HHS Research Initiative Regarding Transformations in Health and Human Services: Report of the Working Group. Strategic Framework

07/24/1996

Implicit in the Secretary's charge are four questions that span the spectrum of health and human services:

  • Which ongoing or prospective changes in the systems that provide health/human services are related or likely to be related to substantial changes in the well-being of the American people?
  • What is the nature of these ongoing or prospective changes in health/human services, and why are they occurring or likely to occur?
  • Which current programs and policies are fostering favorable changes and countering adverse ones?
  • Which changes are likely to be the most significant for the foreseeable future? for the long term?

To be judged successful, the Departmental research initiative must yield significant new knowledge relevant to these questions in forms that are useful to policy-makers, providers, purchasers, program sponsors, and clients and are available in time to help inform their decisions about both the transformations and their consequences.

Changes in Systems That Provide Health/Human Services <------------> Trends in Well-Being of American People

Figure 1: Changes in service programs and trends in well-being are linked reciprocally.

The scope of the charge to the working group is summarized in Figure 1. However, this summary sketch belies the rich diversity and extraordinary complexity of the issues associated with changes in health and human services and/or trends in well-being. No single research project realistically can be expected to address changes and trends across the board. Instead, most projects likely and appropriately will focus on specific issues that, while only a small part of the overall picture, nevertheless are of sufficient importance to warrant in-depth attention in their own right. However, to gain a broad understanding, some projects will have to cut across programs or functional boundaries and consider two or more systems simultaneously. Figure 2 presents some prominent examples.

Changes in Systems <------------> Trends in Well-Being
     
Services: e.g.,   Indicators: e.g.,
----------------   ----------------
Income support   Income levels
Social services   Employment patterns
Child-development services   Health status: children
Health services   Health status: adults
Protection against environmental hazards   Family stability

Figure 2: Examples of (a) health and human services and (b) indicators of well-being.

Changes in Systems <------------> Trends in Well-Being
     
Types of Changes: e.g.,   Types of Data Aggregation: e.g.,
----------------   ----------------
1. Locus of policy making   1. By indicators, e.g.,
  • immunization status
  • homelessness
2. Scope and content of policies  
3. Administrative organization   2. By geographic scales
  • community
  • state or region
  • nation
4. Financing: resource levels  
5. Financing: mechanisms/ incentives   3. By special populations, e.g.,
  • poor children
  • frail elderly
  • chronically disabled
6. Service providers: numbers/ modalities  
7. Efficacy of various modalities  

Figure 3: Examples of (a) service system changes and (b) modes of data aggregation.

Further, research designs will need to be tailored carefully with respect to the types of transformations that are to be monitored and analyzed in relation to trends in well-being; and data on well-being, to be maximally useful, will need to be aggregable in many different ways. Figure 3 identifies some leading candidates for emphasis in each of the two categories. For example, policy changes in the areas of health-care financing and income support already are causing significant changes in the ways the corresponding services are organized and delivered. But effects on the well-being of Americans may not be fully apparent unless the data to be used for analysis first are aggregated in various ways -- e.g., by specific indicators of well-being such as immunization status or homelessness, for particular geographic scales ranging from the community level to the national level, or in terms of special populations such as disadvantaged children and disabled elderly individuals.

Changes in Systems <------------> Trends in Well-Being
-----> Human Behaviors ----->
/\ /\ /\
Federalism/ Public-Private Split --> /\
  /\  
Social/ Economic Trends --> /\
  /\  
Cultural Values --> /\
  /\  
Science/ Technology --> /\
  /\  
Environmental Hazards --> <-- Environmental Hazards
  /\  
Demographic Trends --> <-- Demographic Trends

Figure 4: Service systems and well-being are affected by a variety of secular trends.

Finally, research designs must take into account the fact that the goals, structures, and operations of health/human services are interdependent in many ways with factors that shape the milieu in which these services are delivered. Interactions between system changes and trends in well-being may elude adequate explanation or, worse, be misinterpreted entirely if studies do not take cognizance of pertinent demographic, economic, social, and environmental trends. These relationships are depicted schematically in Figure 4. Some secular trends, especially demographic and economic ones, may be sufficiently prominent to mask or outweigh the effects of changes in health/human services.

These considerations suggest two complementary approaches to guide research on relationships between changes in services and trends in well-being. For cases where investigators are limited to retrospective analysis and interpretation of trends, the following five-part framework is applicable:

  • formulate an hypothesis or model regarding the relationship between one or more changes in health/human services and one or more measures of well-being;
  • characterize the most relevant changes and identify pertinent baseline information;
  • obtain information regarding trends in the well-being of the American people -- expressed in terms of the measure(s), population(s) and geographic scale(s) of interest;
  • obtain relevant information regarding demographic, economic, social, and environmental trends that -- in addition to affecting the goals, structure, or operations of systems for health/human services -- also may exert independent impacts on well-being; and
  • test the hypothesis or model by analyzing changes in health/human services in relation to trends in well-being - - taking into account demographic, economic, social, and environmental influences on both as applicable.

Whereas, for cases where the service transformation of interest is a controlled intervention, formal research-design principles, including the following, may be preferable:

  • formulate an hypothesis or model to be tested prospectively;
  • formulate a research plan, including the definition of "treatment" group(s) and control group and a process for assigning eligible individuals between/among them;
  • develop a plan for data analysis;
  • collect data in accord with the research plan; and
  • analyze and interpret the data, using the data-analysis plan as the starting point.

An array of studies that individually are consistent with one or the other of these approaches as appropriate and collectively span the myriad facets of health and human services would do much to enhance understanding of significant transformations that now are underway or seem sure to come.