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Policy, Systems, and Environmental Strategies: Call for Feedback

on a New Decision-Making Resource

Tuesday, November 5, 2013

Sarah Lifsey
Sheryl Mathis

Across the country, communities are looking

for ways to improve the health and well-being of their residents. It is increasingly clear that
where we live, work, and playin our workplaces, our schools, our neighborhoods, and
our larger communitieshas a strong influence on our health.[1] Partners at the
community, state, and federal levels are working together to develop, implement, and
evaluate community-based strategies to improve health.

For example, the Centers for Disease Control and Preventions Healthy Communities
Program focuses on helping communities make changes to their policies and environments
in ways that help prevent chronic disease. These community-level strategies are sometimes
called policy, systems, and environmental (PSE) strategies, because they seek to make
changes aimed at influencing the health of an entire community. While promising PSE
strategies address the public health issues that are among the most pressing concerns for
communitiestobacco, violence and injury prevention, obesity, access to nutritional foods
and physical activity opportunities, and moreit can be difficult for decision-makers to
know which strategies to pursue. Most PSE strategies have not yet been rigorously
evaluated and take place simultaneously with other interventions and social issues in play,
making it difficult to measure cause and effect.
Decision-makers and practitioners need a clear, easy-to-understand resource for
identifying promising and effective PSE strategies that are most likely to make meaningful
and lasting changes in their communities, states, and regions. To fill this gap, the U.S.
Department of Health and Human Services Assistant Secretary for Planning and Evaluation
(ASPE) has commissioned an expert panel of researchers, policy makers, and community
and state practitioners to develop a decision-making resource for PSE strategies. Working
with the expert panel and the expertise of the ASPE team, Altarum has produced a draft
PSE Strategies Decision-making Resource.

This Resource is being disseminated for public input to ensure the practical utility of the
Resource for multiple stakeholders. Public health practitioners, funders, and researchers
are encouraged to review the draft Resource and provide feedback to help improve the
final version.

What does the Resource offer?

The Resource aims to take stakeholders through a simplified decision-making framework

that draws attention to the unique considerations needed for PSE strategies. PSE strategies
are different in many ways from traditional public health programs. While traditional
programs and clinical interventions have the goal of changing the behavior of people as
individualsfor example, a clinical smoking cessation program where people are
counseled on ways to quit smokingPSE strategies are designed to change upstream
factors. Upstream factors are those that influence the behaviors of people at the community
level and change the environment where a person lives, laws and policies that encourage or
discourage his or her behaviors, and the institutional and organizational systems that
surround him or her.[2] These differences between PSE strategies and more traditional
programs mean that communities need to look at decision-making, implementation and
adaptation, and measurement and evaluation in a different way.
The PSE Strategies Decision-making Resource presents a three-step outline for how
decision-makers can identify appropriate strategies in their communities and build the
evidence base for using those strategies.

First, decision-makers identify the PSE strategies that best address their communitys
needs, using the best available evidence from existing systematic reviews. There are many
well-researched and influential databases where the evidence for public health strategies
is reviewed and weighed. These systematic reviews cover a variety of topics, from
violence prevention to education to community health, and they often include both
individual-level public health interventions and PSE strategies. However, a literature
review conducted for this project found that decision-makers need additional evidence to
make decisions about PSE strategies because of the community-based nature of those
strategies. This resource outlines elements to keep in mind that are important to
population health programs and PSE strategy selection.
Second, decision-makers must implement the strategy within their community context,
balancing the need for adaptation with fidelity to the strategy. This step grows out of the
first, where community needs and resources are considered and compared with those of
the selected PSE strategy. The resource discusses considerations for striking a balance
between adaptation to the needs of the community and fidelity to the original PSE
strategy. It also addresses the importance of carefully documenting aspects of the
Finally, decision-makers must measure the outcomes of the strategy appropriately, taking
into consideration the research questions, evaluation methods, and outcomes measures
best suited for growing the evidence base for PSE strategies and population health
programs. This information closes the loop on cyclical decision-making. It is becoming
more and more common for communities and funders to emphasize the need for
evidence-based approaches. Evidence-based approaches are explicitly linked to the best
available scientific evidence and reflect community context and feasibility.[3] A stronger
evidence base for PSE strategies and population health programs helps decision-makers
select the PSE strategies and programs that are most appropriate for their communities,
beginning the cycle anew.
As communities continue to implement, evaluate, and adapt PSE strategies, promising
practices will emerge, empowering funders and community decision-makers to promote
and fund the strategies that best improve community health.

Click here to view the draft Resource and provide comments and feedback. Your input will
help make this resource as useful as possible for growing the evidence base for promising
PSE strategies to improve community health.
[1] Healthy People 2020. (2013). 2020 topics and objectives: Social determinants of health.
Washington, DC: US Department of Health and Human Services. Retrieved from

[2] Ahlquist, B. (n.d.). Understanding policy, systems, and environmental change to improve
health. Presented to the Minnesota Department of Health. Retrieved from

[3] Fielding, J., & Briss, P. (2006). Promoting evidence-based public health policy: Can we
have better evidence and more action? Health Affairs (Project Hope), 25(4), 969978.

All postings to the Health Policy Forum (whether from employees or those outside the
Institute) represent the views of the individual authors and/or organizations and do not
necessarily represent the position, interests, strategy, or opinions of Altarum Institute.
Altarum is a nonprofit, nonpartisan organization. No posting should be considered an
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