report primarily written for a public health audience and key stakeholders. Because of this, you may need to present data in other formats that are more easily understandable or more relevant to the interests of the planning group.
In addition to the burden report, there are other formats that can be used to communicate the three main types of data that have been collected about chronic disease in the state.
Additional formats that can be used to present data include:
As discussed in Module 2, partners from various backgrounds participate in the state planning process. Not everyone in your coalition will have a public health background or a strong understanding of where data come from, what they mean, and how to apply data to health planning. Some members may enter the planning process with preconceived ideas about the nature of the problem and its solutions based on their organizations’ areas of influence and past experiences.
The state department of health staff should be prepared to present the data in an easy-to-understand format and describe epidemiological concepts in plain words. Presenting the data in this manner helps partners achieve a shared understanding of the problem, creates buy-in, and makes partners comfortable with applying the public health approach of using the data to guide decision-making.Click here to download a glossary of some commonly used epidemiologic terms.
It is important that data is presented to partners in a way that makes sense to them and enables them to get the full picture of the diabetes or chronic disease burden in the state. Click here for tips that will help to accomplish this.
Once the data has been presented, the planning group should have a solid understanding of the diabetes or chronic disease problem in your state. The next step is to think through the implications of the data to create a shared vision and goals focused on changing the burden. The shared vision and goals will shape the remaining steps in the planning process.
First, the planning group can take a step back and think about what the state would look like without the burden of diabetes or chronic disease. This can be accomplished through a visioning exercise, in which you and your partners create a joint vision statement that describes a shared image of the ideal future. Vision statements are:
The facilitator can lead group activities that will involve all participants in the development of the vision statement. Below is a sample visioning exercise.
Next, the planning group can use a diabetes or chronic disease population flow map, in combination with the epidemiological data and the environmental scan, to discuss where interventions can be developed or expanded to have the greatest potential for impacting the problem in the state. The population flow map represents a continuum progressing from a healthy population to those at-risk, those with chronic disease who are undiagnosed, those with chronic disease who are diagnosed, and those with chronic disease and resulting complications.
For example, the diabetes population flow map, shown below, is a framework for understanding the chronological progression of diabetes among the general population and identifying the key leverage points to target interventions. Starting at the far left and moving right, the diagram shows how a portion of the population with normal glycemic levels progresses into a sub-population with diabetes and complications of diabetes. The flow map can be used to show where the current population is, and to show trends in 20-30 years if no interventions are implemented, as well as to show variations caused by disparities.
The flow map helps the planning group stay focused on the key points at which to intervene:
The Diabetes Population Flow Map
Hover over each box in the diagram below for more information about the population and interventions that can be used to target that segment.
When presenting the diabetes population flow map, two versions can be produced in poster size to display in the meeting of the planning group. The first one can show the current distribution of the population of the state into the different sub-populations. The second version can show the future distribution of the population in twenty years if current projections of prevalence of diabetes and diabetes risk factors are accurate. You also may want to produce additional examples of the diabetes population flow map showing how the distribution into sub-populations varies among disparate groups.
After the diabetes flow map is presented and explained to the planning group, participants should break into small groups to identify and post the major organizations and their programs and services currently offered to each subpopulation along the flow map, especially at critical intervention points. (Each small group will need their own poster-size diabetes flow map.)After posting organizations with their programs and services on the diabetes flow map, each small group should make a list identifying gaps and unmet needs in programs and services. After each small group finishes their list, all of the groups should return to a meeting of the whole to compare their postings of organizations, programs, and services, and their lists of gaps and unmet needs. The planning group can then approve a composite version of the diabetes flow map and a finalized list of gaps and unmet needs. This same exercise can be replicated for any or all other chronic diseases.
After the composite flow map with resources is approved, the group facilitator can lead the participants through an exercise to identify long-term goals for inclusion in the state plan.
Thought Provoker: What are the long-term goals in your state’s most recent state plan?
Long-term goals reflect the changes in the burden of chronic disease that you and your partners intend to achieve within three to five years. The goals are concise sentences that focus on how some aspect of the existing status will improve as a result of the efforts of all partners working together. Goals reflect the vision statement and are organized around the critical intervention points and key populations identified in the review of your state’s population flow map, burden data, and environmental scan.
While the vision and goals will not be finalized until later in the planning process, it is important that participants have a preliminary version of a vision and goals in mind as they move toward the next step of identifying and selecting evidence-based interventions to address the burden of diabetes or chronic disease.
Below is a sample goal development exercise.
Section II described how to effectively use your state burden report, other ways to present data, and the population flow map in order to (1) define the chronic disease problem in your state and (2) create a shared vision and goals for how to address the problem.
Now, think about how these concepts apply to your state planning process. Watch the video below featuring members of the Kentucky Diabetes Network (KDN), followed by the Texas DPCP Information Specialist. Then, answer the discussion questions that follow. Click here for a worksheet to record your answers.
After the planning group holds an initial meeting to launch the planning process (discussed in Module 2), the planning group will need to hold another meeting or meetings to present the data, define the problem, and develop a shared vision and goals for the state plan. There are four main actions to take during the meeting(s):
Afterward, the planning group members can share the relevant data, potential intervention points, and vision statement and goals with their respective organizations for input and feedback before moving on to the next step of the planning process.Click here to download a sample agenda that shows how these steps could fit into a meeting (or meetings) of the planning group.
According to the public health approach, data is the foundation – and driver – of health planning and decision making. State department of health staff play a crucial role in ensuring that data are used throughout the state planning process and in communicating data and its significance to planning partners.
Module 3 described how to define the diabetes or chronic disease problem in a state using:
The data that have been collected and the population flow map will continue to be used in subsequent meetings of the planning group to guide the identification and selection of evidence-based interventions to address the burden of diabetes or chronic disease in your state.
You can download a PDF of helpful resources for more information.
Continue the course with Module 4: Identifying and Selecting Appropriate Evidence-Based Interventions.