The National Health Security Preparedness Index’s Environmental and Occupational Health (EOH) domain tracks the nation’s progress in this area, which appears underwhelming in recent years.  The Index measures capabilities for maintaining the security and safety of water and food supplies and testing for hazards and contaminants in the environment. These measures reveal some concerning trends. Although geographic disparities are reflected in many areas tracked by the Index, variation across states is widest in EOH, with the leading state achieving protections 2.4 times greater than its lowest-scoring counterpart. Furthermore, more than 40% of all U.S. states have experienced declines in EOH protections since Index tracking began, while an additional 25% of states have held steady, seeing neither declines nor improvement. Yet during the same period, the U.S. has experienced improvements in most other health security domains tracked by the Index.

The National Conference of State Legislatures and the University of Kentucky’s Index Program Office recently hosted a meeting of environmental and occupational health experts in Washington, DC to explore EOH domain trends. Meeting participants included representatives from the Centers for Disease Control and Prevention, the National Environmental Health Association, the National Institute of Environmental Health Sciences, the National Governors Association, the Association of State and Territorial Health Officials, the Association of Public Health Laboratories, the National Association of County and City Health Officials, state environmental health leadership, and community-based organizations. The meeting’s purpose was threefold: 1) to identify specific policies, practices, and/or measurement issues contributing to variation and declines within the domain; 2) to discuss policy and practice implications for addressing potential drivers; and 3) to develop strategies for strengthening the domain in ways that can more accurately and completely measure environmental and occupational health contributions to health security. What did we learn through this important dialogue? In coming months, this blog will share excerpts from the forthcoming formal meeting report.

In the meantime, learn more about EOH and other 2017 results in the Summary of Key Findings, and explore data for all states, domains, and years in the 2017 Data Download – both are available from the Index Toolkit page. Then join our efforts in continuously improving the Index and supporting its use by participating in one of our standing workgroups.

Anna Goodman Hoover, PhD, MA is an assistant professor in the University of Kentucky College of Public Health Department of Preventive Medicine and Environmental Health, where she conducts research on how multi-sectoral communication and engagement strategies and structures can strengthen partnerships and support evidence-informed environmental health decisions.

Glen P. Mays PhD, MPH is the chair and a professor in the Department of Health Systems, Management and Policy in the Colorado School of Public Health at CU Anschutz. His research examines delivery and financing systems for health services, with a focus on estimating their effects on population health and economic efficiency.

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Community Planning and Engagement

The Index is organized around six broad areas or domains, one of which is community planning and engagement. The role of community planning and engagement is vital to health security since it represents the extent to which there are supportive relationships among government agencies, community organizations, and individual households that are developing shared plans for responding to hazards. Relationships that connect people and organizations make communities more resilient to disasters and can accelerate recovery after events occur. This domain stood out as the nation’s weakest area of preparedness in the first Index released in 2013, but it improved by 16.3 percent as of 2016—more than any other domain monitored in the Index. If maintained over time, improvements in collaboration may help states and communities acquire new resources and expertise that strengthen other domains of health security. Accordingly, an important research and policy question is, “why do some states perform better than others in the domain of community planning and engagement?”  Understanding the underlying reasons for a state’s higher performance can suggest options for other states.

Evidence-Based Policymaking

A January 2017 assessment of state-level policymaking practices by The Pew Charitable Trusts and the MacArthur Foundation shows wide variation among the states with respect to use of evidence-based policymaking.[i] Looking for six actions of evidence-based policymaking (e.g., does the state compare program costs and benefits or otherwise incentivize agencies to engage in evidence-based policymaking) within four broad policy areas (i.e., behavioral health, child welfare, criminal justice, and juvenile justice), the research team categorized each state and DC into one of four groups: leading (5 states), established (11), modest (28), or trailing (7). The leading states, which include Washington, Utah, Minnesota, Connecticut, and Oregon, have developed “processes and tools that use evidence to inform policy and budget decisions across the areas examined.” Conversely, the seven trailing states take “very few evidence-based policymaking actions.”

Our analysis shows that states with higher levels of evidence-based policymaking tend to perform better on the Health Security Index’s community planning and engagement domain (see Figure 1).[ii] Standing in stark contrast to the adage that “good politics beats good policy every time,” evidence-based policymaking is about government marshalling information to formulate policies that are efficient and effective, and represents “the systematic use of findings from program evaluations and outcome analyses (“evidence”) to guide government policy and funding decisions.”

There is a statistically significant relationship between the extent to which a state demonstrates actions toward evidence-based planning and how it performs in the community planning and engagement domain in the 2017 Health Security Index.[iii]  And the relationship is robust,[iv] with the effect of evidence-based planning remaining strong while holding constant the overall wealth of a state (as measured by a state’s 2016 per capita personal income),[v] its fiscal health (as measured by the percentage of a state’s long-term financial obligations, e.g., debt, unfunded pension costs, and unfunded retiree health care costs, as a percentage of the state’s total personal income),[vi] and its experience with disasters (as measured by number of disaster declarations for state since 1953).[vii]

The slope in Figure 2 represents the estimated relationship between the prevalence of evidence‐based policymaking in a state and its Health Security Index Score in the Community & Planning Engagement Domain while holding per capita income, state fiscal health, and disaster experience constant. As a state moves along the horizontal axis—which reflects the four evidence-based planning categories (i.e., trailing, modest, established, and leading)—a state’s estimated Community Planning and Engagement Health Security Index score increases in a substantively and statistically significant way—from below the U.S. average (Trailing), to within the U.S. average (Modest & Established), to above the U.S. average (Leading). This estimate shows that a state imbued with a culture of evidence-based policymaking—residing in the upper reaches of the “established” category or fully embedded in the “leading” category—would likely score above the U.S. average in the Community Planning & Engagement Domain.

These results suggest that health security can be enhanced by creating a culture of evidence-based policymaking at the state level. The authors of How States Engage in Evidence-Based Policymaking offer some guidance on how to build support for it, such as actively championing its adoption, creating a strong data infrastructure to leverage outcome data, and ensuring there are staff members who have the necessary analytical and technical skills to implement it. There are clearly many benefits accruing to states that have a culture of evidence-based policymaking, including, but not limited to, better policy outcomes, more efficient use of government resources, and enhanced health security.

Michael T. Childress is a research associate at the Center for Business and Economic Research, Gatton College of Business and Economics, at the University of Kentucky. He is part of the program management office for the National Health Security Preparedness Index.

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[i] How States Engage in Evidence-Based Policymaking: A National Assessment, The Pew Charitable Trusts & MacArthur Foundation, January 2017.

[ii] The research team awarded points to states on the basis actions taken toward evidence-based policymaking. An advanced action garnered 2 points, a minimum action 1 point, and no action zero points. An example of an advanced action within the category of “comparing program costs and benefits” is whether a state produces a report on the costs and monetized benefits of multiple related programs (2 points) while a similar report focused on non-monetized outcomes is indicative of a minimum action (1 point).

[iii] The evidence-based policy coefficient = 0.04744, t-value = 2.74.

[iv] The evidence-based policy coefficient barely changes (b=0.04892, t=2.9) even after adding per capita income, strength of state finances, and experience with disasters to the equation.

[v] Bureau of Economic Analysis data available at https://www.bea.gov/.

[vi] PEW data available at http://www.pewtrusts.org/en/multimedia/data-visualizations/2014/fiscal-50#ind4.

[vii] FEMA data available at https://www.fema.gov/data-visualization-disaster-declarations-states-and-counties. We use the logged value, base 10.

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