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A hierarchical evaluation process to adopt new content areas for Environmental Public Health Tracking (EPHT) in Minnesota Blair Sevcik MPH, Jeannette Sample MPH Background Phase 2 Evaluation Questions For states with Environmental Public Health Tracking (EPHT) programs, allocating limited resources for the selection and adoption of new content areas is not a new issue. To address this issue, Minnesota EPHT has developed and refined a hierarchical evaluation process to guide the process of adopting new statespecific content areas. Other exploration into the topic of identifying and evaluating new content areas for indicator-based systems has been done.1 Using existing environmental health indicator models and evaluation frameworks, staff first developed a list of selection criteria. Staff then prioritized the criteria into a four phase hierarchical evaluation process that builds a scientific rationale for including potential content areas into MN EPHT: Exploration, Feasibility, Recommendation, and Implementation. In order to best utilize resources, the Advisory Panel is informed and consulted after work for each phase is complete. Work may halt if the rationale for pursuing a content area is judged not robust. For each phase, MN EPHT identified an objective, key concepts, criteria and related questions, tasks and deliverables, and involvement. Throughout the evaluation process, staff consult the Technical Team for input on criteria and rationale, as well as provide progress updates to the Advisory Panel. Using input from Technical Team and Advisory Panel members, Project Management decides whether the completed criteria support further exploration in the next phase. Objectives Methodology Phase 1: Phase 2: Phase 3: Phase 4: Exploration Feasibility Recommendation Implementation DETAILED FEASIBILITY •What is the data quality? •Is there continuity? Are the data timely? Are the data comparable? •Is aggregation possible at different geographic levels? •What is the cost to MDH to obtain data? Phase 3 Evaluation Questions EMERGING ISSUES Key Concepts Under Minnesota law, an external stakeholder Advisory Panel is involved in advising the Commissioner of Health on EPHT program priorities in Minnesota. Ideas for Minnesota-specific content areas and measures could come from a variety of sources, including staff, Advisory Panel members, the public, nongovernmental organizations, local public health officials, or legislators. Given limited time and resources, MN EPHT staff determined that a documented process to evaluate suggestions was needed to help guide the Advisory Panel recommendations for Minnesota-specific content areas. Figure 1: Flowchart representing the four-phase hierarchical evaluation process for selecting new EPHT content areas •Explore rationale for including new content area •Determine if there are resources to evaluate new content area •What is the public health importance? •Do available data exist? •Do resources exist to gather data? •Examine ways data can be visually displayed •Are data robust and of high quality? •Can data be manipulated in useful ways for tracking? •Evaluate how content area perceived by EPHT and partners •Present results to Advisory Panel •How would content area affect EPHT and our partners? •What is the final summary assessment of the content area? •Incorporate content area into EPHT structure as a continuing tracking measure •Is the degree or level of exposure changing or perceived to be changing? INFORMATION BUILDING •Is this a hazard with unknown associations to health outcomes OR unknown level of exposure in the population? •Are there other programs at MDH that would be interested in this content area? OUTSIDE INTEREST •How are data to be consistently displayed and discussed by EPHT? •Is there a high concern regarding the proportion of the population exposed to the hazard? •Is the exposure or disease a priority that has previously been identified by environmental health organizations? •Would this content area utilize existing datasets in a new way? BALANCE •Is there balance between hazard/exposure and disease content areas? •Is there balance between age groups affected among content areas? ECONOMIC IMPACT •What is the economic impact in Minnesota of adding this content area? Phase 4 Summary In 2010, work began to pilot Environmental Tobacco Smoke (ETS) Exposure through Minnesota’s evaluation process as a potential new content area. The evaluation process was refined and eventually became the four-phase evaluation process presented here. A flowchart was produced to guide the evaluation process which outlines the key concepts and criteria that belonged to each of the four phases (see Figure 1). Criteria Results A template document was also produced that lists Evaluation Questions related to the criteria for each phase, to determine the extent to which a new content area addresses the key concepts in the evaluation process. •Available Resources •Prevalence •Causality •Public Health Impact •Actionability •Initial Feasibility •Detailed Feasibility •Literature review •Find data sources •Contact data steward •List potential measures •Select data sources •Draft DUA if needed •Obtain data •Pilot potential measures Once adopted, final documentation on the content area is created, to include a “how-to-guide” about how measures are to be calculated, metadata, and messaging for the data portal. A formal Data Use Agreement (DUA) must now be signed by the data steward(s). •Emerging Issues •Information Building •Outside Interest •Balance •Economic Impact Conclusions In 2011, MN EPHT staff successfully completed the evaluation of ETS Exposure as a new state-specific content area: 1) ETS Exposure was found to be prevalent, causally associated with adverse health outcomes, actionable, important to public health, and feasible. AVAILABLE RESOURCES •Is there staff time/interest/expertise and financial/technical resources? PREVALENCE •Is there a high estimated proportion of the population that is exposed OR a high estimated prevalence of disease or outcome? CAUSALITY •Is there evidence that exposure is a component cause of adverse health outcomes OR that the disease has an environmental component cause? Tasks/Deliverables Phase 1 Evaluation Questions •Focused interviews and information gathering •Report on all criteria with final data and measures •Summarize strengths and limitations •Formalize DUA •Create how-to guide, metadata and messaging •Are there existing prevention or control programs at MDH or other Minnesota organizations for the exposure or its adverse health outcomes? •Can the level of exposure/disease be modified via policy, regulatory, or personal actions? •Is the exposure or disease tied to state or federal public health objectives? •Can this content area be used to develop new program initiatives? PUBLIC HEALTH IMPACT Involvement ACTIONABILITY •Consult Tech Team •Inform and consult Advisory Panel •Consult Tech Team •Inform and consult Advisory Panel •Content area •Consult Tech Team •Advisory Panel votes representative added to Tech to recommend Team adoption •Inform and consult Executive Steering Committee •Is the population attributable risk (PAR) or public health impact of exposure known or be estimated from available data? OR Is the severity of the disease effect known and contributes to mortality or morbidity? In addition to being of high quality, existing data would be utilized in a new way with the adoption of this content area. Minnesota has chosen to incorporate ETS Exposure as a continuing tracking measure. ETS Exposure is currently in Phase 4 (Implementation) and steps are being taken to incorporate this new content area on Minnesota Public Health Data Access, a web-based data access portal. Recommendations This evaluation process successfully addressed public health priorities as well as stakeholder input and provided clear rationale for adding the content area. Given the limited time and resources of EPHT states, it is important to develop a strong rationale prior to adopting new content areas. New content areas come with the cost of implementation and annual maintenance on state portals, making it that much more important that states should be selective in adding content areas and use a process to explore the rationale. Since EPHT programs are often challenged by resource needs, other states may find Minnesota’s evaluation process, flowchart, and template document useful in order to guide the use of resources on new content areas. Acknowledgement (INITIAL) FEASIBILITY •Is there one or more data sources for exploration of “trackable” indicators? •Does MDH have the legal authority to collect and use the data? •Are private data classified and protected according to state and federal law? 2) The data for ETS Exposure measures were found to be: available, populationbased, representative of exposure, timely, and comparable. 1 Malecki KC, Resnick B, Burke TA. Effective Environmental Public Health Surveillance Programs: A Framework for Identifying and Evaluating Data Resources and Indicators. Journal of Public Health Management and Practice. 2008;14(6): 543-551. We gratefully acknowledge the contributions to this project of the MN EPHT Technical Team and the Environmental Health Tracking and Biomonitoring (EHTB) Advisory Panel. Minnesota is part of the National Environmental Public Health Tracking Network. For more information about Minnesota’s EPHT program, visit our website at www.health.state.mn.us/tracking, call us at 651-201-5900, or email us at [email protected]