US opinions on health determinants and social policy as health policy.

To examine what factors the public thinks are important determinants of health and whether social policy is viewed as health policy, we conducted a national telephone survey of 2791 US adults from November 2008 through February 2009. Respondents said that health behaviors and access to health care have very strong effects on health; they were less likely to report a very strong role for other social and economic factors. Respondents who recognized a stronger role for social determinants of health and who saw social policy as health policy were more likely to be older, women, non-White, and liberal, and to have less education, lower income, and fair/poor health. Increasing public knowledge about social determinants of health and mobilizing less advantaged groups may be useful in addressing broad determinants of health.

Awareness of racial and socioeconomic health disparities in the United States: the national opinion survey on health and health disparities, 2008-2009.

INTRODUCTION: Recent initiatives aim to improve public awareness of health disparities. However, little research has actually documented the US public's awareness of racial/ethnic and socioeconomic health disparities. We sought to determine 1) whether the US public is aware of racial, educational, and income disparities in health, 2) whether awareness differs across these disparity domains, and 3) what respondent characteristics are associated with awareness of racial, educational, and income disparities in health. METHODS: We conducted the National Opinion Survey on Health and Health Disparities with 2,791 US adults. We asked respondents to answer questions about disparities in health between 1 of several pairs of population subgroups: African Americans versus whites, non-high school graduates versus high school graduates, high school graduates versus college graduates, the poor versus the middle class, or the middle class versus the rich. We used χ(2) tests and logistic regression to compare correlates of respondents' awareness of disparities across the different pairs of population subgroups. RESULTS: Most respondents were aware of health disparities between the poor and middle class (73%); fewer were aware of health disparities between African Americans and whites (46%). Although respondents recognized that education is associated with many positive life outcomes, they were less aware of the link between education and health. Respondents who were younger, less educated, lower-income, healthier, or politically conservative were less likely to be aware of health disparities. CONCLUSION: Public awareness of disparities in health differs depending on both the type of disparity and the characteristics of the individual respondent.

How healthy could a state be?

OBJECTIVE: We predicted the amount of health outcome improvement any state might achieve if it could reach the highest level of key health determinants any individual state has already achieved. METHODS: Using secondary county-level data on modifiable and nonmodifiable health determinants from 1994 to 2003, we used regression analysis to predict state age-adjusted mortality rates in 2000 for those younger than age 75, under the scenario of each state's "ideal" predicted mortality if that state had the best observed level among all states of modifiable determinants. RESULTS: We found considerable variation in predicted improvement across the states. The state with the lowest baseline mortality, New Hampshire, was predicted to improve by 23% to a mortality rate of 250 per 100,000 population if New Hampshire had the most favorable profile of modifiable health determinants. However, West Virginia, with a much higher baseline, would be predicted to improve the most-by 46% to 254 per 100,000 population. Individual states varied in the pattern of specific modifiable variables associated with their predicted improvement. CONCLUSIONS: The results support the contention that health improvement requires investment in three major categories: health care, behavioral change, and socioeconomic factors. Different states will require different investment portfolios depending on their pattern of modifiable and nonmodifiable determinants.

Grading and reporting health and health disparities.

Report cards are widely used in health for drawing attention to performance indicators. We developed a state health report card with separate grades for health and health disparities to generate interest in and awareness of differences in health across different population subgroups and to identify opportunities to improve health. We established grading curves from data for all 50 states for 2 outcomes (mortality and unhealthy days) and 4 life stages (infants, children and young adults, working-age adults, and older adults). We assigned grades for health within each life stage by sex, race/ethnicity, socioeconomics, and geography. We also assigned a health disparity grade to each life stage. Report cards can simplify complex information for lay audiences and garner media and policy maker attention. However, their development requires methodologic and value choices that may limit their interpretation.

Dissemination research: the University of Wisconsin Population Health Institute.

Despite significant accomplishments in basic, clinical, and population health research, a wide gap persists between research discoveries (ie, what we know) and actual practice (ie, what we do). The University of Wisconsin Population Health Institute (Institute) researchers study the process and outcomes of disseminating evidence-based public health programs and policies into practice. This paper briefly describes the approach and experience of the Institute's programs in population health assessment, health policy, program evaluation, and education and training. An essential component of this dissemination research program is the active engagement of the practitioners and policymakers. Each of the Institute's programs conducts data collection, analysis, education, and dialogue with practitioners that is closely tied to the planning, implementation, and evaluation of programs and policies. Our approach involves a reciprocal exchange of knowledge with non-academic partners, such that research informs practice and practice informs research. Dissemination research serves an important role along the continuum of research and is increasingly recognized as an important way to improve population health by accelerating the translation of research into practice.

Using the Wisconsin County Health Rankings to catalyze community health improvement.

BACKGROUND: Assessment is a core function of public health; however, standard community health assessments often remain within the boundaries of the traditional public health system and rarely elicit public discussion and community-wide action. The University of Wisconsin Population Health Institute developed the annual Wisconsin County Health Rankings (Rankings) report in 2003 with three primary goals: (1) to increase media attention to local health outcomes and determinants; (2) to highlight the broad range of factors that influence health; and (3) to catalyze community health improvement efforts. METHODS: We assessed how well the Rankings met these goals through an examination of media coverage and a survey of the local public health community following the 2006 report. FINDINGS: Newspaper, television, and radio media across the state covered the Rankings, highlighting local results for outcomes and a broad range of determinants. Local public health officials used the Rankings for educating policy makers and community partners, performing needs assessments, and identifying program targets. CONCLUSIONS: The Rankings report is an approach to community health assessment that has received media attention and been found to be useful by local public health officials in their community health improvement efforts.

Public views on determinants of health, interventions to improve health, and priorities for government.

OBJECTIVE: There is increasing evidence about the importance of factors that impact health beyond health care and individual behavior, yet there is little public and policy discourse about these things in the United States. We surveyed Wisconsin adults to see what they think are the most important factors that affect health. We also examined which interventions they believe would improve health, and whether government should prioritize such interventions. METHODS: A phone survey of a random sample of 1459 Wisconsin adults was conducted between September 2006 and February 2007. RESULTS: The Wisconsin public believes that health practices, access to health care, and health insurance are the most important factors affecting health, and that health insurance is a high government priority. Other broader social and economic determinants of health, such as employment, social support, income, housing, and neighborhood factors are seen as less important to health. Although respondents believe that health practices are important to health, they are less likely to suggest that government prioritize improving individual health practices. Although the public believes the government should prioritize access to health care and health insurance, they are not as likely to support government implementing social or economic policies in order to improve health. CONCLUSION: In light of research demonstrating the importance of social and economic determinants of health, and of ongoing public forums meant to raise awareness of these determinants of health, it will be important to track whether public opinion of Wisconsin adults changes over time to increase attention to the social and economic determinants of health and related policy initiatives.

Local public health department funding: trends over time and relationship to health outcomes.

BACKGROUND: Local health departments contribute to population health improvement through the core functions of assessment, policy development, and assurance. Their capacity to perform these functions may be affected by funding and staffing. OBJECTIVE: To describe local health department funding and staffing levels and determine the relationship between these measures and county-level health outcomes. METHODS: Ten years of total funding, funding by revenue source, and staffing data from local health departments in all 72 Wisconsin counties were collected from the Department of Health and Family Services and analyzed. Summary measures for county health outcomes were obtained from the 2006 Wisconsin County Health Rankings, and a correlation matrix was created to determine associations between outcomes and measures of health department capacity. RESULTS: On average, Wisconsin local health departments spend $20.60 per capita, ranging from $7.50 to $68.30 among counties. While total per capita funding in the state (adjusted for inflation) increased $0.82 per year, a closer look reveals 3 distinct periods: increases of $0.20 per year during 1995-1997 and $1.33 per year during 1997-2001; but a decrease of $0.27 during 2001-2004. Local health departments in counties with worse health outcomes had only slightly higher average funding and staffing levels during 2002-2004. CONCLUSION: Levels of health department funding in Wisconsin, already low by US standards, declined slightly in the past 3 years. Although counties with the worst health outcomes had slightly higher levels of public health funding, considerable disparities exist. State policymakers might consider investing more resources in counties with the greatest need, to support evidence-based public health programs and reduce existing geographic health disparities in Wisconsin.

Preventable causes of death in Wisconsin, 2004.

INTRODUCTION: While heart disease, cancer, and injuries are leading proximate causes of death, research has demonstrated that about half of all deaths in the United States are actually due to preventable causes, including tobacco use, poor diet, and physical inactivity. Using state vital statistics data and findings from national studies, we report on the trends in the preventable causes of death in Wisconsin from 1992 to 2004. METHODS: The leading proximate causes of death in Wisconsin were obtained from Wisconsin Interactive Statistics on Health (WISH) data derived from individual death certificates. Information on the preventable causes of death was either obtained from the underlying cause information on the death certificate or from peer-reviewed epidemiologic studies. RESULTS: While the overall age-adjusted death rate declined from 837 to 744 per 100,000 from 1992 to 2004, the top 10 causes of death remain largely unchanged. Nearly half of the deaths in Wisconsin in 2004 resulted from 11 preventable causes, similar to the findings in 1992. DISCUSSION: Epidemiologic research demonstrates that nearly half of all deaths in Wisconsin are due to preventable causes. Programs and policies must continue to address these preventable causes of disease if Wisconsin is to meet its goal of promoting and protecting population health.

Voluntary disenrollment from Medicare managed care: market factors and disabled beneficiaries.

Disenrollment rates from Medicare managed care plans have been reported to the public as an indicator of health plan quality. Previous studies have shown that voluntary disenrollment rates differ among vulnerable subgroups, and that these rates can reflect patient care experiences. We hypothesized that disabled beneficiaries may be affected differently than other beneficiaries by competitive market factors, due to higher expected expenditures and impaired mobility. Findings suggest that disabled beneficiaries are more likely to experience multiple problems with managed care.

Impact of Medicare managed care market withdrawal on beneficiaries.

The 2001 Survey of Involuntary Disenrollees was conducted to investigate the impact of Medicare+Choice (M+C) plan withdrawals on Medicare beneficiaries. Eighty-four percent of a total of 4,732 beneficiaries whose Medicare managed care (MMC) plan stopped serving them at the end of 2000 responded to the survey. Their responses indicated that the withdrawal of plans from Medicare affected beneficiaries in terms of concerns about getting and paying for care, increased payments for premiums and out-of-pocket costs, and changes in health care arrangements. Of particular concern were the impacts on those in vulnerable subgroups such as the disabled, less educated, and minorities.