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Frequently Asked Questions

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General

What is the HI-5 Initiative?
Why develop HI-5 at this time?
Who should use the HI-5 Initiative?
How does HI-5 fit into the “Three Buckets of Prevention Framework?”
What do you mean by community-wide interventions?
How does the HI-5 Initiative relate to the public health impact pyramid?
What is the difference between “changing the context” and “social determinants of health?”
How does the HI-5 Initiative relate to other CDC resources for health system transformation activities such as the 6|18 Initiative?
Why do the HI-5 interventions not align completely with the 6 common and costly health conditions identified in the 6|18 Initiative?
Some of the items on the HI-5 list don’t seem like health interventions or prevention programs. Why are they included in this public health initiative?
Is this a comprehensive list of community-wide interventions?
Is CDC recommending policy changes with the HI-5 Initiative?
Where can I find tools to calculate the impact of implementing select HI-5 interventions?

About the Evidence Summaries

Where did the interventions found in the HI-5 Initiative come from, and how were they chosen?
How were interventions selected for inclusion in the HI-5 Initiative?
How much evidence was there to support each of the health outcomes identified in the HI-5 list?
Was the cost evidence limited to the same 5 year timeframe as evidence for health impact?
Why were interventions that have already been implemented in 85% of states excluded?

General

Q: What is the HI-5 Initiative?

A: The HI-5 (“high-five”) or Health Impact in Five Years Initiative is a tool that highlights non-clinical, community-wide interventions with a proven track record. Each intervention listed is associated with improved health within five years or less as well as reported cost effectiveness and/or cost savings over the lifetime of the population or earlier.

Q: Why develop HI-5 at this time?

A: There is growing interest in population health during an unprecedented transformation in the United States health system. State, tribal, local, and territorial agencies have asked CDC to review and share the science on community-wide approaches to identify what works. Through the HI-5 initiative, CDC is highlighting approaches that have evidence reporting 1) positive health impacts, 2) results within five years, and 3) cost effectiveness and/or cost savings over the lifetime of the population or earlier. With its emphasis on community-wide approaches, HI-5 complements CDC’s 6|18 Initiative, which focuses on 18 traditional and innovative clinical interventions for six high-burden conditions. Together, HI-5 and 6|18 provide public health, health care, and a diverse array of other sectors with evidence across the continuum of prevention and care.

Q: Who should use the HI-5 Initiative?

A: HI-5 is a tool for state and local public health partners in need of evidence-based community-wide approaches that can accelerate health improvement in five years or less and also have evidence reporting projected cost effectiveness and/or cost-savings. The initiative may also be useful to those who apply evidence for policy decisions such as community organizations, healthcare payers and providers, private organizations, foundations, policy makers and other key decision-makers.

Q: How does HI-5 fit into the “Three Buckets of Prevention Framework?”

A: The Three Buckets of Prevention framework categorizes interventions according to three discrete approaches on a continuum of prevention from health care to public health. Buckets 1 and 2 are patient-oriented and focus on both traditional and innovative clinical prevention approaches. These clinical interventions may occur in a doctor’s office or in the community and provide services to individual patients. In contrast, Bucket 3 focuses on population-oriented interventions that are intended as community-wide measures to protect and improve the health of populations of people and the community as a whole. As such, these upstream interventions address the context that affects the health decisions people make and the social, economic, and environmental conditions and risk factors in which people live, learn, work, and play. Through the HI-5 initiative, CDC is highlighting approaches that have evidence reporting 1) positive health impacts, 2) results within five years, and 3) cost effectiveness and/or cost savings over the lifetime of the population or earlier. Using this framework as a guide for health system and community level transformation, CDC’s 6|18 Initiative addresses issues in Bucket 1 and Bucket 2, while HI-5 addresses issues in Bucket 3.

Q: What do you mean by community-wide interventions?

A: Community-wide interventions focus on improving population health, or the health of everyone living in a community. As such, community-wide interventions can have broad health impact, often addressing several health conditions at once, by addressing underlying factors that can promote or prevent health, including social determinants of health (SDOH) like income and economic stability, housing, educational opportunities, employment and working conditions, social support networks, neighborhood safety and physical environment. The HI-5 initiative highlights a list of non-clinical, community-wide approaches associated with improved health within five years or less and reported cost effectiveness and/or cost saving over the lifetime of the population or earlier.

Q: How does the HI-5 Initiative relate to the public health impact pyramid?

A: The public health impact pyramid is a framework for public action.^[2] It visually depicts the potential impact of different types of public health interventions. At the base of the pyramid are those interventions that have the greatest potential for impact on health because they reach entire populations of people at once and require less individual effort. These include interventions that address social and economic determinants of health. Moving towards the top of the pyramid are interventions that change the context to make healthy choices easier; clinical interventions that require limited contact but confer long-term protection; ongoing direct clinical care; and health education and counseling. The HI-5 Initiative maps directly to the two lowest tiers of public health pyramid with the greatest potential for impact. HI-5 interventions focus on addressing the social and economic determinants of health and changing the context to make the healthy choice the easy choice.

Q: What is the difference between “changing the context” and “social determinants of health?”

A: Interventions that focus on “changing the context” aim to change the environmental context to make healthy options the easy or default choice, regardless of education, income, service provision, or other societal factors.^[2] By “changing the context,” these interventions can incentive healthy behaviors. Examples of HI-5 interventions that focus on “changing the context” include school-based programs to increase physical activity and tobacco control interventions.

Interventions that focus on social determinants of health (SDOH) address the conditions (social, economic, and physical) in the places where we live, learn, work and play.^[2-4] By improving factors that directly influence health, these interventions can directly improve the health of communities. Examples of HI-5 interventions that address SDOH include clean diesel bus fleets, home Improvement loans and grants and early childhood education.

Q: How does the HI-5 Initiative relate to other CDC resources for health system transformation activities such as the 6|18 Initiative?

A: The HI-5 Initiative is the community-wide, population-oriented complement to the 6|18 Initiative which focuses on traditional and innovative clinical patient-oriented approaches. 6|18 targets six common and costly health conditions – tobacco use, high blood pressure, healthcare-associated infections, asthma, unintended pregnancies, and diabetes – and 18 proven interventions that form the starting point of discussions with purchasers, payers, and providers. HI-5 highlights evidence-based community-wide interventions proven to have an impact on health within five years and with evidence reporting cost-effectiveness and/or cost-saving over the life-time of the cohort or earlier. In some situations, the HI-5 evidence aligned well with 6|18 Initiative conditions such as asthma and tobacco use. For example HI-5 addresses tobacco use (one of the 6 |18 high-burden conditions) through effective tobacco control interventions such as tobacco price increases, high-impact anti-tobacco mass media campaigns, and comprehensive smoke-free laws. HI-5 also addresses asthma through home improvement loans and grants, that cover weatherization to improve insulation, air quality, dampness, that are associated with reducing asthma symptoms. In other situations, HI-5 evidence highlighted the effectiveness of interventions for additional health conditions such as low birth weight, injuries, and HIV.

Q: Why do the HI-5 interventions not align completely with the 6 common and costly health conditions identified in the 6|18 Initiative?

A: Development of the HI-5 Initiative began with a broad review of the evidence rather than specific health conditions. We initially identified community-wide interventions with the highest evidence rating from the Community Guide and County Health Rankings and Roadmaps What Works for Health. We then reviewed the evidence for those interventions and assessed them against specific inclusion criteria, including evidence of a measurable impact on health within five years and reported cost effectiveness and/or cost savings over the lifetime of the population or earlier.

Q: Some of the items on the HI-5 list don’t seem like health interventions or prevention programs. Why are they included in this public health initiative?

A: Clinical care isn’t the only thing that affects our health. Conditions in the places where we live, learn, work and play affect a wide range of health risks and outcomes.^[4] Interventions that address these conditions have the greatest potential impact on our health.^[2,5-8] We know that poverty limits access to healthy foods and safe neighborhoods and that more education is a predictor of better health.^[9-11] We also know that differences in health are striking in communities with poor SDOH such as unstable housing, low income, unsafe neighborhoods, or substandard education.^[12,13] Resources that enhance quality of life, such as safe and affordable housing, access to education, public safety, and environments free of life-threatening toxins, can have a significant influence on population health outcomes.^[4] CDC’s Social Determinants of Health website offers more tools and resources for addressing the social determinants of health.

Q: Is this a comprehensive list of community-wide interventions?

A: The HI-5 Initiative is not intended to be a comprehensive list of all effective interventions, or to imply that the listed interventions should replace other important initiatives that are occurring in communities. HI-5 focuses on community-wide interventions that have evidence reporting 1) positive health impacts, 2) results within 5 years, and 3) cost effectiveness and/or cost savings over the lifetime of the population or earlier. There are other important interventions that did not meet these specific criteria and many emerging interventions that have not yet been thoroughly evaluated in terms of health and cost impacts. Further research is necessary to fill in these evidence gaps and identify today’s new or pilot interventions that may end up on a future list like HI-5. So it is important that communities continue to explore innovative promising ideas that are appropriate for their populations.

Q: Is CDC recommending policy changes with the HI-5 Initiative?

A: Absolutely not. CDC’s role is to inform public health audiences about what works to improve population health by providing credible evidence based on rigorous science. Through the HI-5 Initiative, CDC is providing the current scientific evidence on community-wide interventions that met specific criteria for evidence of a measurable impact on health within five years and reported cost effectiveness and/ or cost savings over the lifetime of the population or earlier.

Q: Where can I find tools to calculate the impact of implementing select HI-5 interventions?

A: Several tools are available to help you calculate the impact of implementing select HI-5 interventions. See the links below.

Community Health Advisor

CDC

Motor Vehicle Prioritizing Interventions and Cost Calculator for States

Disclaimer:

The Department of Health and Human Services (HHS) cannot attest to the accuracy of a non-federal site. Linking to a non-federal site does not constitute an endorsement by HHS or any of its employees of the sponsors or the information and products presented on the site.

About the Evidence Summaries

Q: Where did the interventions found in the HI-5 Initiative come from, and how were they chosen?

A: We developed the HI-5 tool through a careful and methodical process. We first compiled a list of interventions with the highest evidence rating from the Community Guide (“Recommended”)^[14] and the Robert Wood Johnson Foundation-funded County Health Rankings and Roadmaps: What Works for Health (Scientifically Supported”).^[15] We then screened out duplicates and patient-focused, clinical interventions (those that we refer to as Buckets 1 and 2 prevention approaches), leaving 125 community-wide interventions. This initial list of 125 community-wide interventions was then assessed against the inclusion criteria, primarily a measurable health impact within 5 years and evidence reporting cost-effectiveness and/ or cost savings over the lifetime of the population or earlier.

Q: How were interventions selected for inclusion in the HI-5 Initiative?

A: We included those that:

focus on whole populations or communities
have evidence of a measurable impact on health within five years
have evidence reporting cost effectiveness and/or cost savings over the lifetime of the population or earlier
have not yet been implemented in at least 85% of communities and/or states
have evidence of implementation at the policy level

We also excluded those with evidence of potential harm, insufficient evidence of impact, those that were considered a component of another intervention, and those that were program-level interventions implemented at smaller scales. The final list, using all of these criteria, includes 14 community-wide interventions. Please see the “About the evidence summaries” for more information on how the HI-5 list was developed.

Q: How much evidence was there to support each of the health outcomes identified in the HI-5 list?

A: Our standard of evidence was high: We started with population-based interventions with the highest evidence rating from the Community Guide (“Recommended”)^[14] and the Robert Wood Johnson Foundation-funded County Health Rankings and Roadmaps: What Works for Health (Scientifically Supported”).^[15] In addition, the evidence for each health outcome had to include a systematic review, or at least 3 randomized control trials, or 3 quasi experimental studies with comparisons, or studies with direct evidence of impact, for example exposure to particulate matter.

Q: Was the cost evidence limited to the same 5 year timeframe as evidence for health impact?

A: No. Since economic analyses often use data from a set period of time to model the effect of policies and programs and predict their cost or benefit over time, we did not limit the timeframe for economic evidence. The timeframes used in the studies ranged from 1 year, or annual returns, to lifetime (usually 50 year) horizons.

Q: Why were interventions that have already been implemented in 85% of states excluded?

A: Our focus was on interventions that had not already reached a saturation point – that is, we wanted to identify those interventions that could still have significant impact in a large number of communities.

¹ Auerbach, J. (2016). The 3 buckets of prevention. Journal of Public Health Management and Practice, 22(3), 215-218.
² Frieden, T. R. (2010). A framework for public health action: the health impact pyramid. American journal of public health, 100(4), 590-595.
³ CDC’s Social Determinants of Health website
⁴ Healthy People 2020. Social Determinants of Health
⁵ Hood, C.M., et al., County Health Rankings: Relationships Between Determinant Factors and Health Outcomes. American journal of preventive medicine, 2016. 50(2): p. 129-135.
⁶ Booske, B., et al., County Health Rankings Working Paper: Different perspectives for assigning weights to determinants of health. 2010, University of Wisconsin Population Health Institute (UWPHI). Retrieved from Different Perspectives For Assigning Weights to Determinants of Health WEIGHTS.
⁷ McGinnis, J.M., P. Williams-Russo, and J.R. Knickman, The case for more active policy attention to health promotion. Health affairs, 2002. 21(2): p. 78-93. ¹⁰ Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020, Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the United States, Office of Disease Prevention & Health Promotion, U.S. Department of Health and Human Services. 2010. Available: Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the United States
⁸ Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020, Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the United States, Office of Disease Prevention & Health Promotion, U.S. Department of Health and Human Services. 2010. Available: Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the United States
⁹ Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs 2002;21(2):60-76.
¹⁰ Walker RE, Keane CR, Burke JG. Disparities and access to healthy food in the United States: a review of food deserts literature. Health & Place 2010;16(5):876-884.
¹¹ Saegert S, Evans GW. Poverty, housing niches, and health in the United States. Journal of Social Issues 2003;59(3):569-89.
¹² Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health 2006;27:167-94.
¹³ Norman D, Kennedy B, Kawachi I. Why justice is good for our health: the social determinants of health inequalities. Daedalus 1999;128:215-51.
¹⁴ The Community Guide rated an intervention as “Recommended” if, after conducting a systematic review of the available studies, it determined that they provided strong or sufficient evidence that the intervention was effective. Their systematic reviews consider several factors, including study design, number of studies, and consistency of the effect across studies.
¹⁵ County Health Rankings and Roadmaps rated an interventions as “Scientifically Supported” if it was supported by (1) or more systematic reviews, or at least (3) experimental studies, or (3) quasi-experimental studies with matched concurrent comparisons. Supporting studies had to include strong designs and statistically significant positive findings.