Since 1998, the National Longitudinal Survey of Public Health Systems (NLSPHS, as of 2018 NALSYS) has followed a nationally representative cohort of U.S. communities in order to study the implementation and impact of multi-sector population health activities. The survey captures information about the types of health improvement activities that are implemented in U.S. communities, and the array of organizations that contribute to these activities. By collecting this information consistently in more than 500 U.S. communities over a span of 20 years, the NALSYS has become the nation’s only national, longitudinal source of information about the actions that local communities undertake to protect and improve the health status of their residents.
Figure 1: Mapping the organizations that contribute to population health activities. The size of each box represents the relative importance of each type of organization in supporting population health activities within the community. The thickness of each line indicates how often organizations work together in jointly contributing to population health activities. The figure displays NALSYS data for the average U.S. community in 2016.
Rather than focusing on a single type of organization or sector, the NALSYS measures the network of organizations that support health activities in local communities, tracking how these networks evolve and change over time in size and composition (Figure 1). Using the tools of network analysis, NALSYS data reveal which organizations and sectors are most influential in local population health networks, and how strongly connected organizations are to other network members.
What Are We Learning?
By linking NALSYS data with other health, social and economic data sources, we conduct rigorous longitudinal studies that answer key questions for health policy and practice, such as:
- Why are some communities more successful than others in implementing population health activities?
- What conditions, policies, and strategies help community organizations work together to improve population health?
- How fragile or sustainable are multi-sector population health activities, and what factors build resilient community networks?
- What impact do population health activities and their supporting community networks have on health outcomes? On economic outcomes? On health equity? How do these effects accumulate or dissipate over time?
Our recent studies have estimated the impact of economic shocks on population health activities, the impact of community networks on rates of preventable mortality, and the impact of local public health activities on Medicare spending. A full bibliography of research using the NALSYS is available in Word or Text (which can be imported into EndNote, CiteULike, or Mendeley).
Building a Culture of Health
Knowledge produced by the NALSYS contributes directly to the Robert Wood Johnson Foundation’s action framework for building a Culture of Health. The survey examines cross-sector collaboration in implementing population health activities, expanding our knowledge about ways of supporting and strengthening collective actions in local communities. The survey measures progress in integrating health and healthcare systems by documenting the roles and responsibilities played by different organizations in population health improvement. The NALSYS delineates contributions made by hospitals, physician practices, health insurers, employers, public health agencies, and other community organizations, assessing the degree of coordination and fragmentation that exists in specific local communities.
Figure 2: Percent of population served by a comprehensive public health system. We use data from the NALSYS to estimate the percent of the population who reside in communities that meet the definition of a Comprehensive Public Health System: (1) a broad spectrum of nationally-recommended population health activities are implemented within the community; and (2) these activities are supported by dense multi-sector networks of collaborating organizations. The figure displays these population estimates for each state over time.
The NALSYS is the source of one of the Robert Wood Johnson Foundation’s national metrics used to track progress in building a Culture of Health across the U.S. Based on our previously developed typology of public health delivery systems, this metric indicates the percent of the U.S. population served by a Comprehensive Public Health System (Figure 2). To meet this definition of comprehensiveness, a community must implement a broad spectrum of recommended population health activities, and do so through dense multi-sector networks of contributing organizations. Our research using the NALSYS demonstrates that communities with comprehensive systems achieve larger and faster improvements in population health.
More About the Measures
The NALSYS collects information on a set of 20 activities that federal consensus panels and professional associations have long recommended as essential elements of a comprehensive strategy to improve health status in the population at large (Figure 3). The activities measured by the survey reflect National Academy of Medicine recommendations regarding core functions and foundational capabilities for improving public health, and recommendations for community health improvement processes. These measures also reflect recommendations of the U.S. Centers for Disease Control and Prevention (CDC) regarding community health improvement strategies, essential public health services., and the widely used Planned Approach to Community Health model. The NALSYS activities track closely with the standards and measures developed by the Public Health Accreditation Board for state and local public health agencies, and they also adhere closely to the collective impact framework recommended by the Aspen Institute and others.
Figure 3: Activities measured in the National Longitudinal Survey of Public Health Systems. The NALSYS measures a set of 20 activities that support multi-sector, collaborative approaches to improving population health. Each measure reflects one of the cross-cutting capabilities shown in this figure, which are based on long-standing recommendations of national consensus panels and practice guidelines.
By design, NALSYS does not measure the implementation of specific health interventions and programs, such as those recommended by the CDC’s Guide to Community Preventive Services and by the U.S. Preventive Services Task Force. The ideal combination of interventions to implement in a given community necessarily depends on the distribution of health risks and resources in that community, and on the population groups most at risk. By contrast, the NALSYS focuses on cross-cutting capabilities that every community needs in order to successfully mobilize and manage health improvement activities for the population at large. These capabilities help communities reach decisions about how best to use their individual and collective resources under the real-world constraints of opportunity, uncertainty, competing incentives, and heterogeneous preferences.
The NALSYS is a research initiative of the Robert Wood Johnson Foundation’s Systems for Action national research program, based at the University of Kentucky and led by Dr. Glen Mays. More information about the NALSYS can be found at these links:
- 2018 Survey Instrument
- About 2018 Survey
- Defining Comprehensive Public Health Delivery Systems
- Measuring Public Health System Capital
- Methodology for Comprehensive Public Health Systems (Milbank Quarterly 2010)
- Example NLSPHS Customized Report
- Interpreting Your Customized NALSYS Report
- Public Use Data Files