Procedure. A project advisory group with members representing state health departments, federal agencies (such as the CDC), organizations that address LPCCs, advocacy groups, and service providers nominated potential participants in the concept-mapping process from groups interested in LPCCs, groups needing LPCCs services, and individuals with LPCCs expertise. The nomination process was part of an effort to elicit a wide range of informed opinions about the role of state health agencies in addressing LPCCs.

We collected data from September 9 through December 18, 2002. The concept mapping took place in two sessions. During the first session, we asked 145 individuals to respond to the following focus statement: "If relatively uncommon chronic conditions (such as epilepsy, multiple sclerosis, and Parkinson's disease) are to be addressed effectively, a specific action, program, or service that state public health agencies should do or facilitate is . . . ." We asked respondents to provide up to 10 brief statements or ideas to the project contractors by e-mail, fax, or regular mail or through the project Web site. We did not collect identifying information from any participant. We sent e-mail reminders twice to improve the response rate. From the 222 ideas generated in the first session, a committee of core project staff members identified 100 applicable, nonrepetitive statements to be used in the second session. Factors such as relevance, redundancy, clarity, and appropriateness were used to produce the final set of 100 statements. (The complete list of statements is available in the final report: www.conceptsystems.com/library/whitepapers.cfm*.)

The second session included a sorting task and a rating task. For the sorting task (18), we asked a subset of 53 participants (with 20 of 53 [38%] actually participating) that were selected for their familiarity with LPCCs to sort the 100 statements into groups, or clusters, based on similarity of ideas. During a 7-week period, participants either sorted the statements into clusters using the project's Web site or manually sorted statements that had been printed on cards. The participants were told the following:

We informed participants that individuals in similar concept-mapping projects (also with approximately 100 statements) generally created 6 to 15 clusters.

For the rating task in the second session, we asked the original 145 participants to rate the importance and feasibility of each of the 100 statements relative to the other statements. About 50 participants (35% of the 145 invited) assessed importance and feasibility using a 5-point Likert-type response scale ranging from 5 (very important or very feasible) to 1 (not important or not feasible). For each cluster of statements (identified in the first part of the second session), we developed ratings reflecting the sum of scores for each statement in that cluster divided by the total number of statements in the cluster. For the rating task, we collected information on participants' organizational affiliations to compare perceptions among groups. Participants represented 64 different organizations, with the majority representing state health departments (57.8%). Voluntary health agencies (17.2%) and federal health agencies (12.5%) were also represented.

Data analysis. An expert in concept mapping used The Concept System software, version 1.75 (Concept Systems Inc, Ithaca, NY) (19) to compile and analyze the sorting and rating data. The software was used to integrate the sorting information and develop a series of maps and reports by applying multidimensional scaling and hierarchical cluster analysis. The analysis involved the following tasks:

In February 2003, we invited 26 individuals representing members from various organizations and with diverse perspectives for an in-person meeting to review the analysis results and use the results to formulate recommendations for state health departments. Of the 26 invited individuals, 21 attended the meeting. Participants reviewed the cluster analyses, paying particular attention to statements that were rated as highly important and highly feasible. The recommendations they produced for state-based public health programs included specific actions that could be integrated into current state-level activities.

From August 5 to November 25, 2002, we collected data for the healthy aging project using a separate concept-mapping process. We selected representatives from state health departments and stakeholder groups, including state units on aging and various aging-related groups (researchers, policy-making bodies, and community-based organizations). We used the same concept-mapping procedure for the healthy aging project as we used for the LPCCs project. Concept mapping took place in two sessions. During the first session, we asked approximately 248 individuals to respond to the following focus statement: "If new resources were made available to state public health programs to improve the health of older adults, a specific thing that a program should be able to do or provide is . . . ." From the 489 ideas generated in this session, a committee of core project staff members identified 98 applicable, nonrepetitive statements. Factors such as relevance, redundancy, clarity, and appropriateness were used to produce the final set of 100 statements. (The results of the rating tasks for this project are not relevant to this article, but they are available in the final report: www.conceptsystems.com/library/whitepapers.cfm.) During the sorting task, 28 participants (70% of the 40 invited) sorted the statements into clusters. The participants were provided with the same directives as those provided in the LPCCs sorting task. Approximately 107 participants (43% of the 248 invited) then rated the importance and impact of the resulting statements using a 5-point Likert-type response scale. Participants were given approximately 8 weeks to complete the rating task.

We used the CDC report Promising Practices in Chronic Disease Prevention and Control: A Public Health Framework for Action (10) to identify seven essential elements of state-based chronic disease programs — elements needed by state health departments to establish comprehensive statewide chronic disease prevention programs. The seven essential elements are as follows: 1) leadership, 2) epidemiology and surveillance, 3) partnerships, 4) comprehensive state plans, 5) interventions, 6) assessment and evaluation, and 7) program management and administration.

Map results. The underlying structure for all maps generated by concept mapping was a point-cluster map that resulted from the arrangements of statements by multidimensional scaling. The participants identified nine clusters that best fit the 100 LPCCs statements (Figure 1) and described ways the results could be used by state health departments. (The list of 100 statements is available from www.conceptsystems.com/library/whitepapers.cfm.) The underlying structure for all maps generated by concept mapping was a point-cluster map that resulted from the arrangements of statements by multidimensional scaling. The participants identified nine clusters that best fit the 100 LPCCs statements (Figure 1) and described ways the results could be used by state health departments. (The list of 100 statements is available from www.conceptsystems.com/library/whitepapers.cfm*.) A core group of respondents reviewed, refined, and selected the following labels for each cluster: 1) assessment and evaluation; 2) community education; 3) data and research; 4) disease management and coordination of care; 5) health care policy and cost; 6) information, referral, and support; 7) partnerships and coalitions; 8) planning and capacity building; and 9) professional education. Note that eight of the clusters surround the disease management and coordination cluster (Figure 1). Its central location indicates that this cluster is linked to all of the other clusters.

Ratings. Feasibility ratings for clusters (with 5 being the most feasible and 1 being the least feasible) ranged from 3.32 for partnerships and coalitions (the most feasible) to 2.68 for health care policy and cost (the least feasible). The three clusters rated as having the greatest feasibility were the partnerships and coalitions cluster, the assessment and evaluation cluster, and the professional education cluster. Importance ratings for clusters (with 5 being the most important and 1 being the least important) ranged from 3.77 for health care policy and cost (the most important) to 3.20 for community education (the least important). The three clusters rated as most important were the health care policy and cost cluster, the disease management and coordination of care cluster, and the planning and capacity-building cluster (Table 1).

Recommendations. Participants at the February 2003 meeting used the feasibility and importance cluster ratings, in addition to bivariate plots of the average importance and feasibility of each statement in a cluster, to create the following five recommendations for state health departments:

In the healthy aging project, participants grouped the 98 statements into eight clusters (Figure 2): 1) capacity building and infrastructure, 2) data for action, 3) planning and policy development, 4) professional development, 5) program development and evaluation, 6) public information and education, 7) specific program opportunities, and 8) strategic partnerships. Because the final clusters for LPCCs and healthy aging were similar (Table 2), we only compared the LPCCs clusters (not the healthy aging clusters) with the essential elements of state-based chronic disease programs (10).

We superimposed the cluster map for LPCCs onto the essential elements of state-based chronic disease programs identified in the CDC's Promising Practices in Chronic Disease Prevention and Control (10) (Figure 3). The four clusters at the top of the map in Figure 3 align with four essential elements of chronic disease programs: planning and capacity building aligns with comprehensive state plans; assessment and evaluation aligns with assessment and evaluation; data and research aligns with epidemiology and surveillance; and partnerships and coalitions aligns with partnerships. In addition, the lower four project clusters (health care policy and cost; information, referral, and support; community education; and professional education) fall within the intervention program element. The central cluster, disease management and coordination of care, aligns most closely with the essential service of program management and administration. The central location of this cluster suggests that it may function as a strategic link to the other clusters. Indeed, the final priority recommendations for state health departments are similar to several of the individual statements or ideas in the disease management and coordination of care cluster, such as the recommendations to create comprehensive chronic disease programs and identify and promote best practices. The one essential element of state-based chronic disease programs missing from the LPCCs clusters is leadership.