STEPS TO A HEALTHIER U S :

Prevention Strategies That Work

A PROGRAM AND POLICY PERSPECTIVE

2003

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
STEPS TO A HEALTHIERUS:

A PROGRAM AND POLICY PERSPECTIVE

PREVENTION STRATEGIES THAT WORK

2003

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

III

FOREWORD

As managers of government programs, we often wish for guidance on the best ways to help fellow citizens

improve their health. This volume is a how-to guide—detailing the most effective methods for prevention. It

shares the lessons others have learned as they developed innovative strategies to reduce the burden of chronic

disease.

In support of the President’s HealthierUS initiative, I am leading a new department-wide effort—Steps to a

HealthierUS. The heart of this program is personal responsibility for the choices Americans make and social

responsibility to ensure that policy makers support prevention programs that foster healthy behaviors.

Steps envisions a healthy, strong United States—where diseases are prevented when possible, controlled when

necessary, and treated when appropriate. Steps is a bold shift in our approach to the health of our citizens,

moving us from a disease care system to a health care system. As public managers you know that we can no

longer sustain the skyrocketing health care costs that over-reliance on treatment has created, nor can Americans

sustain the suffering that preventable diseases cause.

We have initially focused the Steps initiative on reducing the major health burden created by diabetes, heart

disease and stroke, and cancer. Steps will also address the related lifestyle choices of poor nutrition, physical

inactivity, tobacco use, and risky youth behavior. This document focuses on promising prevention strategies for

these diseases and the risk factors that cause them.

It is always important to do what works, not just what has always been done. I hope this volume helps you to

envision the path and make real the steps to a healthier US.

Tommy G. Thompson

Secretary of Health and Human Services

U.S. Department of Health and Human Services

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PREVENTION STRATEGIES THAT WORK

TABLE OF CONTENTS

Foreword........................................................................................................................... iii

Reducing the Burden of Disease

1. Diabetes Prevention and Control: A Public Health Imperative ..................................................... 3

2. A Comprehensive Approach to Cancer Prevention and Control:

A Vision for the Future ...................................................................................................... 21

3. Achieving a Heart-Healthy and Stroke-Free Nation ................................................................... 39

Addressing Lifestyle Choices

4. Promoting Healthy Eating and Physical Activity for a Healthier Nation .................................... 61

5. Advancing Tobacco Control Through Evidence-Based Programs................................................ 85

6. Building a Healthier Future Through School Health Programs .................................................. 99

Reducing the Burden

of Disease

3

DIABETES PREVENTION AND CONTROL:

A PUBLIC HEALTH IMPERATIVE

TABLE OF CONTENTS

The Burden of Diabetes Among Americans Continues to Grow

Progress to Date

Healthy People 2010 Objectives

Prevention Opportunities

Levels of Prevention

Types of Strategies

Basic Infrastructure for Diabetes Control

Surveillance and Evaluation

Strategic Plans

Partnerships

Policy

Professional Development and Training

Diabetes Program Examples

National Diabetes Education Program

Diabetes Today

Project DIRECT

New York Centers of Excellence

Improving Diabetes Care through Empowerment, Active Collaboration and Leadership (Project IDEAL)

The Diabetes Collaborative

Wisconsin Collaborative Diabetes Quality Improvement Project

The Michigan Diabetes Outreach Network (DON)

Utah Statewide Communication Campaign

West Virginia Statewide Diabetes Media Campaign

Challenges Ahead

Technical Resources

Federal

Nongovernmental Organizations

References

5

1

DIABETES PREVENTION AND CONTROL:

A PUBLIC HEALTH IMPERATIVE

The Burden of Diabetes Among Americans

Continues to Grow

Type 2 diabetes, which affects 17 million Americans

and their families,1 often causes severe complications

that can ultimately damage every organ in the body

and lead to premature death. These complications

include heart disease, blindness, lower extremity

arterial disease, kidney failure, dental disease, and

increased susceptibility to infections. In many states,

half of all people with diabetes do not receive

recommended preventive care services that are

known to reduce the risk of diabetes complications.2

The direct economic cost of diabetes in the United

States is estimated to be nearly $132 billion per year.3

This figure does not take into account the indirect

economic costs attributable to potential work time

lost to diabetes-related illness or premature death.

The prevalence of diagnosed type 2 diabetes

increased sixfold in the latter half of the last century.4

Diabetes risk factors such as obesity and physical

inactivity have played a major role in the dramatic

increase in rates of type 2 diabetes in recent years.

Age, race, and ethnicity are also important risk

factors. The prevalence of diabetes increases with

age in all racial and ethnic groups. Whereas 8.6%

of Americans over age 20 have diabetes, 20.1% of

Americans over age 65 have diabetes. Far fewer

Americans younger than age 20 have diabetes, but

the prevalence of diabetes in this age group appears

to be rising considerably. The rising prevalence of

diabetes in this age group, as in other age groups,

is attributed to increases in physical inactivity

and obesity.

American Indians, black Americans, Latino

Americans, and some Asian Americans and Pacific

Islanders are disproportionately affected by diabetes.1

For example, black and Hispanic Americans are

almost twice as likely to have diabetes as nonHispanic white Americans of similar age, and

American Indians are almost three times as likely to

have diabetes as non-Hispanic whites of similar age.

As the prevalence of obesity and sedentary lifestyles

increases and the U.S. population becomes older and

more ethnically diverse, the prevalence of diabetes is

expected to continue to rise.5

Socioeconomic and environmental factors may also

play a role in a person’s risk of developing diabetes

and in the course of diabetes once it has developed.5

People with type 2 diabetes are more likely to have

less education and lower incomes than people without diabetes.6

 Elderly minority women, who are more

likely to live alone and to have lower socioeconomic

status, are also more likely to have diabetes and to

lack resources to adequately manage their disease.7

Progress to Date

The last two decades have provided great advances

in clinical care for people with diabetes. For example,

in 1981, photocoagulation treatment was proven

effective in preventing diabetes-related blindness.8

Twelve years later, the results of the landmark

Diabetes Control and Complications Trial (DCCT)

established that intensive control of blood sugar

greatly reduced microvascular complications among

people with diabetes.9

 In 2002, findings from the

Diabetes Prevention Program (DPP) demonstrated
6

PREVENTION STRATEGIES THAT WORK

that lifestyle changes and medications can help

prevent diabetes in people with impaired glucose

tolerance.10

Although diabetes cannot be “cured,” these findings

prove that the devastation of diabetes can be dramatically reduced. However, for many reasons, large

segments of the population have not benefited from

these findings. Without broader public health

interventions and additional resources, the prevalence of diabetes is expected to continue to increase.

This chapter discusses a model for public health

action to improve the lives of people, communities,

and populations affected by diabetes. This model is

based on existing and emerging science and public

health experience.

Healthy People 2010 Objectives

Healthy People 2010 is the third version of the

Healthy People series published by the U.S.

Department of Health and Human Services in which

it lays out 10-year health objectives for the nation.

This document serves as a blueprint for identifying

reasonable, science-based goals that can be modified

as desired by state and federal agencies, local entities,

and communities. Healthy People 2010 includes

467 objectives in 28 focus areas.

In recognition of the significance of the burden of

diabetes and its impact on multiple systems within

the body, the nation’s Healthy People 2010 objectives

include several related to diabetes.11 Most of these

involve secondary prevention (preventing complications of diabetes) or tertiary prevention (preventing

the progression of complications). A few involve

primary prevention (preventing diabetes itself).

Healthy People 2010 Focus Area 5 contains 17

objectives directly related to diabetes prevention and

control. Many other focus areas also contain

objectives that relate to diabetes. For more

information on the diabetes-related objectives in

Healthy People 2010, visit www.healthypeople.gov.

Prevention Opportunities

There is a strong scientific basis for the primary,

secondary, and tertiary prevention of diabetes.

However, translating the science into effective

interventions to lessen the burden of diabetes

requires considerable resources and effort.

Levels of Prevention

Diabetes programs should address all three levels of

diabetes prevention: primary, secondary, and tertiary.

Primary prevention interventions seek to delay or

halt the development of diabetes. The most

compelling evidence for the effectiveness of primary

prevention is for interventions targeting people with

impaired glucose tolerance,10 who are at highest risk

of developing diabetes. Both drugs and lifestyle

changes have proven effective in helping these people

delay or prevent the development of diabetes,

although lifestyle changes related to losing weight

and increasing physical activity have been most

effective.10 Primary prevention efforts in state

diabetes programs cover a wide spectrum. At a

minimum, diabetes programs should partner with

other programs that assume responsibility for

reducing risk factors in the population at large, such

as those that provide broad nutrition and physical

activity interventions. (See Chapter 4.) In such

partnerships, diabetes programs play a supportive

rather than a leadership role. For example, diabetes

programs could participate in coalitions that seek

broad environmental changes to support walking.

These coalitions would typically be developed,

sponsored, and led by state nutrition and physical

activity programs. On the other hand, diabetes

programs should play a leadership role in primary

prevention interventions focused on ensuring that

people at highest risk for diabetes have access to

interventions that will delay or avert the development of the disease. The leadership role may entail

aggressively soliciting partnerships with cardiovascular health, nutrition, and physical activity

programs to develop lifestyle change interventions.
7

DIABETES: A PUBLIC HEALTH IMPERATIVE

Secondary and tertiary prevention interventions

focus on people with diabetes and seek to prevent

(secondary) or control (tertiary) the devastating

complications of this disease. More proven intervention models are available for both secondary and

tertiary prevention than for primary prevention. For

example, maintaining near normal glucose, blood

pressure, and cholesterol levels has been shown

repeatedly to reduce diabetes complications.10, 12

Additionally, routine preventive care practices such as

foot exams, eye exams, and frequent A1C testing are

well-established components of quality diabetes

care.13 To ensure that these benefits reach the people

who need them, programs should develop,

implement, and coordinate multilevel interventions

targeting people with diabetes, their families, their

health care systems, and their communities.

All three types of prevention interventions rely on

active stakeholder involvement and support. Stakeholders include people with diabetes, voluntary

organizations that have an interest in diabetes or

serve populations disproportionately affected by

diabetes, health care providers (e.g., primary care

providers, endocrinologists, diabetes educators, eye

care specialists), and academic institutions. However,

program planners are encouraged to explore partnerships with organizations (e.g., urban planning

groups, restaurant associations) that may not

traditionally work with the diabetes community but

can assist in implementing interventions.

Achieving population-level impact in the primary,

secondary, and tertiary prevention of diabetes is a

complex task that requires resources, competent

leadership, and a diverse staffing mix at the national,

state, and provider levels. Diabetes programs should

collaborate with a wide variety of partners to ensure

an appropriate balance between efforts to prevent

diabetes complications and efforts to prevent the onset

of diabetes. The ability to capitalize on prevention

opportunities requires a strong infrastructure to plan

and support interventions, nurture partnerships, and

monitor and evaluate progress.

Types of Strategies

Diabetes programs should pursue three major types

of strategies: health systems change, community

intervention, and health communications. These

three strategies should be implemented at multiple

levels and in tandem with each other.

Health Systems Change

The U.S. Task Force for Community Preventive

Services strongly recommends disease and case

management to improve diabetes clinical outcomes.14

Programs should not only seek to improve preventive

health care practices by providers and people with

diabetes, but also seek to redesign health care

processes related to diabetes care.

Strategies to improve health care systems and access

to quality care can address either the primary,

secondary, or tertiary prevention of diabetes. Such

strategies addressing primary prevention might aim

to identify more people with impaired glucose

tolerance by increasing screening among populations

at high risk, including obese people, people over age

45, and members of certain racial or ethnic groups.

Health system change strategies addressing secondary

and tertiary prevention might demonstrate the

benefit of policy interventions that support selfmanagement of diabetes (e.g., adding lay health

workers to the staff of some medical practices, using

information technology to communicate with people

with diabetes outside of the provider’s office,15

expanding support for patients with diabetes as the

source of control of diabetes care16).

Community Intervention

Community intervention strategies can combine

aspects of primary, secondary, and tertiary

prevention. Community intervention strategies

aimed at the primary prevention of diabetes might

include community-based exercise and healthy

nutrition programs targeting people at high risk for

diabetes. Community intervention strategies aimed

at secondary and tertiary prevention might seek to

increase the availability of influenza vaccinations or
8

PREVENTION STRATEGIES THAT WORK

to provide diabetes education for people with

diabetes in gathering places for adults.14 Initiatives

can also mobilize community members to improve

access to care for people with diabetes, such as by

establishing community diabetes support groups or

by holding routine diabetes question-and-answer

sessions at local pharmacies.14 Other community

intervention strategies might address broader issues

that affect individuals with diabetes and their

families and communities, such as the need for social

support and stress reduction. For example, efforts

could include advocacy for increasing the availability

of diabetes education programs outside of normal

working hours so that entire families are able to

participate together.

Health Communications

Diabetes health communications interventions are

based on consumer research and often involve raising

awareness of diabetes and its complications by disseminating health information to targeted audiences.

Health communications should be viewed as a

complementary strategy tied to health systems

change or community interventions. Health

communications strategies are rarely effective as

stand-alone activities.

Diabetes health communications strategies are

appropriate for primary, secondary, and tertiary

interventions. Possible primary prevention interventions include awareness campaigns targeting

people with impaired glucose tolerance, as well as

their health care providers and their employers.

Secondary interventions include developing and

disseminating targeted messages to address

misconceptions about flu and pneumococcal

immunizations. Tertiary interventions include

developing and disseminating targeted messages

to increase rates of foot examinations for special

populations.

CDCynergy, a CDC-developed CD-ROM to help

organizations plan health communications

activities,17 suggests that the development of health

communications initiatives include the following

steps:

• Defining and describing the problem.

• Analyzing the problem.

• Identifying and profiling audiences.

• Developing a communication strategy

and tactics.

• Developing an evaluation plan.

• Launching the initiative and gathering feedback

from participants.

Program planners are encouraged to review the

experience of programs in other states or

communities. However, these programs should

be viewed as guides and not templates, since

interventions usually need to be tailored to a

particular population.

Basic Infrastructure for Diabetes Control

Several components are necessary to ensure a complete program in diabetes. The impact of programs is

maximized when all of these components have been

put into action.

Surveillance and Evaluation

A complete program must have information available

to 1) define the nature and extent of the diabetes

burden (surveillance), 2) focus intervention efforts,

and 3) determine if interventions are having an

impact (evaluation).

Surveillance

In June 2000, the Council for State and Territorial

Epidemiologists published a list of indicators for

diabetes surveillance (Table 1). These indicators

cover a wide range of issues important for monitoring diabetes trends and for planning and evaluating

diabetes program efforts. Other important indicators

to follow include levels of physical activity and

obesity, diabetes education, and self-monitoring of

blood glucose. Programs should also monitor

environmental changes that affect the course of

diabetes, including state and federal health policy

changes. In general, surveillance data are critical for

monitoring state and national progress, including

progress toward meeting Healthy People 2010

objectives.
9

DIABETES: A PUBLIC HEALTH IMPERATIVE

The following are the best-developed and most

widely used sources of diabetes-specific state

surveillance data:

Behavioral Risk Factor Surveillance System (BRFSS),

including the diabetes module. BRFSS is a statebased, random-digit-dialed telephone survey

designed to yield representative population samples

for each state. Each state should administer the

BRFSS annually (including the special diabetes

module) to monitor the extent of and trends in the

diabetes burden, behavioral risk factors, and

preventive care practices.

Hospital discharge data. These data are available in

most states, sometimes for a fee, and are important

for monitoring diabetes-related illness. However,

hospital discharge data should be viewed as complementary to BRFSS and other data rather than as a

sole source of information.

State vital records data. Data from death certificates

and birth certificates are used for monitoring

diabetes-related death rates and pregnancy outcomes.

However, only about 40% of people who die with

diabetes have diabetes listed on their death

certificate. As a result, death certificate data cannot

be used to monitor death rates, causes of death, and

relative risk for death among people with diabetes

unless the death certificate has been modified to

collect data on decedents’ diabetes status. The new

standard birth certificate scheduled to be implemented in 2003 will collect data on whether the

mother had either preexisting or gestational diabetes

(diabetes diagnosed during pregnancy). This new

information will help to determine the effects of

diabetes on pregnancy and trends in diabetes-related

birth defects.

Partnering health organizations such as provider

groups, managed care organizations, and community

health centers can be important sources of diabetes

surveillance data. Programs are encouraged to

supplement existing data with data from specialized

surveillance efforts, such as special surveys of

minority and other populations not adequately

represented in available data sources.

Evaluation

Diabetes programs need to conduct evaluations to

determine how effective their activities are in

producing desired short-term and long-term effects.

Logic modeling is a recommended tool for this

purpose (Figure 1).18 Because diabetes and its

complications can take many years to develop and

diabetes mortality data tend to be inaccurate,

programs need to use intermediate measures of

success as part of their evaluations.19 Good process

evaluation is also essential to understanding why a

program is or is not achieving results and how to

1. Mortality from or with diabetes mellitus.

2. Mortality from or with diabetic ketoacidosis.

3. Diabetes mellitus prevalence.

4. Influenza vaccinations among adults with diabetes mellitus.

5. Pneumococcal vaccinations among adults with diabetes mellitus.

6. Foot exams among people with diabetes mellitus.

7. Dilated eye exams among people with diabetes mellitus.

8. Hospitalizations among people with diabetes mellitus.

9. Amputations of lower extremities attributable to diabetes mellitus.

Source: Indicators for Chronic Disease Surveillance: Data Volume, Council for State and Territorial Epidemiologists, 2000.

Table 1. Diabetes Surveillance Indicators
10

PREVENTION STRATEGIES THAT WORK

adjust the program accordingly.20 Ultimately,

however, the success of a program is determined by

its long-term success in reducing diabetes incidence,

illness, complications, and deaths. Evaluation of

progress toward more intermediate objectives should

always be conducted with those long-term objectives

in mind.

Strategic Plans

The development of a strategic plan is critical to the

success of diabetes programs. Stake-holders should

be actively involved in developing, reviewing, and

evaluating the plan. Once developed, plans should be

reviewed and updated as progress is made or

circumstances change. Ideally, the plan’s goals and

objectives should be tailored to national, state, and

local needs, and strategies for achieving these goals

and objectives should be based on proven and

evaluated experiences whenever possible.

The diabetes objectives in Healthy People 2010

(Chapter 5) 21 provide a template for national, state,

and local efforts to prevent and control diabetes.

Plans should address the primary, secondary, and

tertiary prevention of diabetes and should describe

the roles and responsibilities of the various partners.

At a minimum, these roles should be described as

supportive or leadership. For diabetes programs, this

distinction is especially useful in primary prevention

activities, because leadership for some interventions

to reduce obesity in the general population is more

suitable for other public programs.

Figure 1. Diabetes Prevention and Control Program

 

 

 

 

 

 

 

 

 

 

 

 

s
11

DIABETES: A PUBLIC HEALTH IMPERATIVE

Partnerships

State diabetes programs should collaborate with

partners to facilitate and coordinate various efforts to

prevent and control diabetes. Programs can bring

together partners through special initiatives, topical

meetings, and issue-specific planning. Partners can

include professional organizations, voluntary

diabetes organizations, community health centers,

employers and other health care purchasers,

community organizations, businesses, schools, and

faith-based organizations.

If possible, diabetes programs should also establish

an advisory board consisting of representatives of

partnership groups and other key members of the

diabetes community. The activities and membership

of these boards should be strategically planned to

strengthen and help guide program efforts.

Population-level changes invariably require action by

particular groups. Therefore, engaging these groups

in strategy and planning is key to selecting

appropriate and effective interventions and securing

commitments of resources. In addition, advisory

boards can help coordinate diabetes control efforts

with similar efforts of other private- and publicsector partners across the state.

Policy

Another important role of diabetes programs is to

help private organizations and federal, state, and

local agencies design policies that optimize the health

of people with and at risk for diabetes. Most commonly, these programs provide guidance about a

population’s need for diabetes care services and

resources. They also should provide information, on

request, to state legislators and governors as they

develop regulations concerning insurance benefits for

people with diabetes (e.g., for diabetes supplies and

self-management education) or expanded coverage

for people at risk for diabetes (e.g., for nutrition

counseling for people with impaired glucose

tolerance). By tracking changes in laws and regulations over the years, monitoring their health

impact, and offering technical assistance to publicand private-sector policy makers, state diabetes

programs can substantially influence the development of new policies. To be effective in this role,

however, state programs must be able to provide

accurate assessments of science and public health

initiatives related to diabetes.

The role of diabetes programs in policy change

efforts varies from case to case. When the policy in

question relates exclusivly to diabetes, diabetes

programs should take the lead. However, when the

policy in question involves broader public health

concerns, including diabetes, it may be more

appropriate for the program to play a supporting

role in larger partnership efforts.

Examples of policy initiatives include those that

• Promote work environments conducive to

healthy eating and exercise for people with or

at risk for diabetes.

• Provide more support and flexibility for people

with diabetes to administer insulin injections or

monitor blood glucose levels at school or at work.

• Increase the accessibility of safe places to exercise

(e.g., expanded availability of community and

school resources for physical activity).

Professional Development and Training

Professional development for staff involved in

diabetes prevention and control is essential to program success. Because of the rapid pace of scientific

change in the field of diabetes, state programs are

encouraged to establish minimal requirements for

staff training and development. Staff should receive

ongoing training in the latest developments in health

systems change strategies, community interventions,

health communications, the pathophysiology of

diabetes, team building, and diabetes surveillance

and evaluation. The following is a list of just some of

the organizations that offer multidisciplinary diabetes professional training:

The American Diabetes Association sponsors

numerous courses for health professionals

throughout the year.

Web site: www.diabetes.org
12

PREVENTION STRATEGIES THAT WORK

CDC’s Division of Diabetes Translation sponsors

an annual conference and provides numerous

professional development resources.

Web site: www.cdc.gov./diabetes

Wichita State University’s Division of Continuing

Education, Wichita, KS, offers Diabetes Education

Update, a didactic workshop addressing clinical,

educational, and psychosocial issues.

Web site: webs.wichita.edu/continuinged/

deu_form.htm for course curriculum and

registration information

The International Diabetes Center, Minneapolis,

MN, offers concise diabetes update courses for

health professionals.

Web site: www.parknicollet.com/diabetes/

professionals/index.html

The National Diabetes Education Program (NDEP)

offers electronic professional educational materials

through a portion of its Web site.

Web site: www.ndep.nih.gov

NIH’s National Institute of Diabetes, Digestive, and

Kidney Diseases, offers professional education

materials through the NIH Information

Clearinghouse.

Web site: www.niddk.nih.gov

The American Association of Diabetes Educators

offers certification for diabetes educators and

sponsors courses for diabetes educators and health

professionals.

Web site: www.aadenet.org/index2.html

Diabetes Program Examples

These examples of state program strategies,

collaborations, and methods have been collected

from state diabetes programs across the country.

These examples represent specific aspects of a single

program and are not a description of the state

program’s total effort. In each example, the type of

strategy and contact information are provided.

National Diabetes Education Program

The National Diabetes Education Program is a

federally sponsored initiative whose goal is to reduce

the illness and deaths associated with diabetes and its

complications. The program’s objectives are

• To increase awareness of the seriousness of

diabetes and its risk factors and to increase

awareness of strategies for preventing diabetes and

its complications among groups at high risk.

• To improve understanding of diabetes and its

control and promote better self-management

behaviors among people with diabetes.

• To improve health care providers’ understanding

of diabetes and its control and to promote an

integrated approach to care.

• To promote health care policies that improve the

quality of and access to diabetes care.

• To reduce health disparities among racial and

ethnic populations disproportionately affected by

diabetes.

The National Diabetes Education Program is jointly

sponsored by the National Institute of Diabetes and

Digestive and Kidney Diseases of the National

Institutes of Health and the Division of Diabetes

Translation of the Centers for Disease Control and

Prevention and supported by the participation of

over 200 public and private partner organizations.

Type of Strategy: Health systems change/

partnerships

Contact Information:

National Diabetes Information Clearinghouse

1 Information Way

Bethesda, MD 20892-3560

Phone: 1-800-860-8747 or 301-654-3327

Fax: 301-907-8906

Email: ndic@info.niddk.nih.gov

Web site: www.ndep.nih.gov

National Center for Chronic Disease Prevention

and Health Promotion
13

DIABETES: A PUBLIC HEALTH IMPERATIVE

Division of Diabetes Translation

4770 Buford Highway, NE, Mail Stop K-10

Atlanta, GA 30341-3717

Phone: 1-877-CDC-DIAB

Fax: 301-562-1050

Email: diabetes@cdc.gov

Web site: www.cdc.gov/diabetes

Diabetes Today

Diabetes Today (DT) is a course that is offered

around the country and in the Pacific Basin to train

public health professionals and members of the

community in approaches to mobilizing

communities to address diabetes. Using community

participation and leadership to identify and address

community-level diabetes issues is a goal of this

“train the trainer” course, which is offered in

English, Spanish, and other languages. The DT

course offers tools, processes, and methods for

developing community-focused programs that are

geographically appropriate and culturally relevant.

Additionally, DT training promotes collaboration

among community residents, health professionals,

and health systems. As a result of DT training,

participants from many communities whose

residents are at high risk for diabetes have identified

the need for more community support groups and

diabetes education classes. In Laredo, Texas, for

example, the Lado A Lado (Laredoans Against

Diabetes and Overweight) community program now

offers support groups for adults with diabetes.

Several counties in Virginia are working to establish

diabetes education programs in accessible settings,

such as local schools, hospitals, community health

clinics, and churches. A DT program in Guadalupe,

Arizona, trains lay health workers (“promotoras”) to

conduct health promotion programs for people with

diabetes and those at high risk of developing

diabetes.

Type of Strategy: Community intervention

Contact Information:

Division of Diabetes Translation

National Center for Chronic Disease Prevention

and Health Promotion

Centers for Disease Control and Prevention

4770 Buford Highway NE, Mail Stop K-10

Atlanta, GA 30341-3717

Phone: 770-488-5000

Fax: 770-488-5966

Web site: www.diabetestodayntc.org

Project DIRECT

Project DIRECT is a comprehensive, communitybased intervention carried out in a predominantly

black and low-income community in North

Carolina. This project began in 1992 with the

formation of a partnership among local community

stakeholders, who became key decision makers in all

that followed. The project established a multilevel,

community-based model that includes diabetes care

(providing clinical services), outreach (improving

community capacity to identify and treat patients

with diabetes), and health promotion (reducing risk

factors associated with diabetes through information

sharing and environmental and policy changes). This

project promotes the primary, secondary, and tertiary

prevention of diabetes. Because Project DIRECT is a

pioneer program of its type, its leaders now share the

challenges they encountered and the lessons they

learned with local, state, and national leaders

interested in pursuing this community empowerment approach to diabetes prevention and control

elsewhere.22

Type of Strategy: Community intervention

Contact Information:

Diabetes Control Program Director

NC Department of Health and Human Services

Diabetes Prevention and Control Unit

1915 Mail Service Center

Raleigh, North Carolina 27699-1915

Phone: 919-715-3131

Fax: 919-733-0488

New York Centers of Excellence

The New York Diabetes Program collaborates with

14 regional community coalitions and 3 universitybased Centers of Excellence (State University of New

York/Upstate Medical University in Syracuse, Mount

Sinai Medical Center/East Harlem in New York City,
14

PREVENTION STRATEGIES THAT WORK

and Columbia–Presbyterian Hospital/Naomi Berrie

in New York City) to improve diabetes care. The

Centers of Excellence work with peer-review

organizations, health centers, hospitals, and

community organizations to develop educational

initiatives and promote collaboration among health

care providers to improve diabetes services and access

to care. The centers also develop methods to

overcome socioeconomic, cultural, and language

barriers to services. In 2 years, the community- and

provider-focused interventions sponsored by the

Centers of Excellence have reduced hospitalization

rates by 35% and decreased lower-extremity

amputation rates by 39%.

Type of Strategy: Health systems change/

partnerships

Contact Information:

Diabetes Control Program Coordinator

Bureau of Chronic Disease Services

New York State Department of Health

Empire State Plaza Tower, Room 780

Albany, New York 12237-0678

Phone: 518-474-1222

Fax: 518-473-0642

Improving Diabetes Care through Empowerment, Active

Collaboration, and Leadership (Project IDEAL)

Project IDEAL is an initiative developed by the

Minnesota Diabetes Control Program and Health

Partners, a large managed care organization. IDEAL

is a systematic, population-based intervention that

facilitates diabetes care improvements by identifying

the need for changes within primary care clinics and

then making these changes happen. During the pilot

stage of IDEAL, the frequency of eye exams, foot

exams, and microalbumin testing increased

substantially, and these results were replicated in the

intervention phase. In 2 years, participants’ average

A1C values decreased from 9.2% at baseline to

7.7%. Other effects of this intervention include a

higher priority for diabetes in managed care and the

application of the IDEAL methodology to address

asthma, heart disease, hypertension, and other

chronic conditions.

Type of Strategy: Health systems change/

partnerships

Contact Information:

Minnesota Diabetes Control Coordinator

Minnesota Department of Health

P.O. Box 64882

St. Paul, Minnesota 55164-0882

Phone: 651-281-9842

Fax: 651-215-8959

The Diabetes Collaborative

The Diabetes Collaborative is an interagency, publicprivate partnership aimed at improving the quality of

health care for secondary and tertiary diabetes

prevention in federally funded community health

centers. This partnership involves federal, state, and

local entities. National partners include the Health

Resources and Services Administration, the Centers

for Disease Control and Prevention, and the

Institute for Health Care Improvement. State and

local partners include community health centers and

state diabetes programs. To date, 40 state programs

are participating formally in the collaborative, along

with approximately 300 community health centers.

Improvement methods include applying the

MacColl Institute for Healthcare Innovation’s

Chronic Care Model23 and the Institute of Health

Improvement’s Quality Improvement Model. 24

Common objectives include measuring patients’

A1C levels twice per year, at least 90 days apart, and

establishing patient self-management goals. Results

of the collaborative’s efforts to date include a

threefold increase (from 20% to 60%) in the

percentage of patients who receive A1C testing

at the recommended interval.

Type of Strategy: Health systems change/

partnerships

Contact Information:

Health Resources and Services Administration

Bureau of Primary Health Care

Health Disparities Collaborative

4350 East West Highway

Bethesda, MD 20814

Phone: 301-594-4292
15

DIABETES: A PUBLIC HEALTH IMPERATIVE

Fax: 301-443-4983

Web site: bphc.hrsa.gov/programs/

HDCProgramInfo.htm

Division of Diabetes Translation

National Center for Chronic Disease Prevention

 and Health Promotion

Centers for Disease Control and Prevention

4770 Buford Highway NE MS K-10

Atlanta, GA 30341-3717

Phone: 770-488-5000

Fax: 770-488-5966

Email address: diabetes@cdc.gov

Web site: www.cdc.gov/diabetes

Wisconsin Collaborative Diabetes Quality

Improvement Project

The Wisconsin Diabetes Control Program developed

the Collaborative Diabetes Quality Improvement

Project in partnership with the University of

Wisconsin Department of Preventive Medicine. The

objectives of this project are to facilitate standardized

baseline data collection and to identify and address

gaps between current practice and the Wisconsin

Essential Care Guidelines. Twenty organizations and

18 HMOs from across the state reported on six

indicators of diabetes care for approximately 25,000

people with diabetes in Wisconsin. The indicators

were number of A1C tests performed, percentage of

people with poorly controlled A1C levels, number of

lipid profile tests performed, percentage of people

with lipids controlled, number of dilated eye exams

performed, and number of people screened for

kidney disease. In 2000, all participating HMOs had

improved in the six selected indicators since 1999:

the proportion of people receiving lipid profiles

increased by 10%, the proportion receiving dilated

eye exams increased by 8%, and the proportion

receiving one or more A1C tests increased by 2%. In

addition, control of A1C improved by 4%, control

of lipid levels improved by 16%, and screening for

kidney disease increased 13%. Two factors critical to

the success of this project were that all of the

participants, including participating HMOs, were

involved in developing the guidelines, and that

information was shared with all participants, many

of whom were market competitors. These factors

facilitated better coordination of diabetes care, which

helped to improve the clinical indicators listed above.

Type of Strategy: Health systems change/

partnerships

Contact Information:

Diabetes Control Program Coordinator

Wisconsin Department of Health

1 West Wilson Street

Room 218

Madison, Wisconsin 53701-2659

Phone: 608-261-6871

Fax: 608-266-8925

The Michigan Diabetes Outreach Network (DON)

The Michigan DON consists of a series of regional

networks designed to facilitate comprehensive

diabetes assessment, education, referral, and followup care through innovative partnerships. Through

the coordinated efforts of health departments,

private home-care agencies, hospitals, clinics,

physicians, and Native American health agencies,

people who have diabetes are identified and provided

individualized care. As a result of these efforts, most

people enrolled in this system have been referred to

and have seen all of the recommended health care

providers. Furthermore, many of the participants

have improved their self-care practices and are now

able to self-manage their diabetes. The effectiveness

of the DON model was established in 1991, when a

published analysis showed that, in just 5 years, the

DON serving the Upper Peninsula had reduced the

diabetes-related death rate by 27%, the diabetesrelated hospitalization rate by 45%, and the diabetesrelated lower-extremity amputation rate by 31%.

The DON model is the cornerstone of the Michigan

Diabetes Control Program and an integral part of

quality diabetes care efforts throughout the state.

Type of Strategy: Health systems change/

partnerships

Contact Information:

Diabetes Control Program Coordinator
16

PREVENTION STRATEGIES THAT WORK

Diabetes, Dementia, Kidney Section

Michigan Department of Community Health

P.O. Box 30195

Lansing, Michigan 48909

Phone: 517-335-8445

Fax: 517-335-9461

MDON Web site: www.diabetes-midon.org

Utah Statewide Communication Campaign

The goals of this campaign are to improve awareness

of diabetes risk factors and screening methods,

especially among groups at high risk, and to improve

awareness of the most effective ways to control

diabetes. The process for developing the campaign

included the following:

• Updating the social marketing plan.

• Gathering and analyzing market research on

media habits and appropriate messages for target

population groups, including Hispanics,

Polynesians, and seniors.

• Developing messages and choosing media

channels and vehicles appropriate for the target

population with diabetes. Decisions were based

on market research and a review of materials

previously developed by the Utah Diabetes

Control Program (UDCP) and the National

Diabetes Education Program (NDEP).

• Testing all messages and materials and distributing them.

• Airing NDEP/UDCP television and radio public

service announcements, distributing news releases,

and developing news stories.

• Developing other promotional items that list the

UDCP Web page address and health resource line

toll-free number and sending these materials to

community partners to distribute to the public.

• Collaborating with local health departments

and other community partners to implement

public awareness and education activities in

their districts.

• Providing materials and training to help health

resource line telephone operators respond

proficiently to diabetes-related calls and make

appropriate referrals.

• Updating and distributing the Diabetes Resource

Manual (for professionals) and the Diabetes

Directory (for consumers).

• Maintaining the program’s Web page and adding

frequently asked questions and questions for

patients to ask their doctor.

Evaluation efforts to date have been limited to

process evaluation. Utah will conduct an overall

diabetes awareness campaign evaluation as well as

the Utahns with Diabetes Follow-Up Survey. This

communications campaign is only one component

of Utah’s Diabetes Control Program. Together, the

health communications, health systems, and community interventions should help reduce the burden

of diabetes in the state.

Type of Strategy: Health communications

Contact Information:

Diabetes Control Program Coordinator

Utah Department of Health

Chronic Disease Control

Division of Community and Family Health

 Services

288 North 1460 West

P.O. Box 142107

Salt Lake City, Utah 84114-2107

Phone: 801-538-6141

Fax: 801-538-9495

Web site: www.health.utah.gov/diabetes

West Virginia Statewide Diabetes Media Campaign

The West Virginia Diabetes Program implemented a

media campaign from September 1999 through July

2002 to improve the preventive health care practices

of Medicare beneficiaries with diabetes. The campaign featured rotating messages about A1C testing,

eye examinations, influenza immunizations, and

other diabetes prevention and diabetes care topics.

Evaluation of this effort focused on determining

whether Medicare beneficiaries with diabetes saw or

heard mass media messages about diabetes and

whether hearing messages was associated with a selfreported response. The telephone survey was of a

random sample of 1,500 beneficiaries in the West

Virginia Diabetes Database from two groups of
17

DIABETES: A PUBLIC HEALTH IMPERATIVE

counties: those with high and those with low

exposure to the media campaign as determined from

broadcast logs and station coverage maps. The survey

asked whether the beneficiary had heard and

responded to messages on specified topics.

Beneficiaries who had had high exposure to the

messages were about 1.2 times more likely to recall

hearing messages on A1C, foot examinations, and

influenza immunizations than were beneficiaries

with low exposure, and this difference was

statistically significant (p<0.05). Furthermore, for all

four message topics, having heard the messages was

significantly associated with the likelihood of selfreported action (e.g., talking to a doctor about A1C

testing).

Type of Strategy: Health communications

Contact Information:

Peggy Adams, RNC, MSN, CDE

Diabetes Control Program

Department of Health and Human Resources

350 Capitol St., Room 319

Charleston, West Virginia 25301

Phone: 304-558-0644

Fax: 304-558-1553

Challenges Ahead

Diabetes is an enormous public health problem.

However, by continuing to learn more about

diabetes and by doing all that is possible to prevent

and control this disease, Americans may ultimately

succeed in reducing the great burden it creates.

Although a greater proportion of public health

resources will likely be devoted to primary

prevention in the years to come, secondary and

tertiary prevention will remain important public

health opportunities for reducing the incidence and

severity of diabetes complications among people who

already have the disease. Moreover, while exercise

and physical activity can reduce people’s risk for type

2 diabetes, particularly among those with elevated

fasting glucose levels and impaired glucose tolerance,

translating this knowledge into effective public

health actions will not be easy. To provide tangible

evidence of the impact of specific interventions,

public health diabetes programs must have a strong

evaluation component, and to establish priorities in

accordance with scientific evidence, they must be

able to respond rapidly to lessons learned.

Technical Resources

The following Web sites provide valuable technical

resources for state and local diabetes control

programs.

Federal

Health Resources and Services Administration.

www.hrsa.gov. Provides information on programs,

resources, and funding.

Centers for Disease Control and Prevention.

www.cdc.gov/diabetes. Provides diabetes statistics,

programs, and publications information.

www.cdc.gov/cdcynergy. Provides information

about CDCynergy.

CDC link to Web sites of state diabetes control

programs.

www.cdc.gov/diabetes/states/index.htm.

National Diabetes Education Program (NDEP).

www.ndep.nih.gov. Provides information on diabetes

resources and tools and on NDEP campaigns.

National Institutes of Health.

www.niddk.nih.gov. Provides information on

diabetes research and clinical trial.

http://hstat.nlm.nih.gov/hq/Hquest/db/

local.gcps.cps/screen/Browse/s/36462/cmd/HF/

action/GetText?IHR=CH19. The diabetes

chapter of the Guide to Clinical Preventive Services.
18

PREVENTION STRATEGIES THAT WORK

U.S. Department of Health and Human Services

(HHS) Office of Minority Health.

www.omhrc.gov. Provides information on HHS

efforts to address racial and ethnic health

disparities.

Healthy People 2010.

www.healthypeople.gov. Provides information

about Healthy People 2010. See chapter 5 for

information on diabetes.

Agency for Health Care Research and Quality

(AHRQ)

http://www.ahrq.gov/research/tripdiab.htm.

Provides information on AHRQ-funded research

on diabetes care.

http://www.ahrq.gov/research/

diabdisp.htm#Reducing%20Disparities. The

AHCR publication Reducing Diabetes Disparities

Among Ethnic and Racial Minorities includes

information on the Chronic Disease SelfManagement Program, research regarding the

prevention of type 2 diabetes in Mexican

American populations, and research on family

support.

Food and Drug Administration (FDA)

http://www.fda.gov/womens/taketimetocare/

diabetes/default.htm. Provides information on the

Take Time To Care ...About Diabetes campaign

from the FDA’s Office of Women’s Health.

Centers for Medicare and Medicaid Services

http://www.cms.hhs.gov/partnerships/outreach/

initiatives/diabetes.asp. Provides information on

the Diabetes Practitioners Kit and the

Community Kit.

Indian Health Service (IHS)

http://www.ihs.gov/medicalprograms/diabetes/

kids%26diab.pdf. IHS’s Best Practice Model:

Type 2 Diabetes in Youth.

Nongovernmental Organizations

American Association of Diabetes Educators.

www.aadenet.org.

American Diabetes Association.

www.diabetes.org.

Juvenile Diabetes Research Foundation

International.

www.jdrf.org.

References

1. Centers for Disease Control and Prevention.

National Diabetes Fact Sheet: National Estimates

and General Information on Diabetes in the

United States, Revised edition. Atlanta, GA: U.S.

Department of Health and Human Services,

2002.

2. Centers for Disease Control and Prevention.

Levels of diabetes-related preventive-care

practices—United States, 1997–1999. MMWR

Morb Mortal Wkly Rep 2000;49(42):954-8.

3. Hogan P, Dall T, Nikolov P. Economic

consequences of diabetes mellitus in the U.S. in

1997. Diabetes Care 2003;26(3):917-32.

4. Centers for Disease Control and Prevention.

Diabetes: A Serious Public Health Problem.

Atlanta: U.S. Department of Health and Human

Services, 2001.

5. Boyle JP, Narayan V, Thompson TJ, Geiss LS.

Projection of diabetes burden and cost through

2050: impact of changing demography and

disease prevalence in the U.S. Diabetes

2001;50(S2):A206.

6. Engelgau MM, Geiss LS. The burden of diabetes

mellitus. In: Leahy JL, Clark NG, Cefalu WT,

editors. Medical Management of Diabetes Mellitus.

New York: Marcel Dekker, 2000.

7. Centers for Disease Control and Prevention.

Socioeconomic status of women with diabetes—

United States, 2000. MMWR Morb Mortal Wkly

Rep 2002;51(7):147-8.
19

DIABETES: A PUBLIC HEALTH IMPERATIVE

8. Diabetic Retinopathy Study Group.

Photocoagulation treatment of proliferative

diabetic retinopathy: clinical application of

Diabetic Retinopathy Study (DRS) findings.

DRS Report No.8. Opthalmology 1981;88:

5583-600.

9. The Diabetes Control and Complications Trial

Research Group. The effect of intensive

treatment of diabetes on the development and

progression of long-term complications in

insulin-dependent diabetes mellitus. N Engl J

Med 1993;329(14):977-86.

10. Knowler WC, Barrett-Connor E, Fowler SE,

et al. Reduction in the incidence of type 2

diabetes with lifestyle intervention or metformin.

N Engl J Med 2002;346(6):393-403.

11. U.S. Department of Health and Human

Services. Healthy People 2010. Washington, DC:

U.S. Department of Health and Human

Services, 2000.

12. UK Prospective Diabetes Study (UKPDS)

Group. Tight blood pressure control and risk of

macrovascular and microvascular complications

in type 2 diabetes: UKPDS 38. BMJ

1998;317(7160):703-13.

13. American Diabetes Association: Clinical practice

recommendations, 2002. Diabetes Care

2002;25(Suppl 1):S1-147.

14. Task Force on Community Preventive Services.

Strategies for reducing morbidity and mortality

from diabetes through health-care system

interventions and diabetes self-management

education in community settings. A report on

recommendations of the Task Force on

Community Preventive Services. MMWR

Recomm Rep 2001;50(RR16):1-15.

15. Committee on Quality Health Care in America,

Institute of Medicine. Crossing the Quality

Chasm: A New Health System for the 21st Century.

Washington, DC: National Academy Press,

2001.

16. Centers for Disease Control and Prevention. A

Diabetes Community Partnership Guide. Atlanta:

U.S. Department of Health and Human

Services, 1999.

17. Centers for Disease Control and Prevention,

Office of Communication and Division of

Diabetes Translation. CDCynergy 2001, Diabetes

Version (CD-ROM). Oak Ridge, TN: Oak Ridge

Institute for Science and Education (ORISE),

2001.

18. Centers for Disease Control and Prevention.

Framework for program evaluation in public

health. MMWR Recomm Rep 1999;48(RR-11):

1-40.

19. Lindholm L, Rosen M. What is the “golden

standard” for assessing population-based

interventions?—problems of dilution bias.

J Epidemiol Community Health 2000:54(8):

617-22.

20. Rossi P, Freeman H, Lipsey M. Evaluation: A

Systematic Approach, 6th Edition. Thousand

Oaks, CA: Sage Publications, 1999.

21. Vinicor F, Burton B, Foster B, Eastman R.

Healthy People 2010: Diabetes. Diabetes Care

2000;23(6):853-5.

22. Goodman R, Liburd L, Green-Phillips A. The

formation of a complex community program for

diabetes control: lessons learned from a case

study of Project DIRECT. J Public Health Manag

Pract 2001;7(3):19-29.

23. Bodenheimer T, Wagner E, Grumbach K.

Improving primary care for patients with chronic

illness. JAMA 2002;288(14):1775-9.

24. Wagner EH, Austin BT, Von Korff M.

Organizing care for patients with chronic illness.

Mibankl Q 1996;74(4):511-44.

21

A COMPREHENSIVE APPROACH TO CANCER PREVENTION

AND CONTROL: A VISION FOR THE FUTURE

TABLE OF CONTENTS

Introduction

Cancer Burden

Healthy People 2010 Cancer Objectives

Opportunities in Cancer Control

Primary, Secondary, and Tertiary Prevention

Essential Strategies and Interventions

Infrastructure to Support Programs

Program Management and Administration

Comprehensive Cancer Control Plans

Surveillance and Evaluation

Partnerships

Communications

National Leadership

Technical Resources

References

23

2

A COMPREHENSIVE APPROACH TO CANCER PREVENTION

AND CONTROL: A VISION FOR THE FUTURE

Introduction

Comprehensive cancer control is an integrated and

coordinated approach to reducing cancer incidence,

morbidity, and mortality through prevention, early

detection, treatment, rehabilitation, and palliation.

This comprehensive approach is based on the

premise that effective cancer control planning and

programming should address a continuum of

services, from primary prevention and early

detection through effective treatment, quality care,

and end-of-life services such as pain relief.

State, territorial, and tribal cancer control programs

should be comprehensive in the functions they

incorporate (e.g., basic and applied research,

surveillance, clinical services, health

communications). They should comprehensively

address all major types of cancer and the needs of all

population groups, while giving special emphasis to

the needs of groups disproportionately affected by

cancer. Finally, they should be comprehensive in

recruiting a wide base of partners and in

coordinating the efforts of these partners in

developing and implementing a cancer prevention

and control plan that all stakeholders can embrace.

Agencies can expect to face numerous issues as they

work to develop comprehensive cancer control

programs. These include

• Establishing an effective infrastructure (i.e.,

administrative and organizational systems).

• Obtaining adequate resources (e.g., staff, funding)

for cancer control.

• Accessing sufficient cancer data (e.g., incidence

data, treatment data) to make informed program

decisions.

• Coordinating cancer control efforts.

• Reducing racial and ethnic disparities in cancer

burden and in access to appropriate treatment.

• Conducting ongoing evaluations of program

effectiveness.

Cancer Burden

The American Cancer Society (ACS) estimates that,

in 2003, more than 556,500 Americans will die of

cancer—more than 1,500 people every day—and

that about 1,334,100 new cases of cancer will be

diagnosed.1 These estimates do not include

carcinoma in situ (except urinary bladder) or basal

and squamous cell skin cancers. Cancer is the second

leading cause of death in the United States,

accounting for one of four deaths. From 1950 to

1991, cancer death rates increased steadily. Rates

began to decline in 1991, largely because of a decline

in rates of lung cancer deaths.2

 However, the aging

and increasing size of the U.S. population will cause

the total number of cancer cases to double by 2050 if

current incidence rates remain steady.3

The National Cancer Institute (NCI) of the National

Institutes of Health (NIH) estimates that almost

nine million Americans with a history of cancer were

living in 1997; some were under treatment and some

were considered cured.4 The combined 5-year

survival rate for Americans with any type of cancer is

62%.1

The ACS estimates that cancers that can be detected

by screening account for about half of all new cancer

cases. If all these cancers were detected at a localized

stage through appropriate screening, the 5-year

survival rate would approach 95%.1 For these
24

PREVENTION STRATEGIES THAT WORK

reasons, the bulk of cancer prevention and control

research dollars are dedicated to the prevention and

early detection of these cancers.

African Americans have higher rates of many cancers

than other racial or ethnic groups. During 1992–

1999, the overall cancer incidence rate per 100,000

persons was 526.6 among African Americans, 480.4

among whites, 329.6 among Hispanics, 348.6

among Asian/Pacific Islanders, and 244.6 among

American Indians/Alaska Natives. Racial disparities

in outcomes are often even more pronounced than

disparities in incidence rates. For example, although

breast cancer is diagnosed more often in white

women, African American women are more likely to

die of the disease. The overall cancer mortality rate is

also about one-third higher among African

Americans than among whites.1

Mortality rates also vary by gender. The most recent

age-adjusted annual cancer death rates were 259.1

for U.S. men and 171.4 for U.S. women.3

Cancer’s financial costs are significant. NCI estimates

that cancers cost the nation more than $171.6

billion in 2002: $60.9 billion in direct medical costs

(i.e., expenditures for medical procedures and

services associated with treatment and care for

cancer), $15.5 billion in indirect morbidity costs

(such as the value of work disability and absenteeism

associated with cancer), and $95.2 billion for

indirect mortality costs (such as the cost of lost

productivity due to premature death). More than

half of all medical costs for cancer are estimated to be

for the treatment of breast, lung, prostate, and

colorectal cancers,4 again underscoring the

importance of directing prevention and early

detection activities toward these cancers.

The nonmonetary costs of cancer are also substantial

but cannot be adequately quantified. Cancer pain,

though usually manageable, can be a significant

problem, as can the discomfort of treatment and

damage to the cancer patient’s self-image. After

treatment for cancer, many people can continue an

active, vital life—but they must live with the fear

and uncertainty that the cancer might return. As one

cancer survivor commented, “the fear for me now,

eight and a half years out from my diagnosis, is

Table 1. Statistics for Selected Cancers

*ICD-9 = International Classification of Disease, 9th Revision.

Source: American Cancer Society, Cancer Facts and Figures, 2003 (Ref. 1).

Cancer Type

(ICD-9*)

No. of New

Cases

(est. for 2003)

No. of Deaths

(est. for 2003)

Five-Year

Survival

Rate (%)

All sites (140–239) 1,334,100 556,500 62

Breast (174) 212,600 40,200 97 (localized)

Prostate 220,900 28,900 97

Lung (162) 171,900 157,200 15

Colon (153) and

rectum (154)

 147,500 57,100 62
25

A COMPREHENSIVE APPROACH TO CANCER PREVENTION AND CONTROL: A VISION FOR THE FUTURE

generally background noise. Most of the time I am

not aware of it, yet it waits ready to pounce at the

slightest provocation.”5

 Because between eight and

nine million Americans have a history of cancer, the

toll of the disease is enormous no matter how the

burden is calculated.

Healthy People 2010 Cancer Objectives

Healthy People (HP) 2010,6 which defines the

nation’s long-term health objectives, contains 15

health objectives in a chapter focusing on cancer and

additional related objectives in chapters on nutrition,

oral health, and tobacco. The overarching goal of

these objectives is to reduce the overall burden of

cancer and to eliminate racial and ethnic disparities

in cancer morbidity and mortality rates.

All cancer prevention and control programs are

encouraged to incorporate the goals of HP 2010 into

their program activities. The full text of HP 2010

can be found at www.healthypeople.gov.

Opportunities in Cancer Control

Primary, Secondary, and Tertiary Prevention

Many factors that contribute to cancer deaths are

preventable. It has been estimated that from 50% to

70% of cancer deaths are attributable to preventable

risk behaviors;7 30% of cancer deaths can be

attributed to tobacco use and more than 30% to

poor nutrition.8 Obviously, state and local programs

need to focus on such preventable risk factors.

Cancer prevention can be divided into three stages:

primary, secondary, and tertiary. Primary prevention

refers to the complete prevention of disease, often

through methods that inhibit exposure to risk

factors. The four most important risk factors for

cancer are tobacco use, lack of physical activity,

exposure to ultraviolet light, and poor nutrition.

Primary prevention is often used synonymously with

prevention.

Secondary prevention activities detect disease early

and limit disease effects after diagnosis. Outcomes

for patients with breast cancer, for example, can be

dramatically improved through early detection

followed by appropriate treatment.

Tertiary prevention involves preventing further

disability and restoring a higher level of functioning

in someone with a disease. Like secondary

prevention, tertiary prevention can involve

treatment; however, it also includes rehabilitation

and pain control. Even though cancer pain can be

relieved through proper therapies, the National

Cancer Institute suggests that the undertreatment of

pain is a serious and neglected public health

problem.9 To help alleviate this problem, programs

should work with medical partners to ensure that

cancer patients receive effective pain relief.

Local programs that are adopting a comprehensive

cancer approach need to work with partners to

ensure that patients with cancer receive appropriate

tertiary care. Prevention opportunities offered

through a particular intervention will vary

depending on the risk factor or stage of disease at

which the intervention is directed and the type of

cancer being addressed.

Essential Strategies and Interventions

Programmatic Interventions

Cancer prevention and control interventions can be

directed at individuals, at health care providers or

systems, or at organizations such as religious

institutions or employers. Rates of cancer-related

illness and death can be lowered by increasing public

awareness about cancer and its risk factors,

promoting behavior that decreases people’s cancer

risk, and providing people with better access to

cancer-related health care services.

Environmental and policy actions affect

communities, work places, homes, and schools,

influencing lifestyle choices that people make.

Environmental factors, defined broadly to include

smoking, diet, and infectious disease, as well as some

chemicals and radiation, are associated with perhaps

three-quarters of all cancer deaths in the United

States.1

 Strong regulatory controls and promotion of
26

PREVENTION STRATEGIES THAT WORK

safe occupational practices, in combination with

healthier individual lifestyle choices, can be effective

in reducing cancer incidence and mortality rates.

Policy and environmental interventions specific to

cancer risk factors, such as those that encourage

physical activity, good nutritional choices, or tobacco

use cessation, are especially useful in supporting

behavioral change among individuals. (See Chapter 4

on physical activity and nutrition and Chapter 5 on

tobacco use.)

Interventions important for the prevention and early

detection of cancer include those designed to reduce

the prevalence of smoking, reduce people’s

consumption of fat and increase their consumption

of fiber, increase people’s level of physical activity,

increase the percentage of women who undergo

regular breast cancer screening and Pap testing,

increase the proportion of the population over 50

years of age who are screened for colorectal cancer,

decrease people’s level of ultraviolet radiation

exposure, and encourage the use of appropriate stateof-the-art cancer treatment.

In The Guide to Community Preventive Services (also

called The Community Guide; available at

www.thecommunityguide.org), the Task Force on

Community Preventive Services recommends

specific evidence-based interventions for promoting

breast, cervical, and colorectal cancer screening;

preventing sun exposure and promoting skin

protection; and helping people make informed

decisions about screening for cancers. It also

identifies areas for future prevention research and

programming and includes chapters related to

tobacco control and physical activity. When

choosing or designing interventions, decision makers

should consider these evidence-based

recommendations as they examine their own needs,

goals, resources, and constraints.

The North Carolina example below provides a clear

model for how individual site-specific and riskfactor-specific interventions can be coordinated

within a framework that integrates surveillance,

communications, policy, and evaluation. Currently,

interventions implemented through cancer

prevention and control programs often overlap with

those implemented through other programs. A

comprehensive cancer control approach would foster

collaboration among such overlapping programs and,

as a result, potentially provide more effective

interventions at a lower cost.

Comprehensive Cancer Control Programs

in Action—North Carolina: North Carolina

has expanded its planning and coordination

efforts, developed and implemented the

statewide “Nutrition Challenge” campaign,

created professional education resources to

promote colorectal cancer screening,

developed a campaign to inform people about

clinical trials for cancer prevention and

control, enhanced its youth tobacco control

efforts, and designed a comprehensive

evaluation plan. These activities were selected

as funding priorities by the North Carolina

Advisory Committee on Cancer Coordination

and Control. (www.nccancer.org/

ccplan06.htm )

Using Data and Research Results to Design Interventions

Accurate and complete data and solid research form

the underpinnings for comprehensive cancer control.

They help planners to understand the extent of the

cancer burden and the existing infrastructure to

address that burden. Data and research help ensure

that politically popular strategies are also sound.

Because a major goal of public health is to translate

research into effective practice, partners should be

encouraged to participate in the data review process,

reviewing data that document the burden of cancer

and its costs in human and monetary terms.

Information useful in assessing and addressing

(through interventions) cancer burden include data

derived from basic and applied research; data on the

relevance, efficacy, and cost-effectiveness of possible

intervention strategies; and data on the existing or

developing capacity to implement effective
27

A COMPREHENSIVE APPROACH TO CANCER PREVENTION AND CONTROL: A VISION FOR THE FUTURE

interventions. Such data should help programs select

relevant and affordable intervention strategies that

they can tailor to priority populations and

implement successfully. When incorporated into an

organization’s comprehensive cancer control plan,

these strategies will provide all stakeholders with a

blueprint for action to address the cancer burden.

A comprehensive cancer control plan should be

reviewed on a specified, routine basis to determine

whether its objectives are being met and whether

program activities should be redirected. Supervising

officials should ensure that evaluation activities are

useful, feasible, accurate, and ethical. A detailed

discussion of how to conduct program evaluations

can be found in “Framework for program evaluation

in public health.”10 This document can be accessed at

www.cdc.gov/eval/framework.htm.

Opportunities for the Prevention and Control of Selected Cancers

Five cancers have been chosen for discussion because

of 1) their importance in new cancer cases and

cancer deaths (breast, colorectal, and prostate), 2) the

ability to detect them early through screening

(breast, cervical, and colorectal), 3) their increasing

prevalence (melanoma), and 4) their potential for 5-

year survival with early diagnosis (cervical and

prostate).

Breast Cancer Interventions

Breast cancer is the most common type of

nondermatologic cancer among women in the

United States. Because opportunities for the primary

prevention of breast cancer are limited, we encourage

public health practitioners to focus on secondary

prevention (i.e., on early detection and appropriate

treatment). Regular use of screening mammograms

can help reduce the risk of dying of breast cancer.

For women aged 50–69, strong evidence indicates

that screening lowers this risk by 30%. For women

in their 40s, the risk can be reduced by about 17%.7

The 5-year survival rate for women with localized,

early-stage breast cancer is excellent—97%.1

A number of states have state- and CDC-funded

programs to encourage breast cancer screening. An

example of a nationwide program is the CDCfunded National Breast and Cervical Cancer Early

Detection Program (NBCCEDP; information is

available at www.cdc.gov/cancer/nbccedp/

index.htm). Through this program, CDC and its

partners in state, tribal, and territorial health

agencies provide low-income, uninsured, or

underinsured women free or low-cost breast and

Comprehensive Cancer Control Programs

in Action—West Virginia: In addition to

using data from the Cancer Registry and the

Behavioral Risk Factor Surveillance System,

West Virginia’s Comprehensive Cancer

Control Coalition has used the nationwide

oncology outcomes database of the American

College of Surgeons to describe patient-care

patterns and has used evaluation studies and

marketing data (such as the NCI Consumer

Health Profiles) to help plan intervention

programs. (www.cdc.gov/cancer/ncccp/

contacts/wv.htm)

Evaluation data, the means by which the

effectiveness of programs are measured, provide

feedback for ongoing refinement of the program

planning and implementation process. Core

evaluation activities include surveillance (i.e.,

identifying and monitoring cancer and risk factor

trends in the general population and cancer-burden

disparities among groups of people) and the

collection of data measuring the process and

outcomes of program activities.

Comprehensive Cancer Control Programs

in Action—Illinois: To select priorities for its

comprehensive cancer plan, the Illinois state

health department and its cancer control

partners created several work groups. These

work groups submitted priorities for their

respective areas to the partnership. These were

collapsed into six overarching priorities for the

state cancer plan. For each priority, one or

more related strategies, each involving

multiple recommended activities, were

approved by the partnership. (www.cdc.gov/

cancer/ncccp/contacts/il.htm)
28

PREVENTION STRATEGIES THAT WORK

cervical cancer screening. The program operates in

all 50 states, the District of Columbia, 6 U.S.

territories, and 14 American Indian/Alaska Native

tribal organizations.

Cancer support groups, such as the American Cancer

Society’s Reach to Recovery program, are often a

valuable resource for women being treated for breast

cancer, as well as for their families and friends.

Cervical Cancer Interventions

Cervical cancer is not common in the United States.

Although the incidence rate has leveled off in the last

few years, until then incidence and mortality rates

had both decreased steadily for 50 years. A major

reason for these decreases is the widespread use of

screening for cervical cancer with the Pap test. As a

result, preinvasive lesions of the cervix are detected

more frequently than invasive cancer.1

The annual cervical cancer incidence rate among

African American women is still substantially higher

than that among white women (13.9 versus 8.8 per

100,000 in 1999).11 Health officials should institute

screening programs and, to reduce this disparity,

behavioral change interventions that target

underserved African American populations.

Behaviors to be promoted include limiting one’s

number of sex partners, delaying sexual intercourse,

using condoms, and avoiding tobacco products.

Cervical cancer screening is often offered through

programs that provide both breast and cervical

cancer education and screening services. The

NBCCEDP, discussed in the previous section, is an

example of a nationwide screening program that

addresses cervical cancer. A goal of the NBCCEDP is

to identify those women who have not had a Pap test

in at least 5 years. Sixty percent of women diagnosed

with cervical cancer are in this group, and many of

them have a poor prognosis; however, women whose

cervical cancer is diagnosed and treated early have a

5-year survival rate of 92%.1

Colorectal Cancer Interventions

Colorectal cancer is the second most common

nondermatologic cancer in the United States.

Definite risk factors for colorectal cancer include a

personal or family history of colorectal cancer, colon

polyps, or inflammatory bowel disease. Other

potential risk factors include smoking, physical

inactivity, a high-fat and/or low-fiber diet, alcohol

consumption, and low intake of fruits and

vegetables.

The number of deaths from colorectal cancer and the

incidence of the disease can both be reduced by

detecting and removing precancerous polyps and by

detecting and treating the cancer in its early stages.

Precancerous polyps can be present in the colon for

years before invasive cancer develops. The 5-year

survival rate for patients with colorectal cancer (all

stages) is 62%.1

One way to promote colorectal cancer screening

nationwide is by educating health care providers and

the public about the benefits of screening, the

availability of screening procedures, and current

screening guidelines.

Prostate Cancer Interventions

Other than skin cancer, prostate cancer is the most

commonly diagnosed form of cancer among men in

Comprehensive Cancer Control Programs

in Action—Nebraska: To help ensure

diagnosis and treatment for women with

breast or cervical cancer, Nebraska’s Every

Woman Matters program collaborates with

the Junior League of Omaha and the Susan G.

Komen Foundation to sponsor the annual

Race for the Cure and associated activities,

with the proceeds going to the program. The

Breast and Cervical Cancer Advisory

Committee also does fundraising, and

providers throughout the state have donated

their services to women who could not

otherwise afford screening. (www.cdc.gov/

cancer/ncccp/contacts/ne.htm)
29

A COMPREHENSIVE APPROACH TO CANCER PREVENTION AND CONTROL: A VISION FOR THE FUTURE

the United States and is second only to lung cancer

as a cause of cancer-related death among men. Age,

race, ethnicity, and family history are all significantly

associated with risk for prostate cancer. The

incidence of prostate cancer is substantially higher

among African American men than among white

men (229.3 versus 152.3 per 100,000 in 1999).11

Medical and public health experts agree that every

man needs balanced information on the pros and

cons of prostate cancer screening to help him make

an informed decision. Balanced information is

important because medical experts disagree about

whether men should be screened regularly for

prostate cancer.

Those who encourage regular screening believe

current scientific evidence shows that finding and

treating prostate cancer early, when treatment might

be more effective, may save lives. They recommend

that all men who have a life expectancy of at least 10

years should be offered the prostate-specific antigen

blood test and digital rectal examination annually

beginning at age 50. They also recommend offering

screening tests earlier to men at higher risk for

prostate cancer, specifically African American men

and men who have a father or brother with prostate

cancer. They do not recommend routine screening,

but instead using a form of shared decision-making.

Those who do not recommend regular screening want

convincing evidence that finding early-stage prostate

cancer and treating it is beneficial. They believe that

some of these cancers detected by screening may never

affect a man’s health and that treating them could

cause temporary or long-lasting side effects such as

impotence and incontinence. Because they believe it is

unclear if the potential benefits of screening outweigh

the known side effects of screening and treatment,

they recommend that all men be given information on

the pros and cons of screening before making their

own screening decision.

Results from clinical trials that are currently

underway are expected in 5 to 10 years, and these

results will help to clarify guidance about prostate

screening. Each man must make his own decision

about prostate cancer screening in consultation with

his physician. This decision should be based on an

understanding of his own risk factors and the risks

and benefits of screening and the alternatives.

Skin Cancer Interventions

Among Americans, more than 1 million cases of the

highly curable basal cell or squamous cell cancers are

diagnosed each year. The American Cancer Society

estimates that melanoma, the most serious form of

skin cancer, will be diagnosed in over 54,000 people

in 2003.1

 However, even melanoma is treatable if

detected early: the 5-year survival rate of patients

with localized melanoma is 96%.1

Risk factors for skin cancer include excessive

exposure to ultraviolet radiation, fair complexion,

occupational exposure to certain chemicals, a family

history of skin cancer, and multiple or atypical

moles. Strategies to help prevent skin cancer include

limiting or avoiding exposure to the sun during the

midday hours, covering the skin when outdoors, and

using a sunscreen with a sun protection factor (SPF)

of 15 or greater. Because of the possible link between

severe sunburns during childhood and risk for

melanoma in later life, children, in particular, should

be encouraged to avoid excessive sun exposure.

Infrastructure to Support Programs

Program Management and Administration

Building infrastructure is a critical activity in any

comprehensive approach to cancer prevention and

control. Such infrastructure, including staff, funding,

and in-kind support from partners, must be

adequate to support the implementation of program

activities.

To build an effective infrastructure for a

comprehensive cancer prevention and control

program, the coordinating agency should provide at

least a full-time coordinator and preferably several

dedicated staff positions. Because of the importance

of cancer data for identifying problems, evaluating

programs, and making decisions, the core planning
30

PREVENTION STRATEGIES THAT WORK

team for any comprehensive cancer control program

should include cancer registry personnel as well as

people with expertise in evaluation and epidemiology

both from within and outside the health department.

Comprehensive Cancer Control Plans

Essential Elements for Developing/Expanding

Comprehensive Cancer Control Programs

(www.cdc.gov/cancer/ncccp/elements/index.htm)

uses case studies to illustrate barriers to fully

implementing comprehensive approaches and

provide examples of successful comprehensive

programs. CDC’s Guidance for Cancer Control

Planning (www.cdc.gov/cancer/ncccp/index.htm)

also suggests specific activities (called building blocks

for comprehensive cancer control planning) to help

public health agencies and their partners develop a

comprehensive cancer control plan and establish a

comprehensive cancer control program. These

building blocks are presented graphically in Figure 1.

Estimates of the time needed to complete the

activities suggested in the building block model

range up to 2 years.

A comprehensive cancer control plan that is

thorough, integrated, and realistic will provide

participating organizations with a detailed outline of

what each is doing and allow for better coordination

of activities. Comprehensive cancer control plans

should

• Include a population-based assessment of the

cancer burden in the jurisdiction.

• Include short-term and long-term goals,

measurable objectives, proposed strategies for

Figure 1: Building Blocks of Comprehensive Cancer Control Planning

T

H

E 

P

L

A

N

C

O

P

L

E

T

E

D

R

E

V

I

E

W

E

D

D

I

S

S

E

M

I

N

A

T

E

D

Build 

Partnerships

Agree on goals, 

vision and 

decision-making 

process with 

partners

Establish 

partnership 

leadership

Create 

work 

groups

Assess partner 

satisfaction

Prepare for 

first 

partnership 

meeting

Assess 

partner 

interest and 

capacity 

Identify, 

contact, and 

invite 

potential 

partners

Develop ways for new members to 

join & nonmembers to 

provide input

ïOriginal members remain 

committed as new members 

join.

ïPartnership/subcommittee 

meetings held and 

attended.

Build 

Partnerships

Agree on goals, 

vision and 

decision-making 

process with 

partners

Establish 

partnership 

leadership

Create 

work 

groups

Assess partner 

satisfaction

Prepare for 

first 

partnership 

meeting

Assess 

partner 

interest and 

capacity 

Identify, 

contact, and 

invite 

potential 

partners

Develop ways for new members to 

join & nonmembers to 

provide input

ïOriginal members remain 

committed as new members 

join.

ïPartnership/subcommittee 

meetings held and 

attended.

Enhance 

Infrastructure

ïManagement and 

administrative structures 

and procedures developed.

ïPlanning products 

produced, disseminated 

and archived

Create core 

planning 

team 

Develop work 

plan to guide 

the planning 

process

Identify/ hire 

dedicated 

coordinator/ 

staff

Gain buy-in 

from leadership 

of coordinating 

agency

Coordinate and 

monitor the 

CCC process 

staff 

Involve other 

cancer-related 

staff of the 

coordinating 

agency/ies 

Assess 

infrastructure 

needs and 

capacity

Enhance 

Infrastructure

ïManagement and 

administrative structures 

and procedures developed.

ïPlanning products 

produced, disseminated 

and archived

Create core 

planning 

team 

Develop work 

plan to guide 

the planning 

process

Identify/ hire 

dedicated 

coordinator/ 

staff

Gain buy-in 

from leadership 

of coordinating 

agency

Coordinate and 

monitor the 

CCC process 

staff 

Involve other 

cancer-related 

staff of the 

coordinating 

agency/ies 

Assess 

infrastructure 

needs and 

capacity

Build linkages 

to registry and 

other data 

agencies and 

sources 

Identify 

available 

data/ 

research 

Assess data 

gaps

Collect needed 

data if feasible 

&/or incorporate 

into Plan

Review data and 

research as the 

basis for Plan 

objectives and 

strategies 

Utilize

Data/Research

Identify or collect 

baseline data 

against which to 

measure outcomes

ïPlanning and research 

data reviewed for needs 

assessment and strategy 

development

ïData/research gaps 

identified

Build linkages 

to registry and 

other data 

agencies and 

sources 

Identify 

available 

data/ 

research 

Assess data 

gaps

Collect needed 

data if feasible 

&/or incorporate 

into Plan

Review data and 

research as the 

basis for Plan 

objectives and 

strategies 

Utilize

Data/Research

Identify or collect 

baseline data 

against which to 

measure outcomes

ïPlanning and research 

data reviewed for needs 

assessment and strategy 

development

ïData/research gaps 

identified

Organize 

partnership 

around 

areas of 

interest

Assess 

gaps in 

strategies 

already in 

place

Prioritize 

goals, 

objectives 

and 

strategies

Identify 

possible 

intervention 

strategies

Determine 

critical areas 

of burden and 

high-risk 

populations

Assess/ 

Address 

Cancer Burden

Create 

measurable 

goals and 

objectives 

for plan

Identify 

implementing 

organizations 

for plan 

strategies

ïTarget areas for cancer 

prevention and control 

selected and prioritized.

Organize 

partnership 

around 

areas of 

interest

Assess 

gaps in 

strategies 

already in 

place

Prioritize 

goals, 

objectives 

and 

strategies

Identify 

possible 

intervention 

strategies

Determine 

critical areas 

of burden and 

high-risk 

populations

Assess/ 

Address 

Cancer Burden

Create 

measurable 

goals and 

objectives 

for plan

Identify 

implementing 

organizations 

for plan 

strategies

ïTarget areas for cancer 

prevention and control 

selected and prioritized.

Mobilize 

Support

(funding, resources, 

political will etc.)

ïPartnership develops 

priorities for allocation of 

existing resources

ïGaps in resources and 

level of support identified

Build support among 

the public and 

private sectors

Reassess partnership 

representation and 

coverage for 

implementation

Secure funds 

and in-kind 

resources for 

planning 

Develop approaches 

for funding plan 

strategies

Publicize efforts 

of the partnership 

Assess 

current 

level of 

support 

Mobilize 

Support

(funding, resources, 

political will etc.)

ïPartnership develops 

priorities for allocation of 

existing resources

ïGaps in resources and 

level of support identified

Build support among 

the public and 

private sectors

Reassess partnership 

representation and 

coverage for 

implementation

Secure funds 

and in-kind 

resources for 

planning 

Develop approaches 

for funding plan 

strategies

Publicize efforts 

of the partnership 

Assess 

current 

level of 

support 

ïA strategy for assessing 

planning process, 

monitoring implementation, 

and measuring outcomes in 

place.

Conduct 

Evaluation

Provide TA/ 

training on 

evaluation to 

partners

Identify 

resources 

and staff for 

evaluation

Identify emerging 

challenges, 

solutions, and 

outcomes of the 

planning process

Create 

evaluation plan 

for 

implementation

Document 

the planning 

process

Define planning 

evaluation 

questions

ïA strategy for assessing 

planning process, 

monitoring implementation, 

and measuring outcomes in 

place.

Conduct 

Evaluation

Provide TA/ 

training on 

evaluation to 

partners

Identify 

resources 

and staff for 

evaluation

Identify emerging 

challenges, 

solutions, and 

outcomes of the 

planning process

Create 

evaluation plan 

for 

implementation

Document 

the planning 

process

Define planning 

evaluation 

questions

Objectives Planning Activities Outcomes Planning 

Goal
31

A COMPREHENSIVE APPROACH TO CANCER PREVENTION AND CONTROL: A VISION FOR THE FUTURE

reducing the cancer burden, and a plan for

evaluating the effectiveness of proposed

interventions.

• Be created with diverse partners, inside and

outside the health department, who are

committed to achieving the goals and objectives of

the plan.

• Address cancer-related issues across a continuum

of care, including those associated with primary

prevention, early detection, treatment,

rehabilitation, pain relief, and survivorship.

Comprehensive Cancer Control Programs

in Action—Kentucky: To define its priorities

and select targets for intervention, the

Kentucky Cancer Program administered a

needs survey to cancer stakeholders

throughout the state. It then used data from

this survey and from a review of existing

categorical plans and of Healthy Kentuckians

2010 goals to develop a plan that contains 14

recommended actions and from one to four

priority strategies for executing each of them.

(www.cdc.gov/cancer/ncccp/contacts/ky.htm)

Surveillance System (BRFSS, www.cdc.gov/brfss);

state cancer registries supported by CDC’s National

Program of Cancer Registries (NPCR, www.cdc.gov/

cancer/npcr/register.htm); cancer registries

participating in NCI’s Surveillance, Epidemiology,

and End Results (SEER) program

(www.seer.cancer.gov); and United States Cancer

Statistics: 1999 Incidence (www.cdc.gov/cancer/npcr),

a joint publication of CDC and NCI in

collaboration with the North American Association

of Central Cancer Registries, which contains the first

set of official cancer incidence statistics from states

that meet high-quality data standards, as well as

statistics on more than 1 million invasive cancer

cases diagnosed during 1999 in residents of 37 states,

6 metropolitan areas, and the District of

Columbia—geographic areas in which approximately

78% of the U.S. population resides. Another data

source is the National Breast and Cervical Cancer

Early Detection Program (www.cdc.gov/cancer/

nbccedp/index.htm), which maintains program

records incorporating a set of standardized data

elements, called minimum data elements; these

records provide consistent and complete service and

outcome information on women screened by the

program. Cancer control programs should also

Surveillance and Evaluation

Using Data and Research

The commitment of participants in comprehensive

cancer control planning will be substantially

influenced by the quality of the data on which the

planning is based.

To evaluate their effectiveness, comprehensive cancer

control programs need an established mechanism

with which to identify and track cancer case data,

including the extent of disease, the kinds of

treatment patients receive, and patient outcomes

(death or survival). Such mechanisms also allow

them to monitor overall changes in disease and riskfactor rates as well as changes within specified

geographic areas and populations.

Sources of data on cancer-related deaths, cancer

incidence, and cancer screening include vital records;

cancer registries; the Behavioral Risk Factor

Comprehensive Cancer Control Programs

in Action—Northwest Portland Area Indian

Health Board: Although American Indians/

Alaska Natives are generally thought to have

disproportionately high cancer incidence and

mortality rates, official rates tend to be

underestimated because many health registries

do not accurately code race. Using record

linkages between the Northwest Tribal

Registry and state health registries, the

Northwest Tribal Registry showed that the

true incidence of cancer among its tribal

members was 267.5 per 100,000 population

rather than 153.5 per 100,000 as previously

reported. These more accurate data gave the

board the factual support it needed in arguing

for additional cancer control resources.

(www.npaihb.org/cancer/ntccp.html)
32

PREVENTION STRATEGIES THAT WORK

incorporate data collection activities into their own

plans.

Conducting Evaluations

Stakeholders should be involved in the entire

evaluation process, including describing program

processes and defining program activities and

expected results. By collaborating to define specific

activities and the results they should achieve,

partners will have a common basis for understanding

evaluation plans, activities, and results.

Evaluations should include both quantitative and

qualitative measures and should address short-term,

intermediate, and long-term outcomes. The planning

group should build evaluation processes into the

program itself rather than consider evaluation

activities as separate from program activities and

should identify resources necessary for evaluation early

in the planning process. Some agencies have in-house

evaluation staff, while others obtain help from

partners or through contracts with local colleges or

universities. The Community Toolbox

(www.ctb.lsi.ukans.edu) is another resource that can

help agencies monitor their comprehensive cancer

prevention and control activities.

Comprehensive cancer control programs should

monitor the cancer-related indicators defined in

Indicators for Chronic Disease Surveillance: Consensus

of CSTE, ASTCDPD, and CDC, which is available at

www.cste.org. These indicators provide a common

set of measures for chronic disease surveillance that

program planners can use to establish priorities and

implement surveillance activities consistent with

those in other jurisdictions.

Contained in this consensus document are

surveillance indicators specific to cancer. These

indicators include the incidence and rate of death

attributable to the following types of cancer: lung,

colon/rectum, female breast, prostate, cervix, bladder

(in situ included), melanoma, and oral cavity/

pharynx, as well as overall rates for all types

combined. The document also includes indicators

related to screening for colorectal, cervical, and

female breast cancers. These indicators closely mirror

several of the Healthy People 2010 objectives.

Evaluation questions should be designed to identify

those issues most pertinent to stakeholders. Care

should be taken to select questions that can be

readily answered with available evaluation resources.

Examples of evaluation questions that can be asked

at different stages in an evaluation process are shown

in Table 2.

Partnerships

To create a fully comprehensive approach to cancer

prevention and control, organizations must work

synergistically with others involved with similar

activities. Collaboration is key to a comprehensive

effort.

In most of the examples presented in this section,

health department staff serve as core members of

comprehensive cancer control programs; however,

the staffing pattern can vary, as can the “lead”

responsibility for the program. Participating

organizations can work semi-independently to

implement plan activities as long as they keep the

Comprehensive Cancer Control Programs

in Action—Michigan: Comprehensive cancer

control in Michigan is guided by the Michigan

Cancer Consortium, an advisory body to the

state health department and to all other cancer

control players in the state. The consortium,

which includes cancer experts and other

representatives from more than 70 member

organizations, provides leadership for decisionmaking and a forum to coordinate achievement

of priority objectives in its comprehensive state

plan. The representatives from these agencies are

often in a position to influence cancer control

policy within their own organization as well as

within the consortium. (www.michigan.gov/

documents/MCCIPlan_6718_7.pdf;

www.michigan.gov/mdch/0,1607,7-132-

2940_2955_2975-13561--,00.html#priorities)
33

A COMPREHENSIVE APPROACH TO CANCER PREVENTION AND CONTROL: A VISION FOR THE FUTURE

Table 2. Sample Evaluation Questions for Comprehensive Cancer Control

Evaluation Level Evaluation Questions

•Is the comprehensive cancer control process working well?

 Are members satisfied with the process?

 Are planning tasks being accomplished and are planning products being

 produced in a timely manner?

 

 

Process Evaluation 

of Program

•Are the partnership’s overarching goals and objectives being achieved?

 Is infrastructure for cancer control being enhanced?

 Is support for the initiative being mobilized?

 Are data and research being utilized?

 Are partnerships being built?

 Is the cancer burden being assessed? Addressed?

 Are the planning process and outcomes being evaluated? 

Outcome Evaluation

of Program

•Are strategies proposed in the plan being implemented?

 Are knowledge gaps being addressed through surveillance and research?

•Are interventions being delivered— 

 To subpopulations with high risk and high burden?

 In a culturally appropriate manner?

 In a timely manner?

 In a cost effective manner?

•Are implementation difficulties being successfully overcome?

Process Evaluation

of Plan

 • Are the outcomes anticipated by the partnership for each strategy

 being achieved?

 Has the baseline problem status identified by partners improved?

 Have intermediate measures of behavior such as cancer screening rates 

 or rates of various risk behaviors changed?

 Over time, has cancer incidence, morbidity, and mortality from cancer

 decreased?

 Over time, have health disparities related to cancer among

 subpopulations decreased?

Outcome Evaluation

of Plan

Source: Adapted from CDC’s Guidance for Comprehensive Cancer Control Planning. (Avalable at www.cdc.gov/cancer/ncccp/index.htm.)
34

PREVENTION STRATEGIES THAT WORK

planning group (and thus other participating

organizations) informed of what they are doing.

Early in the planning process, agencies should

identify and solicit the help of partners able to

support their efforts. Possible partners include

• Representatives of organizations likely to

implement plan strategies.

• Legislators who can provide political and

legislative support.

• Representatives of priority populations who can

suggest health-promoting strategies and

interventions appropriate for those populations.

• Representatives of organizations that may be able

to fund activities or that will be doing similar

activities under other sponsorship.

To reach specific priority populations, cancer control

programs should also seek community partners who

can help them create culturally sensitive messages

and programs.

As comprehensive cancer control projects move from

the planning stage to the implementation stage, what

might have begun as a loose network of

organizations and individuals should be forged into a

fully functioning collaborative capable of significant

advocacy, coordination, and action. To ensure the

continued involvement of committed partners,

project leaders should work to identify and recruit

new partners, involve partners in decision-making

processes and planning activities, and regularly assess

the satisfaction and commitment of partners.

Samples of state-developed tools, including a

planning meeting invitation letter and registration

form, a partner interest survey and commitment

form, a partner questionnaire, and a proposed

process for creating a comprehensive cancer control

plan can be found in Guidance for Comprehensive

Cancer Control Planning (www.cdc.gov/cancer/

ncccp/index.htm).

Comprehensive Cancer Control Programs

in Action—West Virginia: As an initial step

in the planning process to establish a

comprehensive cancer control program in

West Virginia, representatives of four

founding organizations (the West Virginia

Breast and Cervical Cancer Screening

Program, the Office of Epidemiology and

Health Promotion in the West Virginia

Bureau of Public Health, The American

Cancer Society’s Mid-Atlantic Division, and

the Mary Babb Randolph Cancer Center of

West Virginia University) began efforts to

promote the concept of comprehensive cancer

control and to generate interest from a diverse

group of potential coalition stakeholders.

Now, more than 120 individuals and

organizations make up the membership of

Mountains of Hope, the state’s comprehensive

cancer control coalition. (www.cdc.gov/

cancer/ncccp/contacts/wv.htm)

Comprehensive Cancer Control Programs

in Action—Colorado: In June 2001,

Colorado launched a public education

campaign that included a special brochure,

“Sun Smart Tips.” The goal of this campaign

was to educate visitors to Colorado’s state and

national parks about the need to protect

themselves from the damaging rays of the sun.

This campaign resulted from a unique

partnership among national park officials and

the state health department. Working

together, Colorado’s Comprehensive Cancer

Prevention and Control Program, the Mesa

Verde National Park, and park concessioners

educated Colorado residents, as well as visitors

from all over the world, about the easy steps

they can take to prevent skin cancer.

(www.cdphe.state.co.us/pp/ccpc/

CancerPlan.pdf)
35

A COMPREHENSIVE APPROACH TO CANCER PREVENTION AND CONTROL: A VISION FOR THE FUTURE

Communications

A solid health communications strategy is essential to

successful interventions. For comprehensive cancer

control, this strategy should entail an integrated and

coordinated approach to educating the public,

government leaders, health care providers, and others

about cancer and its risk factors and how best to

prevent, detect, and treat the disease. Health

communications strategies should be coordinated as

much as possible with other program initiatives such

as improving health care service delivery and creating

supportive public policies.

Because everyone is at risk for cancer, cancer

messages are needed for all population groups.

However, each message should be tailored for a

specific, targeted audience (e.g., people with a certain

form of cancer, members of a specific racial or ethnic

group, members of professional and health

organizations). Messages should be accurate, use

consistent terminology, and describe what people can

do to help reduce their risk for cancer, detect it in its

early stages, and obtain appropriate treatment if

cancer is diagnosed.

Health communications activities should be part of a

larger plan to address factors affecting behavior (e.g.,

social norms, governmental policies). In developing

their communication plan, states should

• Identify and define the health problem they want

to address.

• Incorporate an evaluation component into the

communications plan.

• Be culturally sensitive in developing strategies and

messages, conducting research, and implementing

and evaluating communications efforts.

• Ensure that the targeted audience receives a single,

simple, specific, and consistent message.

• Conduct qualitative and quantitative audience

research to help understand how the audience

perceives concepts and to determine their

willingness and ability to do what is being asked.

In addition to conducting formative research and

pretesting concepts and messages, health

Members of partner organizations often

participate in important work groups. Following

are three examples of how work groups have

contributed to state cancer control efforts:

Comprehensive Cancer Control Programs in

Action—Arkansas: In Arkansas, work groups

were organized around the structure of the

state cancer control plan. Three separate

groups each developed a chapter for the plan:

these chapters included an introduction on

cancer in the state, a background section

containing in-depth statistics, and a chapter on

strategic options. Other work groups included

an implementation team (which will become

more active as the plan is finished), an

evaluation team, and a communication team.

(www.healthyarkansas.com/disease/

cancerplan.pdf )

Comprehensive Cancer Control Programs in

Action—Kansas: In Kansas, cancer sitespecific work groups developed priorities for

breast, cervical, skin, colorectal, prostate, and

lung cancers. In addition, two crosscutting

work groups developed priorities in the areas of

cross-cultural competency and rehabilitation

and pain. (www.cdc.gov/cancer/ncccp/

contacts/ks.htm)

Comprehensive Cancer Control Programs in

Action—Maine: Maine provided its work

group members with both surveillance data

and research literature to help them develop

evidence-based goals, objectives, and strategies

for the state’s comprehensive cancer control

plan. At least one member organization of the

work group had to commit to a goal and its

related objectives before the goal could become

part of the plan. The Maine plan contains 18

goals and about 100 related objectives, each

with multiple related strategies, and each with

an organization accepting responsibility for its

implementation. (www.cdc.gov/cancer/ncccp/

contacts/me.htm)
36

PREVENTION STRATEGIES THAT WORK

communicators should monitor the effectiveness

of the communications campaign itself.

• Examine the wide range of actual and perceived

barriers to and incentives for healthy (and

unhealthy) behaviors and address them. Social

marketing provides a useful framework for

thinking about how to make behavior change

easier.

• Devise health communications messages capable

of competing effectively against possibly

conflicting “unhealthy” messages that people may

receive from other sources, including advertisers,

the music and entertainment industry, and family

and friends.

National Leadership

In 2000, the National Dialogue on Cancer

(www.ndoc.org) and partner organizations such as

CDC (cdc.gov/nccdphp/dcpc), ACS

(www.cancer.org), the Health Resources and Services

Administration (www.hrsa.gov), NCI

(www.nci.nih.gov), and the National Governor’s

Association (www.nga.org) began to accelerate the

development and implementation of comprehensive

cancer control plans at the state, tribal, and territory

level. These plans are to be based on research data

and stakeholder input and must establish clear lines

of responsibility and accountability.

NCI provides cancer information through

publications, reports, and its toll-free Cancer

Information Service (CIS). CIS is a national resource

for current, accurate cancer information for patients

and their families, the general public, and health

professionals. CIS is also a leader in translating

cancer information into terms the public can easily

understand. CIS reaches the medically underserved,

including minority groups and people with limited

access to health information and services, through

partnerships with state and regional organizations

that directly serve these audiences. For more

information, call 800-422-6237 or visit the CIS Web

site at http://cis.nci.nih.gov.

NCI also provides grant funds, supports training

programs for health professionals, and partners with

other academic and national organizations on

projects related to cancer prevention and control.

The American Cancer Society is a nationwide

community-based voluntary health organization

dedicated to eliminating cancer as a major health

problem by preventing cancer, saving lives, and

diminishing suffering from cancer through research,

education, advocacy, and service. It includes

chartered divisions throughout the country and over

3,400 local units.

Technical Resources

Several national public health organizations offer

training and technical assistance in cancer

surveillance, research, and intervention. The Web

sites of NCI (www.nci.nih.gov) and ACS

(www.cancer.org) are particularly good sources of

information and materials on various forms of cancer

and related issues. Numerous cancer-related

publications and materials can also be accessed at

www.cdc.gov/cancer.

References

1. American Cancer Society. Cancer Facts and

Figures, 2003. Atlanta: American Cancer Society,

2003.

2. Brownson RC, Reif JS, Alavanja MCR, Bal DG.

Cancer. In: Brownson RC, Remington P, Davis

JR, editors. Chronic Disease Epidemiology and

Control. Washington, D.C.: American Public

Health Association, 1998:335-73.

3. Edwards BK, Howe HL, Ries LAG, Thun MJ,

Rosenberg HM, Yancik R, et al. Annual report to

the nation on the status of cancer, 1973-1999,

featuring implications of age and aging on U.S.

cancer burden. Cancer 2002;94(10): 2767-92.

4. Brown ML, Lipscomb JL, Snyder C. The burden

of illness of cancer: Economic cost and quality of

life. Annu Rev Public Health 2001;22:91-113.
37

A COMPREHENSIVE APPROACH TO CANCER PREVENTION AND CONTROL: A VISION FOR THE FUTURE

5. Bowes A, Gingras TS, Kaplowitt BA, Perkins A,

editors. Unbearable Uncertainty. Northampton,

MA: Pioneer Valley Breast Cancer Network,

2000.

6. Department of Health and Human Services.

Healthy People 2010. 2nd ed. 2 vols. Washington,

D.C.: U.S. Government Printing Office, 2000.

7. National Cancer Institute, National Institutes of

Health. Cancer Progress Report 2001.

Washington, D.C.: Department of Health and

Human Services, 2001.

8. Doll R, Peto R. The Causes of Cancer:

Quantitative Estimates of Avoidable Risks of

Cancer in the United States Today. New York:

Oxford University Press, 1981.

9. National Cancer Institute. NCI Workshop on

Cancer Pain. September 14-15, 1990, Bethesda,

MD. As quoted in Department of Health and

Human Services. Management of Cancer Pain:

Clinical Practice Guideline. Rockville, MD:

Public Health Service, Agency for Health Care

Policy and Research, 1994.

10. Centers for Disease Control and Prevention.

Framework for program evaluation in public

health. MMWR Recomm Rep 1999;48:(RR11):1–40.

11. U.S. Cancer Statistics Working Group. United

States Cancer Statistics: 1999 Incidence. Atlanta:

Department of Health and Human Services,

2002.

39

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

TABLE OF CONTENTS

A National Approach for State Heart Disease and Stroke Prevention Programs

The Burden of Heart Disease and Stroke in the United States

Magnitude

Disparities

Costs

Healthy People 2010 : Heart Disease and Stroke

Public Health Opportunities

Health Promotion and Primary and Secondary Prevention

Essential Strategies: The Socioecological Approach

Interventions

Infrastructure To Support Heart Disease and Stroke Prevention Programs

Program Management and Administration

Surveillance and Evaluation

Partnerships

Strategic Plans

Policies

Health Communications

Professional Development, Training, and Technical Assistance

Supporting Evidence and Consensus Documents

National Leadership

Resources

References

41

3

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

The Burden of Heart Disease and Stroke in the

United States

Magnitude

Heart disease and stroke are the principal

components of cardiovascular disease (CVD), the

leading cause of death and disability among adults in

the United States.1 As the burden of heart disease

and stroke continues to grow, CVD is projected to

be the number one cause of death worldwide by the

year 2020. In 1999, the overall worldwide death rate

for CVD was 354.1 per 100,000 people: 303.2 per

100,000 women and 418.2 per 100,000 men.2 In

the United States, CVD affects 61.8 million

Americans and claims nearly 1 million lives annually.

More than one in five people has some form of

CVD,1 which affects people of all racial/ethnic

groups and ages. Although CVD death rates

decreased in the 1980s and 1990s, the actual

numbers of CVD-related deaths increased because of

increases in the number of older Americans. In

addition, the rate of decline in deaths from heart

disease and stroke has slowed significantly in recent

years. Meanwhile, hospitalizations for heart failure

have increased steadily since 1975.3, 4

In the United States, 1.1 million heart attacks occur

each year, and coronary heart disease causes more

than 515,000 deaths, or about one death every

minute. Almost half (250,000) of those who die of

coronary heart disease do not live to reach the

hospital. Of those who have a heart attack, 25% of

men and 38% of women will die within a year

despite medical and surgical interventions. Those

who survive longer are at high risk for a recurrent

heart attack and death and may have significant

discomfort and disability. Almost 150,000 of those

who die of CVD each year are younger than age 65,

and sudden or unexpected cardiac deaths among

young adults have increased in recent years.1

 Heart

failure is diagnosed for the first time in approximately 550,000 Americans each year, and more than

51,000 deaths annually are due to this condition.

In addition, the 700,000 strokes that occur each year

cause more than 167,000 deaths, or approximately

1 death every 3 minutes. Among survivors, 15%–

30% are permanently disabled.1

These CVD events and conditions are manifestations

of atherosclerosis, a disease process that often begins

in childhood and adolescence. The major risk factors

for atherosclerosis and its complications are high

total cholesterol and high blood pressure. Diabetes

also increases a person’s risk for CVD. These risks

arise from dietary imbalance (such as excessive intake

of animal fats and calories), physical inactivity, and

use of tobacco products. These underlying behavioral

risks and their health consequences are rooted in

social and environmental conditions that foster

unhealthy lifestyle choices. Therefore, populationbased approaches addressing policy and environmental change must be a major focus of a successful

national public health approach.

Disparities

In 2000, CVD was the leading cause of death among

both women and men in the United States. CVD

causes more deaths among women than among men,

in part because of the greater number of older

women in the population. African Americans are at

substantially higher risk for death from CVD than

are whites. This difference is attributable in part to a

greater risk for strokes and a higher prevalence of high

blood pressure among African Americans. For every
42

PREVENTION STRATEGIES THAT WORK

100,000 people, the rate of death from CVD was

509.6 for African American men, 397.6 for white

men, 397.1 for African American women, and 285.8

for white women. The rate of death due to high blood

pressure per 100,000 people was 46.3 for African

American men, 13.2 for white men, 40.8 for African

American women, and 13.1 for white women.1

Data indicate substantial disparities in risk factors for

CVD among racial and ethnic groups in the United

States (Table 1).1

 Risk behaviors and risk factors such

as obesity and diabetes are more prevalent among

African Americans and Mexican Americans than

among non-Hispanic whites. For example, physical

inactivity is higher among Mexican American

women (57%) and non-Hispanic African American

women (57%) than among non-Hispanic white

women (39%). These disparities undoubtedly

contribute to the substantially greater burden of

CVD among these two population groups.

Costs

The estimated cost of CVD to the nation is expected

to exceed $351 billion in 2003.1 The direct costs for

health care are projected to be $209.3 billion, while

lost productivity accounts for an additional $142.5

billion. One-quarter of the lost productivity amount

is due to disability that results in unemployment,

and three-quarters is due to premature death (death

before age 65).

These sobering figures can only be expected to

increase unless effective programs and policies are

implemented nationwide to reduce the burden of

CVD. Future cost increases will be created in part by

the aging of the population and by the growth of

ethnic minority populations at high risk for CVD.3

Advances in medical technology also can be expected

to increase the cost of services for each CVD event.

In addition to these financial costs, CVD creates

social costs to families and communities that cannot

be calculated.

If all major forms of CVD were eliminated, life

expectancy would be extended by almost 7 years.1 In

addition, Americans’ quality of life would be greatly

improved, and health care costs and dependency

would be substantially reduced.

Healthy People 2010: Heart Disease and Stroke

National health goals and objectives for the current

decade are published in Healthy People 2010 and

include those for heart disease and stroke in Chapter

12.5 The Centers for Disease Control and Prevention

(CDC) and the National Institutes of Health (NIH)

are co-leads for goals for heart disease and stroke.

The universal goals of Healthy People 2010 are to

improve the quality and increase the duration of

people’s lives and to eliminate disparities. The one

goal specific to preventing heart disease and stroke

has three components:

• Prevention, detection, and treatment of risk

factors.

• Early identification and treatment of heart attacks

and strokes.

• Prevention of recurrent cardiovascular events.

Focus area 12 of Healthy People 2010 has 16

objectives that address heart disease, congestive heart

failure, stroke, high blood pressure, and high total

blood cholesterol levels. Fortunately, because most

cardiovascular disease is preventable, much can be

done to lessen the burden of heart disease and stroke

and meet Healthy People 2010 objectives.

Other objectives relevant to heart disease and stroke

can be found in Healthy People 2010 focus areas

addressing chronic kidney disease, tobacco use,

access to quality health services, nutrition and

overweight, physical activity and fitness, and public

health infrastructure. This broad spectrum of goals

and objectives represents a wide range of

opportunities for prevention programs.

Public Health Opportunities

Health Promotion and Primary and Secondary Prevention

Preventive strategies, the traditional focus of public

health programs, should include overall health

promotion as well as primary and secondary prevention.
43

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

Health promotion targets the general population.

This strategy enables people to gain control over

the behaviors and conditions that affect their health

status. Educational campaigns to increase public

awareness of the signs and symptoms of heart attack

and stroke, policy changes to ensure universal 9-1-1

coverage, and policy and environmental changes that

support heart-healthy behaviors in the general population are examples of health promotion strategies.

Primary prevention targets people who are at

increased risk for a first CVD event because they

have one or more CVD risk factors. Guidelines from

the American Heart Association (AHA) and other

national organizations advocate for primary

prevention of CVD by addressing the risk factors of

high blood pressure, high cholesterol, tobacco use,

poor nutrition, physical inactivity, overweight and

obesity, and diabetes.

Secondary prevention targets populations with

established CVD to prevent recurrent events. These

strategies include ensuring compliance with guidelines on the use of aspirin, beta-blockers, ACE

inhibitors, anticoagulants, and other antiplatelet

agents. In addition, reducing risk factors through

lifestyle changes such as losing weight and quitting

smoking is an important strategy for secondary as

well as primary prevention.

Race/Ethnicityand Sex

Non-Hispanic

Whites

African

Americans 

Mexican

Americans

Risk Factors and

Conditions

Males Females Males Females Males Females

High blood pressure

High LDL-cholesterol

Smoking

d

Obesity

Diabetes

Physical Inactivity

36.7

46.3

26.1

44.1

28.1

7.6

20.5

43.7

21.6

36.2

30.1

4.7

25.2

49.6

25.8

32.5

27.3

5.4

36.6

41.6

20.8

55.2

49.7

9.5

24.2

43.6

24.1

48.9

28.9

8.1

22.4

41.6

12.3

57.4

39.7

11.4

a

f

e

c

b

Table 1. Prevalence of Risk Factors for CVD in the United States, by Race/Ethnicity and

Sex, American Heart Association, 2003

a

 Systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or on anti-hypertensive medication: age adjusted for people aged 20

and older.

b LDL-cholesterol ≥130 mg/dL: age adjusted for people aged 20 and older. c Among people aged 18 years and older.

d

 No leisure time activity among people aged 18 years and older.

e Body mass index ≥30 kg/m2

 among people aged 20 and older. f Physician-diagnosed diabetes: age adjusted for people aged 20 and older.

Source: Heart and Stroke Statistics—2003 Update.

1
44

PREVENTION STRATEGIES THAT WORK

Although other classification systems may include

tertiary prevention, our program groups this

prevention level with secondary prevention.

Essential Strategies: The Socioecological Approach

Because of the complexity of the CVD burden,

comprehensive programs are needed to reduce CVD

rates, eliminate disparities, and achieve the long-term

goals of Healthy People 2010. Key components of a

state heart disease and stroke prevention program

include the following:

• Promotion of cardiovascular health (CVH) to

prevent the development

of risk factors (e.g., high blood pressure, high

cholesterol, tobacco use, physical inactivity, and

poor nutrition) and conditions (e.g., diabetes

and obesity).

• Primary prevention of heart disease and stroke.

• Secondary prevention of heart disease and stroke.

• Elimination of health disparities for heart disease

and stroke.

• Heart-healthy policies and supportive

environmental changes.

• Programs in multiple settings: health care sites,

work sites, schools, and communities.

Research and experience indicate that health is connected to both the physical and social environment.

Individual behaviors are supported and reinforced in

numerous ways by legislation, regulations, organizational policies, social norms, and environments.

For this reason, a comprehensive and integrated

approach to promoting CVH and addressing CVD

requires not only education and increased awareness,

but also a major emphasis on environmental and

policy change at multiple levels of society. Changes

in policy and the social and physical environment are

necessary to foster and maintain individual-level

behavior change; for example, restricting young

people’s access to tobacco products will reduce the

likelihood that they will use tobacco.6

 Approaches

should address policy and environmental change in

multiple settings (e.g., health care sites, work sites,

schools, communities) to reach people throughout

their lives with a variety of messages and

interventions. The primary roles of state heart disease

and stroke prevention programs are to provide public

and professional education and training and to

facilitate policy and environmental changes. In

addition,

state heart disease and stroke prevention programs

should work with partners to ensure that they

provide appropriate interventions for behavior

change among individuals.

Policy and environmental approaches are part of

three core functions of public health: assessment,

policy development, and assurance. According to a

2001 Institute of Medicine report, “An understanding of the social factors influencing behavior is

growing and should be considered in programs and

policies for public health. Many social, economic,

political, and cultural factors are associated with

health and disease for which changes in individual

health behaviors alone are not likely to result in

improved health and quality of life...The law can

change the informational, physical, social, or

economic environment to facilitate healthier

behavior.”7 The report states that “program planners

and policy makers need to consider modifying social

and societal conditions to enable healthy behavior.

Use of population-based policy and environmental

strategies shifts public health from a direct service

role to one that focuses on guidance, agenda setting,

and coordination of CVH improvement efforts.”7

The socioecological approach is the basis for the

logic model for heart disease and stroke prevention

programs shown in Figure 1. The model depicts

relationships between actions (e.g., links between

environmental and policy changes and individuallevel behavior change) that are necessary to reduce

rates of CVD. Because logic models are often

cyclical, an outcome from one activity can provide

information that then feeds back into a previous

activity. Activities involve building capacity,

conducting surveillance, and developing/establishing

interventions. These activities influence changes that

lead to short-term outcomes such as the
45

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

development of a CVH plan, new strategies for

system-level changes, and more effective

implementation of interventions. These activities

and outcomes result in changes in policy and

environmental supports, changes in people’s

behavior, and eventually improvements in their

health.

The program logic model describes the program and

is a tool to guide program evaluation. By identifying

the steps necessary to reach intended outcomes, the

logic model indicates where emphasis should be

placed in evaluating the process and outcomes of the

program.

Interventions

Heart disease and stroke prevention program

interventions should address the population as a

whole while giving special attention to priority

populations (e.g., populations that the state

determines to be priority for CVH interventions on

the basis of such factors as rates of cardiovascular

disease and related risk factors, lack of access to

services, and socioeconomic levels). Interventions

should

• Be culturally appropriate.

• Use population-based strategies such as

environmental and policy changes.

• Increase education on and awareness of heart

disease and stroke issues among the public,

decision makers, and health care professionals.

• Monitor primary and secondary prevention

services to ensure the provision of quality care.

Programs should emphasize interventions and in

various settings (e.g., health care sites, work sites,

schools, community) in which policy or

environmental changes can produce substantial

health benefits. However, they should focus their

efforts at the highest level possible; for example,

activities should focus on business coalitions and

unions rather than individual work sites and on

managed care organizations and state medical

Figure 1. Logic Model for Heart Disease and Stroke Prevention Programs
46

PREVENTION STRATEGIES THAT WORK

associations rather than on individual health care

settings or physicians.

Population-based approaches can be disseminated

through various settings and groups. Policy and

environmental changes and education should be

used to make each setting more supportive of hearthealthy choices and ensure that it provides appropriate CVH promotion and CVD prevention and

control services. Settings in which policy and

environmental changes might be instituted include

the following:

• State-level and government settings (e.g., creating

smoke-free environments in state buildings,

requiring health care coverage that reimburses for

primary and secondary prevention services related

to CVD, providing high blood pressure

medication to people on limited incomes,

establishing statewide 9-1-1 coverage, requiring

training [e.g., protocols for working with stroke

patients for emergency medical staff], and

accrediting food services).

• Health care settings (e.g., implementing primary

and secondary prevention guidelines for heart

disease and stroke to ensure quality of care).

• Work sites (e.g., providing blood pressure

screening and monitoring, having staff trained on

use of CPR and AEDs, providing time for and

access to physical activities, establishing clean

indoor air policies, and offering heart-healthy food

options in cafeterias and vending machines).

• Schools (e.g., educating students about healthy

lifestyle choices, heart disease and stroke, and

CPR; providing heart-healthy school food choices;

and requiring schools to be tobacco-free).

• Communities (e.g., providing blood pressure

screening at all fire stations, ensuring 9-1-1

coverage, building parks).

In addition, the media can be used to increase public

awareness of the importance of CVH, the risk factors

for CVD, and the need for policy and environmental

changes. The media can also be instrumental in

educating the public about the signs and symptoms

of heart attack and stroke and when to call 9-1-1.

Key partners for implementing these activities should

include the American Heart Association (AHA),

state quality improvement organizations (QIOs),

and private health care providers and hospitals. The

state heart disease and stroke prevention program

should partner with its QIO to monitor secondary

prevention practices (e.g., aspirin and drug therapy,

physical activity regimens, and hypertension and

lipid management) and to help improve compliance

with secondary prevention guidelines. In collaboration with partners, it should also promote professional education and policy changes that support

efforts to implement the guidelines on primary and

secondary prevention. Providing blood pressure and

cholesterol screenings is not appropriate for the state

heart disease and stroke prevention program itself.

However, the state program should encourage partners to provide these services and ensure that health

care staff are trained in accurately measuring blood

pressure and in applying quality assurance standards.

Interventions should be coordinated with internal

and external partners to ensure that health messages,

policies, and environmental measures are consistent,

effective, synergistic, and not redundant. Further

research is needed on how to best implement

intervention strategies in different settings and with

different populations.

For further discussion of effective interventions to

address heart disease and stroke, please refer to

related chapters in this document, including those

on tobacco, school health, nutrition, physical

activity, and diabetes.

State Examples:

• The Tri-State Stroke Network, which includes

representatives of the Georgia, South Carolina,

and North Carolina CVH programs, works to

increase public awareness of stroke symptoms and

the need to treat stroke as a medical emergency.

One of the main objectives of the network is to

promote the development and implementation of

stroke prevention and control programs in the TriState area.
47

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

Program contact: Tynetta Brown, Cardiovascular

Health Program, North Carolina Division of

Public Health/DHHS.

• The Missouri CVH Program has partnered with

the state Diabetes Prevention and Control

Program (DPCP) to establish a diabetes/CVD

collaborative to improve the care that federally

qualified health centers provide to people with

these conditions. The collaborative focuses on

system changes (e.g., in delivery system design,

decision support, clinical information systems,

and self-management support) in these health

centers. In addition, the CVH Program and the

DPCP have supported the statewide establishment

of the American Diabetes Association’s “ABC

Campaign,” which focuses on managing clinical

factors related to diabetes and CVD, including

blood pressure and cholesterol levels.

Program contact: Diana Hawkins,

Cardiovascular Health Program, Missouri

Department of Health.

• The New York Healthy Heart Program assesses

supports for CVH in work sites with a high need

and high readiness for change and with a preponderance of low-income employees. Hearthealthy policies and environments are assessed

using a tool (Heart Check) developed by the

program. Following an initial 3-year intervention,

a reassessment with Heart Check indicated that

participating work sites had increased policy and

environmental supports for heart health by 65%.

Many of these work sites now are making blood

pressure screening available, offering low-fat food

choices in vending machines, instituting smokefree policies, and providing physical activity breaks

during the workday.8

Program contact: Margaret Casey, Healthy Heart

Program, New York Department of Health.

• The North Carolina CVH Program collaborates on

the BASIC Preventive Benefits Initiative with

North Carolina Prevention Partners, which

includes a variety of health plans and employers,

the state QIO, and various HHS programs. The

initiative is working to ensure that benefits to

prevent CVD are voluntarily purchased by

employers, voluntarily covered by insurers, and

offered by providers and health systems. The

initiative aims to increase the quality of care

received by consumers and to improve the health

status of individuals and populations. From 1998

through 2002, the initiative has led to a 75%

increase in the number of health plans offering

tobacco, nutrition, and physical activity insurance

products to employer groups.

Program contact: Libby Puckett, Cardiovascular

Health Program, North Carolina Division of

Public Health/DHHS.

• The Wisconsin CVH Program is collaborating with

its state QIO and DPCP to collect Health Plan

Employer Data and Information Set (HEDIS)

indicators for diabetes, cholesterol, and high blood

pressure. These indicators will enable the program

to work with participating health care providers to

implement system enhancements to improve these

CVD-related measures.

Program contact: Mary Jo Brink, Cardiovascular

Health Program, Wisconsin Division of Public

Health.

Infrastructure To Support Heart Disease and

Stroke Prevention Programs

Program Management and Administration

A strong system of management, staff, and support

are necessary to effectively address CVH. A heart

disease and stroke prevention program in a health

department should have staff who are able to

• Provide leadership for overall program development, program coordination, and implementation.

• Use a variety of data to assess the burden of CVD,

CVD-related disability, and risk factors, and

interpret data for program planning.

• Frame public health issues for policy makers and

apply policy and environmental strategies to

improve CVH.

• Develop and maintain partnerships.

• Carry out health communications, health education, training, advocacy, and media activities.

• Provide appropriate support to community-based

intervention programs in a variety of settings and

work with diverse populations.
48

PREVENTION STRATEGIES THAT WORK

• Develop and analyze health policy.

• Provide policy and administrative support for

CVH program activities.

• Ensure that programs are implemented with

integrity and evaluated for effectiveness.

Qualified personnel at the state, regional, and local

levels are critical to implementing and managing a

comprehensive heart disease and stroke prevention

program.

State agency management should encourage

collaboration between the state heart disease and

stroke prevention program and related programs

such as coordinated school health, diabetes, tobacco

control, physical activity, and nutrition.

Surveillance and Evaluation

The burden of CVD should be well defined. To

assess that burden, the health department needs

capacity in the areas of chronic disease epidemiology,

statistics, surveillance, data analysis, and the

application of data in program planning and priority

setting. Staff should be able to use data to support

allocating resources to CVH prevention.

Staff should have access to data systems such as vital

statistics, the Behavioral Risk Factor Surveillance

System (BRFSS), the Youth Risk Behavior Survey,

hospital discharge data, HEDIS, Medicaid and

Medicare data, and other data sources that are useful

for defining the burden of CVD in the state. In

addition, heart disease and stroke prevention

program staff should be able to use data from

geographic information systems to document the

distribution of CVD, delineate disparities, and

specify the needs of priority populations.

(Geographical data by state and county are available

on CDC’s Heart Disease and Stroke Prevention

Program Web site: www.cdc.gov/cvh.)

The BRFSS modules on hypertension awareness,

cholesterol awareness, cardiovascular disease, and

heart attack and stroke signs and symptoms should

be part of the state BRFSS survey; optional modules

and state-added questions should be used to help the

state program track trends in CVD and related risk

factors. The state BRFSS sample size should be large

enough to gather statistically adequate responses for

priority populations, including racial and ethnic

groups. States should consider surveillance questions

as a means for gathering community- and regionallevel data for targeted interventions.

Communication strategies should be based on state

and local data so that partners and the public

understand CVD’s relevance to, and impact on, both

their personal health and the health of the people in

their communities. A published document defining

the burden of CVD in the state should communicate

data in ways that are appropriate for different

audiences, including community groups, state

leaders, and decision makers. It should describe the

burden of CVD (primarily heart disease and stroke)

and related risk factors and conditions (e.g., high

blood pressure, high cholesterol, tobacco use,

physical inactivity, poor nutrition, diabetes). The

document should describe the geographic and

demographic distribution of CVD, highlighting

disparities in CVD burden based on geography, sex,

socioeconomic status, and race and ethnicity. It

should also identify trends in CVD, including

changes in numbers of deaths, average age at onset

of disease, and average age at death.

This burden document should be used as a tool to

increase public awareness of CVD as a public health

priority, to mobilize partners to address CVD in a

comprehensive manner, and to support the commitment of resources to promoting CVH. Data can be

presented to staff, partners, community groups,

policy makers, and decision makers to enhance their

understanding of how to use data for program

planning. The data should provide a basis for

developing the CVH state plan and for identifying

priority populations and strategies.

Program evaluation is essential for planning programs and building the scientific capacity of state

health departments. Heart disease and stroke

prevention program staff should have a good

understanding of methodologies to evaluate process
49

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

data. The report was used to establish the CVH

Program’s priorities, track changes in data trends,

and help the state coalitions implement strategies

to achieve CVH goals.

Program contact: Amy Carte, Cardiovascular

Health Program, West Virginia Bureau for Public

Health.

• The Oregon CVH Program compared the

prevalence of major CVD risk factors, including

hypertension and high cholesterol levels, among

Medicaid-eligible residents with their prevalence

among the general population and evaluated

associations between these risk factors and

Medicaid claims for CVD hospitalization. It

found that CVD risk factors are more common

among Oregon’s Medicaid populations than

among the general population and are associated

with CVD hospitalizations among the former

group. The CVH Program is using this information to identify priority populations and to help

set program priorities.

Program contact: Laura Chenet Leonard,

Cardiovascular Health Program, Oregon

Department of Human Services.

• The New York Healthy Heart Program has

developed a reporting system to monitor policy

and environmental changes occurring in work

sites so that it can evaluate the outcomes of its

work site interventions. It is evaluating the Heart

Check tool to determine whether the number of

questions for the work site assessment can be

reduced, thereby increasing ease of use. Pre- and

post-Heart Check scores have increased an average

of 75%, with improvements in nutrition, physical

activity, and administrative support.

Program contact: Margaret O. Casey, Healthy

Heart Program, New York State Department of

Health.

Partnerships

The multifaceted nature of opportunities for

promoting CVH and preventing CVD requires the

cooperation and collaboration of many partners in

public and private sectors. A key task for partners is

to develop a comprehensive CVH state plan and

and outcome and should develop and implement an

evaluation plan. Heart disease and stroke prevention

programs should be able to validate and demonstrate

the existence of “core capacities,” which include

committed partnerships; surveillance, assessment,

and evaluation functions; the ability to document

the burden of CVD; the ability to develop a

comprehensive CVH state plan; training and

technical assistance capabilities; and the ability to

identify or devise population-based intervention

strategies that are culturally competent and address

priority populations. Without this basic

infrastructure in place, CVH activities may be

scattered and lack focus and thus have a limited

impact on the cardiovascular health of state residents.

State Examples:

• The Mississippi CVH Program collaborated with its

AHA state affiliate to produce the 2000 Mississippi

State of the Heart Report and the 2000 Mississippi

Stroke Report. These documents contain data on

CVD-related illness, death, and risk factors. Data

include county-specific mortality rates depicted in

county maps, which have a visual impact for local

legislators. Strategies to reduce risk behaviors also

are listed in the reports. The reports have been

shared with members of the Mississippi Chronic

Illness Coalition to increase their awareness of the

burden of these diseases, provided to legislative

study committees to enhance their understanding

of the need for policy and environmental supports

to reduce CVD, and used by public health staff to

guide program planning.

Program contact: Wanda Magers, Cardiovascular

Health Program, Mississippi State Department of

Health.

• The West Virginia CVH Program produced a

burden report in 2001 that includes data on

mortality rates, behavioral risk factors, cost, and

access to medical care. The report also describes

CVH program goals and activities to eliminate

health disparities. In March 2002, this report was

placed on the West Virginia Department of

Health and Human Resources, Bureau of Public

Health Web site, where West Virginia risk factor

data could be compared with national risk factor
50

PREVENTION STRATEGIES THAT WORK

ensure that it is implemented. The involvement of

partners should promote the coordination of

activities to avoid duplication of effort and to share

responsibility for improving CVH. The state heart

disease and stroke prevention program should secure

the involvement of diverse partners and provide

leadership.

The heart disease and stroke prevention program

should partner internally with health department

programs that address the following:

• CVD-related risk factors, such as high blood

pressure, high cholesterol, tobacco use, physical

inactivity, and poor nutrition.

• Related areas, such as diabetes and school health.

• Priority populations.

• Data (e.g., vital statistics, the state’s BRFSS).

The heart disease and stroke prevention program

should also form external partnerships with the

following types of organizations:

• State agencies that address CVD risk factors, such

as the departments of education, public safety, and

emergency medical services.

• Organizations whose missions are associated with

promoting heart health and reducing heart disease

and stroke, such as the AHA.

• Other professional and voluntary organizations

interested in improving health and quality of life

and eliminating disparities in CVD burden, such

as quality improvement organizations, minority

health organizations, health care organizations,

media, community-based organizations, academic

institutions, and businesses.

In addition, the health department should

collaborate with academic institutions and

Prevention Research Centers (see www.cdc.gov/prc)

to conduct research to improve programs and

policies for CVH promotion and CVD prevention;

to translate knowledge from social, behavioral, and

medical sciences into sound public health practice;

and to ensure that program interventions and

evaluations are well grounded in science.

State Examples:

• The Virginia CVH Program coordinates strategic

partnerships through the Healthy Pathways

Coalition. The coalition is charged with comprehensively addressing primary and secondary

prevention of CVD and promoting CVH.

Partners represent private and governmental statelevel organizations, including those representing

priority populations. The CVH Program has

developed a logic model that clarifies relationships

among partners, sectors, and program activities.

The logic model is being used to guide the

coalition’s strategic planning and will be in the

resulting Call to Action document.

Program contact: Jody Stones, Cardiovascular

Health Program, Virginia Department of Health.

• The Utah CVH Program’s key state partners form

the Alliance for Cardiovascular Health in Utah.

The alliance comprises more than 140 organizations representing government, private businesses,

health care organizations, and nonprofit agencies.

The alliance has developed a 3-year CVH plan

(Uniting Partners for a Legacy of Health), which

is designed to coordinate efforts among organizations and identify key strategies, with an

emphasis on policy and environmental supports.

Program contact: Joan Ware, Cardiovascular

Health Program, Utah Department of Health.

Strategic Plans

Heart disease and stroke prevention programs need a

comprehensive plan that identifies their priorities

and focuses the efforts of their many partners. The

heart disease and stroke prevention program and its

diverse partners should develop and regularly update

this plan, which should present strategic objectives

that require leadership, ownership, coordination, and

commitment of resources by both public- and

private-sector partners. It should be a heart disease

and stroke prevention program plan and not a health

department plan. The strategic objectives should

include population-specific strategies that address the

needs of priority populations and should emphasize

policy and environmental approaches, systems

changes, and educational interventions that increase
51

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

support for heart-healthy choices and provide a

context for more effective CVD prevention.

The CVH plan should be based on data, including

the burden of CVD in the state and the results of an

assessment of policies and legislation that influence

heart health. It should also be based on an

assessment of regulations, policies, and

environmental barriers in work sites, health care

settings, schools, and communities. The results of

such an assessment will help program planners identify systems change interventions that may be needed

to achieve the objectives of the CVH plan.

The CVH plan may be a stand-alone plan or an

identifiable section within another state plan, such as

a larger chronic disease plan. In either case, it should

provide guidance for a comprehensive state heart

disease and stroke program. The CVH plan may be

packaged in a variety of formats (e.g., executive

summary, monograph, visual presentation) for

different audiences (e.g., decision makers, public

health planners, the health care community,

minority health organizations, the general public).

Although developing and updating a comprehensive

CVH plan requires a major commitment of time and

staff, such a plan can play a critical role in attaining

the heart disease and stroke objectives.

State Examples:

• The North Carolina Plan to Prevent Heart Disease

and Stroke 1999–2003 provides a comprehensive

vision that builds upon existing services and

promotes new strategies for preventing CVD. The

plan is based on the socioecological prevention

model, which has been proven effective for creating environmental and policy change in multiple

levels of society. The plan guides state and local

interventions by providing strategies for preventing CVD risk factors, managing CVD, raising

public awareness, and developing supportive

policies. The plan’s strategies are designed to be

implemented in collaboration with partners from

private and governmental sectors. It will be updated in 2003.

Program contact: Libby Puckett, Cardiovascular

Health Program, North Carolina Division of

Public Health/DHHS.

• The Alabama Cardiovascular State Health Plan

contains recommendations for changing policies,

health systems, community settings, and environmental factors that influence CVH. The plan is

designed to help policy makers, public health

personnel, health care providers, schools, communities, and voluntary organizations develop

coordinated approaches to CVD prevention.

The plan is organized around three major goals:

increasing awareness of CVD and how various

sectors (e.g., health care providers and payers,

schools, communities) can promote CVH;

minimizing CVD risk factors through supportive

environments; and promoting the use of recommended treatment guidelines by health care

providers and facilitating state residents’ access to

and use of early detection and treatment options

for CVD.

Program contact: Janice Cook, Cardiovascular

Health Program, Alabama Department of Public

Health.

Policies

To identify priority policy areas for intervention, the

state heart disease and stroke prevention program

should assess existing policy and environmental

supports. The assessment should also identify

elements of the physical and social environments

that can be modified to improve CVH-related

behaviors.

The assessment should address the needs of priority

populations and should focus on health promotion

and primary and secondary prevention of CVD and

related risk factors, including high cholesterol, high

blood pressure, tobacco use, physical inactivity, and

poor nutrition. The assessment should identify

policies at the state level that could affect

communities, such as state legislation that may affect

CVH-related policies in schools or agency policies

that may affect the implementation of nationally

accredited guidelines for primary and secondary

prevention of CVD in health care settings.
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PREVENTION STRATEGIES THAT WORK

Although the assessment should initially identify

state-level policies and environmental supports,

additional assessments should eventually be

conducted to identify policies in health care sites,

work sites, schools, and communities. As a planning

tool, the assessment does not need to be performed

statewide for each setting, but the geographical area

selected should be justified and should help the state

meet the objectives of its CVH plan.

State Examples:

• The Oklahoma Cardiovascular Health Program

assessed policies guiding stroke response and care

and is working with local heath departments and

hospitals to develop stroke protocols. The protocols will guide emergency medical personnel and

other hospital personnel in providing comprehensive, appropriate care for stroke patients from

the initial call for emergency services through

rehabilitation. The CVH Program is collaborating

with the AHA Oklahoma affiliate; Oklahoma

Foundation for Medical Quality; Oklahoma

Hospital Association; and local hospital

physicians, stroke coordinators, and emergency

medical service units. Although modified to meet

Oklahoma’s needs, the protocols are based on

those developed by the AHA and the National

Stroke Association.

Program contact: Adeline Yerkes, Chief, Chronic

Disease Service, Oklahoma State Department of

Health.

• The Healthy Maine Partnership is a collaborative

effort of the Maine Cardiovascular Health

Program, the Community Health Program,

Partnership for a Tobacco-Free Maine, and the

Coordinated School Health Program. The

Healthy Maine Partnership is working with 31

local communities and 54 school administrative

units to assess local and school policies supporting

cardiovascular health, such as tobacco-use policies

in public places and nutrition guidelines in

schools. The Maine Cardiovascular Health

Program will use the assessment results to identify

supportive policies and key partners for future

policy development.

Program contact: Debra Wigand, Maine

Cardiovascular Health Program, Department of

Human Services.

Health Communications

Heart disease and stroke prevention programs and

their partners should have the capacity to effectively

plan, implement, and evaluate communications and

education strategies that support policy and

environmental changes for CVH. Recognizing the

need for a tool that incorporates the most effective

communication models and strategies for change,

CDC has developed a tailored edition of

CDCynergy for CVH. The CVH edition has the

same features and format as CDCynergy 2001 Basic

but includes CVH case examples and resources. In

addition to providing training on specific

communications topics such as media and policy

advocacy and product development, the tool will

help users strategically convey information in ways

that advance the overall program goal of making

states heart healthy and stroke free.

Communications plans created by heart disease and

stroke prevention programs using CDCynergy 2001

should be based on data from state surveys and

burden documents, CVH state plans, and policy

inventories. The communications plan should

involve partners and their communications resources

and should consider multiple and innovative

channels to convey key messages, including

conferences, work-shops, and seminars for select

audiences; media outreach; and personal contact

with policy and decision makers in health care,

workplace, school, and community settings.

State Examples:

• The West Virginia CVH Program’s partnership with

St Mary’s Hospital, Genesis Hospital System, led

to the development of a social marketing

campaign to educate residents of Lincoln County

about the symptoms of heart attacks. CDCynergy

was used to plan the campaign, and data from

BRFSS, household surveys, Prizm national

consumer surveys, and hospitals were used to
53

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

staff, partners, and others. Training and technical

assistance should be provided to help state and local

health department staff and partners acquire the

skills needed to support the development and

implementation of the CVH plan. This training may

include areas such as population-based interventions,

policy and environmental strategies, cardiovascular

diseases and related risk factors, primary and

secondary prevention strategies, health

communications, cultural competency, epidemiology

and use of data in program planning, media

relations, strategic planning, program management,

and evaluation. The program might also provide

technical assistance on implementing programs in

health care sites, work sites, schools, and

communities.

CVH-related training needs should be assessed to

ensure that ongoing training and skill building are

available for health department staff, their CVH

partners, health care and human service providers,

and priority populations. States also might assist or

collaborate with partners (e.g., AHA, managed care

organizations, academic institutions) to provide

professional and public education. Programs need to

look for imaginative ways to provide training and

skill building, including the use of technology and

Web-casting. Programs should encourage staff to

participate in national and regional training

programs and conferences and then disseminate

what they learn statewide.

Supporting Evidence and Consensus Documents

In the 1980s, large community demonstration

projects that tested multiple intervention approaches

for improving CVH were conducted in Finland and

the United States. Many of the core capacities

needed for state heart disease and stroke prevention

programs are based on lessons learned from these

projects.9

Results from these community projects suggested

that states can play critical roles in activities such as

strategic planning, working with other stakeholders,

ensuring that projects are data-driven, supporting

community participation, and providing guidance

select the target county and develop media

messages. Four radio spots and print ads were

developed, and a pretest telephone survey was

conducted in February 2001. The media

campaign was launched in May 2001. It

promoted awareness of the symptoms of a heart

attack, the importance of immediate medical care,

and healthy choices for daily living. The posttest

telephone survey was conducted in December

2001 and showed an increased public interest

(from 68% in the pretest to 84% in the posttest)

in learning more about heart attack and stroke

symptoms. Approximately 40% of those surveyed

noticed the public service announcements (PSAs)

regarding heart attack and stroke. Perceptions

regarding stroke and heart attack symptoms

closely mirror the results of the pretest survey.

Further review of the evaluation results is planned.

Program contact: Amy Carte, Cardiovascular

Health Program, West Virginia Bureau for Public

Health.

• The Georgia CVH Program has four main

components in its communications plan: media

advocacy, public relations, advertising, and social

marketing. Its major social marketing campaign,

“Take Charge of Your Health,” is coordinated

through the Georgia Coalition for Physical

Activity and Nutrition (GPAN). The campaign

goal is to communicate three simple messages:

Take Action (walk, dance, play), Take 5-A-Day

(fruits and vegetables), and Take Down Fat

(choices, portions, and preparation). Media for

conveying these three messages statewide include

billboards, radio PSAs, and educational programs

in schools for youth and in community settings

for all age groups. Campaign evaluation and

communications training for GPAN members and

district chronic disease coordinators are under way.

Program contact: Pamela Wilson, Cardiovascular

Health Program, Division of Public Health,

Georgia Department of Human Resources.

Professional Development, Training, and Technical

Assistance

Heart disease and stroke prevention programs should

identify ways to meet the training needs of their
54

PREVENTION STRATEGIES THAT WORK

for quality assurance and intervention approaches.

Project evaluators found that “interventions that

simultaneously target the community environment

as well as organizations, groups, and individuals tend

to influence the public’s health far more than

interventions at any one of these levels alone.”9

Results from these projects also indicated that

policy and environmental interventions were often

more effective than direct behavior-change strategies.

Social marketing techniques were used to create

awareness of CVH issues and to create demand for

services, access to primary and secondary prevention,

and support for public policy and environmental

change.

In addition to the lessons learned from these studies,

programs also should use the following resources

when developing their own comprehensive state

heart disease and stroke prevention programs:

• Preventing Death and Disability from

Cardiovascular Diseases: A State-Based Plan for

Action. CVD Plan Steering Committee,

Association of State and Territorial Health

Officials, 1994.

• Publications of the Advisory Board of the

International Heart Health Conferences,

including The Victoria Declaration on Heart Health

(1992), The Catalonia Declaration—Investing in

Heart Health (1996), Worldwide Efforts to Improve

Heart Health: A Follow-Up to the Catalonia

Declaration—Selected Program Descriptions (1997),

and The Singapore Declaration: Forging the Will for

Heart Health in the Next Millennium (1998).

• Evaluating Community Efforts to Prevent

Cardiovascular Diseases: Community Changes.

Department of Health and Human Services,

CDC, 1995.

• North Carolina Plan to Prevent Heart Disease and

Stroke 1999–2003. North Carolina Heart Disease

and Stroke Prevention Task Force, 1999.

• Women and Heart Disease: An Atlas of Racial and

Ethnic Disparities in Mortality. Second Edition and

Men and Heart Disease: An Atlas of Racial and

Ethnic Disparities in Mortality. First Edition.

Available at www.cdc.gov/nccdphp/cvh.

• Policy as intervention: environmental and policy

approaches to the prevention of cardiovascular

disease. Am J Public Health 1995;85:1207-11.

• Community heart health programs: components,

rationale, and strategies for effective interventions.

J Public Health Policy 1993;14(4):463-79.

• Three articles in Health Education Quarterly in

1995 (volume 22, number 4): “Environmental

and policy approaches to cardiovascular disease

prevention through nutrition: opportunities for

state and local action;” “Environmental and policy

approaches to cardiovascular disease prevention

through physical activity: issues and

opportunities;” and “Environmental and policy

interventions to control tobacco use and prevent

cardiovascular disease.”

National Leadership

A formal partnership has been formed among CDC;

AHA; the Centers for Medicare & Medicaid

Services; NIH’s National Heart, Lung, and Blood

Institute and National Institute of Neurological

Disorders and Stroke; and the Office of Public

Health and Science, HHS, through a memorandum

of understanding that created the Healthy People

2010 Heart and Stroke Partnership. The goal of the

partnership is to maximize the participating

organizations’ investments in CVH and to capitalize

on their individual strengths to achieve the Healthy

People 2010 goal for preventing heart disease and

stroke. The partnership divided this goal into the

following four separate areas based on the different

intervention approaches that would be needed to

achieve them:

• Prevention of risk factors.

• Detection and treatment of risk factors.

• Early identification and treatment of heart

attacks and strokes.

• Prevention of recurrent cardiovascular events.

The Healthy People 2010 Heart and Stroke Partnership has improved communication, coordination,
55

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

and collaboration at the national, state, and local

levels. Activities proposed by the partnership to meet

the Healthy People 2010 goal and targets include

• Conducting population- and community-based

health education and health promotion.

• Coordinating public awareness messages and

media activities.

• Effecting environmental, policy, and system

changes.

• Jointly promoting professional education and

training, including joint presentations, cohosting

of national conferences, dissemination of best

practices, and joint consultation on cardiovascular

issues for conferences and workshops.

• Facilitating relationship development, support,

data collection, and resource sharing.

• Sharing scientific and information resources.

Examples of accomplishments to date include

• Developing a Healthy People 2010 Heart and

Stroke Partnership database of activities, which

will eventually be made available to the public.

• Developing and implementing the Act in Time to

Heart Attack Signs campaign, including a joint

press conference.

• Developing a year one evaluation report of the

strategic partnership.

• Cosponsoring Cardiovascular Health for All:

Meeting the Challenge of Healthy People 2010—A

National Conference, which was held April 11-13,

2002, in Washington, DC.

The Cardiovascular Health Collaborative

In 1998, the Health Resources and Services Administration, CDC and the Institute for Health

Improvement formed the National Diabetes

Collaborative to aggressively address chronic disease

by reducing disparities and increasing access to

quality care in federally qualified community health

centers. In April 2001, the first Cardiovascular

Health Collaborative was initiated and integrated

with the Diabetes Collaborative. In July 2002, the

collaborative provided training and support to help

community health centers and state heart disease and

stroke prevention programs improve quality of care

by implementing a chronic care model and an

improvement process model for CVD management.

Future training is planned.

Other Federal Partnerships

National High Blood Pressure Education Program

The National High Blood Pressure Education

Program (NHBPEP), a cooperative effort of

professional and voluntary health agencies, state

health departments, and many community groups,

has as its goal reducing death and disability related to

high blood pressure. Strategies to achieve this goal

include developing and disseminating professional,

patient, and public education materials and

programs that have a strong science base and

developing partnerships among the program

participants. The NHBPEP is coordinated by NIH’s

National Heart, Lung, and Blood Institute. At the

core of the program is the NHBPEP Coordinating

Committee, composed of representatives from 38

national health organizations and 7 federal agencies.

For more information, see www.nhlbi.nih.gov.

National Cholesterol Education Program

NIH’s National Heart, Lung, and Blood Institute

launched the National Cholesterol Education

Program (NCEP) to help reduce illness and death

from coronary heart disease (CHD) in the United

States by reducing the percentage of Americans with

high blood cholesterol. Through educational efforts

directed at health professionals and the public, the

NCEP aims to raise awareness and understanding

about high blood cholesterol as a risk factor for

CHD and the benefits of lowering cholesterol levels.

The NCEP relies on partnerships to bring

cholesterol information to a wide audience. The

NCEP Coordinating Committee, NCEP’s policysetting body and board of directors, embodies this

partnership principle: its membership consists of

representatives from more than 40 major medical

and health professional associations, voluntary health

organizations, community programs, and

governmental agencies. For more information, see

www.nhlbi.nih.gov.
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PREVENTION STRATEGIES THAT WORK

Hearts N’ Parks

Hearts N’ Parks is a national, community-based

program supported by NIH’s National Heart, Lung,

and Blood Institute. This innovative program aims

to reduce the growing trend of obesity and the risk of

coronary heart disease in the United States by

encouraging Americans of all ages to aim for a

healthy weight, follow a heart-healthy eating plan,

and engage in regular physical activity. Through

Hearts N’ Parks, park and recreation departments

and other community-based agencies offer sciencebased information about lifestyle choices that can

reduce a person’s risk of heart disease and teach skills

for incorporating heart-healthy behaviors into one’s

life. An evaluation of a pilot Hearts N’ Parks

Program at 33 sites in North Carolina showed that

participants retained information about hearthealthy behaviors and intended to eat healthier. In

addition, children reported learning new physical

activities and improving their performance in others;

seniors reported feeling healthier and experiencing

less pain in their daily lives by the end of the

program. Community organizations interested in

signing up to become a Hearts N’ Parks community

should contact the National Recreation and Park

Association at 800-649-3042 or by E-mail at

programs@nrpa.org. For more information, visit the

Hearts N’ Parks Web site at www.nhlbi.nih.gov/

health/prof/heart/obesity/hrt_n_pk/index.htm.

Native American Cardiology Program

The Native American Cardiology Program, based at

the University of Arizona, was developed by the

Indian Health Service (IHS) to provide on-site

cardiovascular care to Native Americans at

reservation clinics within the Navajo, Phoenix, and

Tucson areas of the IHS. It has evolved to become a

unique collaboration involving the IHS, the

University of Arizona, the University Medical

Center, the Flagstaff Medical Center, the Southern

Arizona VA Healthcare System, and Native

American tribes and communities. The program

promotes cardiovascular health and wellness for

Native American patients throughout the Southwest

through state-of-the-art treatment, education, and

prevention to stem the rising epidemics of

cardiovascular disease and diabetes now affecting

Native American communities. For more

information, see www.ihs.gov/MedicalPrograms/

Cardiology/index.cfm

Professional Development Opportunities

The Cardiovascular Health Practitioner’s Institute

provides intensive training and skill building to state

heart disease and stroke prevention program

managers and AHA state health department liaisons

from 12–15 states each year. The training is cosponsored by CDC, the Association of State Chronic

Disease Directors, AHA, and the University of

Rochester Department of Community and

Preventive Medicine. The goal of the training is to

enhance participants’ abilities to develop and

maintain public health programs for preventing and

controlling CVD, reducing related risk factors,

eliminating disparities, and promoting CVH. In

future years, an annual skill-building workshop will

be provided to state heart disease and stroke

prevention program staff from all states.

Resources

Web Resources

Communications and Health Promotion

University of Kansas’s Community Toolbox.

ctb.lsi.ukans.edu. Provides information on how to

develop, manage, and evaluate community projects;

includes tools and helpful hints.

HealthComm KEY.

www.cdc.gov/od/oc/hcomm/additsource.pdf.

Provides communications resources.

CDCynergy.

www.cdc.gov/communication/CDCynergy.htm.

Provides an interactive CD-ROM designed as a

decision-making tool and step-by-step guide for

planning health communications programs.

Contact the CDC Heart Disease and Stroke

Prevention Program for the CVH version.
57

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

Social Marketing

www.social-marketing.com/. Provides information

on social marketing publications and the latest news

in the field.

Evaluation

www.cdc.gov/eval/resources.htm. Provides CDC

evaluation resources, including logic models,

evaluation standards, organizations, and evaluation

concept documents.

University of Kansas’s Community Toolbox,

Evaluation Model.

ctb.lsi.ukans.edu/tools/EN/section_1007.htm.

Provides a model for evaluating comprehensive

community initiatives.

Success Measures Guidebook.

www.developmentleadership.net/smp/manual/

toc.htm. Provides a step-by-step guide for developing

and implementing an evaluation plan and specific

outcome indicators to help define success and

effective allocation of resources.

Funding

University of Kansas’s Community Toolbox, Grant

Writing Tools.

ctb.lsi.ukans.edu/tools/en/chapter_1042.htm.

Provides information on how to apply and receive

grants and other financial resources.

The Foundation Center.

fdncenter.org. Provides the foundation’s annual

reports, directories, books, and periodicals on fundraising, program planning, and current data on the

nation’s largest funders.

Interventions and Program Development

Centers for Disease Control and Prevention (CDC).

www.cdc.gov/cvh. Provides information on heart

disease, stroke, and state activities, including state

program contacts.

Health Policy Coach.

www.policymatters.org. Provides tools, strategies,

and information for creating policy change in

communities.

Health Disparity Collaboratives.

www.bphc.hrsa.dhhs.gov/programs/

hdcprograminfo.htm. Provides information on

interventions in federally qualified health centers to

improve health outcomes, including management of

CVD, in underserved populations.

Fit, Healthy, and Ready to Learn: School Health

Policy Guide.

www.nasbe.org/healthyschools/fithealthy.mgi.

Provides direction on establishing an overall policy

framework for school health programs and specific

policies on physical activity, healthy eating, and

tobacco-use prevention.

Get With the Guidelines.

www.americanheart.org/presenter.jhtml?

identifier=1165. Provides a hospital-based CVD

quality improvement program.

G8 Promoting Heart Health Telematics Project.

www.med.mun.ca/g8hearthealth. Provides a

qualitative database of best practices for CVH

programs; includes heart health issues such as

tobacco control, diet, physical activity, psychosocial

factors, hypertension, diabetes, and lipid

management.

American Dietetic Association.

www.eatright.org/gov/tools.html. Provides grassroots

tools for food and nutrition policy.

Public Education Network: Communities at Work.

www.publiceducation.org/interventions. Provides a

guidebook of strategic interventions for engaging the

community in school improvement to create

systemic change through community dialogue,

constituency building, engagement of practitioners,

collaboration with districts, policy analysis, and legal

strategies.
58

PREVENTION STRATEGIES THAT WORK

Turning Point Publications and Resources.

www.wkkf.org/Programming/Resources.

aspx?CID=8. Provides a variety of publications and

resources produced by Turning Point (national

initiative of the W.K. Kellogg and Robert Wood

Johnson foundations) that provide actionable,

evidence-based lessons for policy, practice, and

research.

Center for Livable Communities.

www.lgc.org/center/. Provides resources on building

livable communities, including selected publications,

manuals, conferences/trainings, and a land-use

resource library.

National Committee for Quality Assurance.

www.ncqa.org. Provides resources such as The

Business Case for Health Care Quality and The State of

Managed Care Quality, 2001.

Partnerships, Alliances, and Coalitions

University of Kansas’s Community Toolbox,

Community Work Station.

ctb.lsi.ukans.edu/tools/CWS/coalitionbuilding/

create_maintain_coalitions.htm. Provides

information on establishing and maintaining

partnerships, including coalitions.

Collaboration: What Makes it Work.

www.wilder.org/pubs/collab_wmiw/index.html.

Provides a review of research literature on factors

influencing successful collaboration among service

delivery agencies.

Building Community Health Partnerships.

www.communityhealthpartners.org/default.cfm.

Provides information on successful community

health partnership models.

Coalition for Healthier Cities and Communities.

www.healthycommunities.org/usa/index.cfm.

Provides information on a collaborative established

to improve the quality of life in communities

through community-based development and

coalition building.

Surveillance and Research

National Center for Health Statistics.

www.cdc.gov/nchs. Provides data systems on vital

events, health status, lifestyle, exposure to unhealthy

influences, the onset and diagnosis of illness and

disability, and the use of health care.

Centers for Medicare & Medicaid Services.

cms.hhs.gov. Provides CVD-related data and

statistics.

National Heart, Lung, and Blood Institute.

www.nhlbi.nih.gov/resources/index.htm. Provides

scientific resources on heart disease.

American Heart Association/American Stroke

Association.

www.americanheart.org. Provides scientific resources

on heart disease and stroke.

CDC CVH Statistical Information.

www.cdc.gov/cvh/statisticalinfo.htm. Provides data

such as interactive maps on county-specific heart

disease mortality rates by state, racial/ethnic group,

and sex.

Print Resources

Schmid TL, Pratt M, Howze E. Policy as

intervention: environmental and policy approaches

to the prevention of cardiovascular disease. Am J

Public Health 1995;85:1207-11.

Committee for the Study of the Future of Public

Health, Division of Health Care Services, Institute of

Medicine. The Future of Public Health. Washington,

DC: National Academy Press, 1988.

Sallis JF, Owen N. Ecological models. In: Glanz K,

Lewis FM, Rimer BK, editors. Health Behavior and

Health Education: Theory, Research and Practice. 2nd

ed. San Francisco: Jossey-Bass Publishers, 1997:403-

24.
59

ACHIEVING A HEART-HEALTHY AND STROKE-FREE NATION

North Carolina Heart Disease and Stroke Prevention

Task Force. North Carolina Plan to Prevent Heart

Disease and Stroke 1999–2003. North Carolina:

North Carolina Heart Disease and Stroke Prevention

Task Force 1999;15-16.

Casper ML, Barnett E, Halverson JA, et al. Women

and Heart Disease: An Atlas of Racial and Ethnic

Disparities in Mortality. 2nd ed. Morgantown, WV:

Office for Social Environment and Health Research,

West Virginia University, 1999. Available at

www.cdc.gov/cvh.

Barnett E, Casper ML, Halverson JA, et al. Men and

Heart Disease: An Atlas of Racial and Ethnic

Disparities in Mortality. 1st ed. Morgantown, WV:

Office for Social Environment and Health Research,

West Virginia University, 2001. Available at

www.cdc.gov/cvh.

Centers for Disease Control and Prevention. Policy

and Environmental Change: New Directions for Public

Health. Atlanta, GA: Department of Health and

Human Services, 2001.

Department of Health and Human Services. Third

Report of the Expert Panel on Detection, Evaluation,

and Treatment of High Blood Cholesterol in Adults

(Adult Treatment Panel III). Bethesda, MD:

Department of Health and Human Services,

National Institutes of Health, 2001. NIH

publication no. 01-3670.

Department of Health and Human Services. The

Sixth Report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of

High Blood Pressure. Bethesda, MD: Department of

Health and Human Services, National Institutes of

Health, 1997. NIH publication no. 98-1080.

Mittlemark MB, Hunt MK, Heath GW, Schmid TL.

Realistic outcomes: lessons from community-based

research and demonstration programs for the

prevention of cardiovascular disease. J Public Health

Policy 1993;14(4):437-62.

Gerber JC, Stewart DL. Prevention and control of

hypertension and diabetes in an underserved

population through community outreach and disease

management: a plan of action. J Assoc Acad Minor

Phys 1998;9(3):48-52.

Shediac-Rizhallah MC, Bone LR. Planning for the

sustainability of community-based health programs:

conceptual frameworks and future directions for

research practice and policy. Health Educ Res

1998;13(1):87-108.

Sorensen G, Emmons K, Hunt MK, Johnston D.

Implications of the results of community

intervention trials. Public Health 1998;19:379-416.

Golaszewski T, Fisher B. Heart check: the

development and evolution of an organizational

heart health assessment. Am J Health Promot

2002;17(2):132-53.

Golaszewski T, Barr D, Cochran S. An organizationbased intervention to improve support for employee

heart health. Am J Health Promot 1998;13(1):26-35.

McKinlay JB. The promotion of health through

planned sociopolitical challenges for research and

policy. Soc Sci Med 1993;36(2):109-17.

Goldman L, Phillips KA, Coxson P, et al. The effect

of risk factor reductions between 1981 and 1990 on

coronary heart disease incidence, prevalence,

mortality and cost. J Am Coll Cardiol

2001;38(4):1012-7.

Druss B, Marcus SC, Olfson M, Taneilian T, Elinson

L, Pincusl HA. Comparing the national economic

burden of five chronic conditions. Health Affairs

2001;20(6):233-40.

Galvin R, Milstein A. Large employers’ new

strategies in health care. N Eng J Med

2002;347(12):939-41.
60

PREVENTION STRATEGIES THAT WORK

Tu K, Davis D. Can we alter physician behavior by

educational methods? Lessons learned from studies

of the management and follow-up of hypertension.

J Contin Educ Health Prof 2002;22:11-22.

Stroebel RJ, Broers JK, Houle SK, et al. Improving

hypertension control: a team approach in a primary

care setting. J Qual Improvement 1997;26(11):623.

Pronk NP, O’Connor PJ. Systems approach to

population health improvement. J Ambulatory Care

Management 1997;20(4):24-31.

Bodenheimer T, Wagner EH, Grumbach K.

Improving primary care for patients with chronic

illness. JAMA 2002;228(14):1775-9.

Bodenheimer T, Wagner EH, Grumbach K.

Improving primary care for patients with chronic

illness: the chronic care model, part 2. JAMA

2002;288(15):1909-14.

References

1. American Heart Association. Heart and Stroke

Statistics—2003 Update. Dallas, TX: American

Heart Association, 2002.

2. Murray CJL, Lopez AD. Alternative projections

of mortality and disability by causes 1990–2020:

Global Burden of Disease Study. Lancet

1997;349:1498-504.

3. National Heart, Lung, and Blood Institute.

Morbidity and Mortality: 2002 Chart Book on

Cardiovascular, Lung, and Blood Diseases.

Bethesda, MD: National Heart, Lung, and Blood

Institute, 2002. Available at www.nhlbi.nih.gov/

resources/docs.

4. Cooper R, Cutler J, Desvigne-Nickens P, et al.

Trends and disparities in coronary heart disease,

stroke and other cardiovascular diseases in the

United States. Findings of the National

Conference on Cardiovascular Disease

Prevention. Circulation 2000;102:3137-47.

5. Department of Health and Human Services.

Healthy People 2010. 2nd ed. Vol. 1. Washington,

DC: US Government Printing Office, November

2000.

6. Brownson RC, Koffman DM, Novotny TE,

Hughes RG, Eriksen MP. Environmental and

policy interventions to control tobacco use and

prevent cardiovascular disease. Health Educ Q

1995;22(4):478-98.

7. Pellmar TC, Brandt EN, Macaran AB. Health

and behavior: the interplay of biological,

behavioral, and social influences: summary of

an Institute of Medicine Report. Am J Health

Promot 2002;16(4):206-19.

8. Fisher B, Golaszewski T, Barr D. Measuring

worksite resources for employee heart health. Am

J Health Promot 1999;13(6):325-32.

9. Elder JP, Schmid TL, Dower P, Hedlund S.

Community heart health programs: components,

rationale, and strategies for effective

interventions. J Public Health Policy

1993;14(4):474.
Addressing

Lifestyle Choices
63

PROMOTING HEALTHY EATING AND PHYSICAL

ACTIVITY FOR A HEALTHIER NATION

TABLE OF CONTENTS

Introduction

Burden of Physical Inactivity and Poor Nutrition

Overall Magnitude

Economic and Social Costs

Disparities

Related Healthy People 2010 Objectives

Prevention Opportunities

Levels of Prevention

Socioecological Approach

Essential Strategies

Interventions

Surveillance and Evaluation

Partnerships

Strategic Plans

Policy

Communications

Professional Development

Challenges Ahead

Web-Based Resources

Public Health Policy

Surveillance, Evaluation, and Research

Interventions and Program Development

Communications and Social Marketing

Partnerships, Alliances, and Coalitions

References
65

4

PROMOTING HEALTHY EATING AND PHYSICAL

ACTIVITY FOR A HEALTHIER NATION

Introduction

This chapter provides a framework for a

comprehensive program to address the problems of

poor nutrition and physical inactivity on a state or

community level. This framework is designed to give

state and local guidance in establishing a

coordinated, comprehensive nutrition and physical

activity program and soliciting a broad coalition of

stakeholders and partners. Health and human

services are in a unique position to strengthen and

coordinate efforts to improve nutrition and physical

activity among Americans.

Burden of Physical Inactivity and Poor Nutrition

Overall Magnitude

The importance of proper nutrition and physical

activity in reducing rates of disease and death from

chronic diseases has been well established.1-3 Poor

diet and physical inactivity cause 310,000 to

580,000 deaths per year and are major contributors

to disabilities that result from diabetes, osteoporosis,

obesity, and stroke. The results of one study showed

that 14% of all U.S. deaths in 1990 could be

attributed to poor diet and activity patterns,1 and

another study linked sedentary lifestyles to 23% of

chronic disease-related deaths in the United States

in 1986.2

According to Healthy People 2010,4 about 75% of

Americans do not eat enough fruit, more than half

do not eat enough vegetables, and 64% consume too

much saturated fat. The diets of many population

subgroups contain too much total fat, saturated fat,

and calories but not enough of other important

elements such as calcium. Low fruit and vegetable

consumption and high saturated fat intake are

associated with coronary heart disease, some cancers,

and diabetes.4-6

Breast milk is acknowledged to be the most complete

source of nutrition for infants and offers many

benefits for mothers and babies. According to the

HHS Blueprint for Action on Breastfeeding,

breastfeeding reduces the incidence or severity of

childhood infections and chronic diseases such as

type 1 and 2 diabetes, asthma, and childhood

cancers.7

 Additional evidence suggests that

breastfeeding may help prevent childhood obesity.8

Despite recognition by the American Academy of

Pediatrics that breastfeeding is the ideal method of

infant feeding,9 only 64% of all mothers in the

United States initiate breastfeeding, and only 29%

continue to breastfeed their infants for 6 months

after birth.4

Regular physical activity is essential for a healthy

life.3 Physically inactive people are almost twice as

likely to develop coronary heart disease as people

who engage in regular physical activity.3 Thus

physical inactivity poses almost as much risk for

heart disease as cigarette smoking, high blood

pressure, or a high cholesterol level, but is more

prevalent than any of these other risk factors.10

People with other risk factors for coronary heart

disease, such as obesity and hypertension, may

particularly benefit from physical activity.3

 It also

helps older adults remain independent and enhances

the quality of life for people of all ages.
66

PREVENTION STRATEGIES THAT WORK

Obesity or overweight status is defined by body mass

index (BMI), which is derived by dividing weight in

kilograms by the square of height in meters. From

1991–2000, the prevalence of obesity (defined as

BMI > 30 k/m2) among adults increased nationally,

in every state, and in all segments of the

population.11-14 Obesity leads to numerous health

problems, including hypertension, dyslipidemia,

type 2 diabetes, coronary heart disease, stroke, gall

bladder disease, osteoarthritis, sleep apnea,

respiratory problems, and some cancers (e.g.,

endometrial, breast, prostate, and colon cancers).

Because obesity is a risk factor for several chronic

diseases, the economic and social consequences of

this obesity epidemic could be overwhelming.15

While many factors have contributed to the obesity

epidemic, prevention efforts should focus on helping

people reduce their calorie intake and increase their

physical activity. The prevalence of obesity is

increasing more rapidly among children than among

adults. Because a growing body of evidence suggests

that breastfeeding offers protection against excessive

weight gain in childhood and adolescence,8 the

Centers for Disease Control and Prevention (CDC)

advocates breastfeeding as a reasonable strategy for

reducing children’s risk of becoming overweight.

Economic and Social Costs

The economic burden of poor diet, physical

inactivity, and obesity is substantial. All are

significant risk factors for developing coronary heart

disease, certain types of cancer, stroke, and diabetes,

conditions that involve considerable medical expense

as well as lost work time, disability, and premature

death. In one study, the direct medical cost for dietrelated manifestations of these four conditions was

estimated at $33.6 billion (in 1995 dollars), and the

total cost, including lost productivity because of

illness and premature death, was estimated to be

$70.9 billion.16 In another study based on 1987

medical expenditure data, researchers estimated that

if the more than 88 million inactive Americans over

the age of 15 began engaging in regular moderate

physical activity, annual national medical costs could

be reduced by as much as $76.6 billion in 2000

dollars.17 The medical costs associated with obesity

are even higher: an estimated $100 billion annually

based on 1995 data.18 Taken together, inactivity and

obesity accounted for 9.4% of the 1995 health care

expenditures in the United States.18 In addition to

these economic costs, immeasurable costs due to

social and emotional problems, both for those

affected and for their friends and families, may result

from inactivity- and obesity-related diseases.19

Disparities

The problems associated with poor diet, physical

inactivity, and obesity affect most population

segments; however, there are marked disparities in

the impact that these problems have on various

groups of people, particularly by race/ethnicity and

by education level. Data from Healthy People 2010 4

indicate that physical inactivity, vegetable intake,

breastfeeding, and weight status vary by race/

ethnicity, sex, educational level, and age

(Table 1).

Related Healthy People 2010 Objectives

Healthy People 2010 4 contains 19 objectives directly

related to nutrition and breastfeeding and 15 directly

related to physical activity. However, because poor

nutrition and physical inactivity are associated with

increased risk for many health problems, they are

also mentioned in almost every other priority area.

The full text of Healthy People 2010 can be found at

www.healthypeople.gov.

Prevention Opportunities

Levels of Prevention

Because poor dietary habits and physical inactivity

are associated with many adverse health outcomes,

most adults and children could benefit from

interventions designed to improve their eating habits

and increase their activity levels. Such intervention

programs fall into three general categories: health

promotion, primary prevention, and secondary

prevention. The goal of health promotion is to help

people establish an active lifestyle and healthy eating

habits early in life and to maintain these behaviors

throughout their lives. The goal of primary

prevention is to help people who have risk factors for
67

PROMOTING HEALTHY EATING AND PHYSICAL ACTIVITY FOR A HEALTHIER NATION

Table 1. Percentages of U.S. Adults in Various Physical Activity or Nutritional Categories,

Overall and by Select Sociodemographic Characteristics

Overall 40 49 29 31

Race/Ethnicity

White 38 50 31 29

Black 52 43 19 40

Hispanic 54 47 28 34

Sex

Men 36 64‡ 28

Women 43 49‡ 33

Educational level (among people 25 years of age and older)

Less than 9th grade 73

Grades 9–11 59 23

High school graduate 46 21

Some college or AA 35 21

College graduate 24 40

Family income level

< 130% poverty threshold 42

>130% poverty threshold 50

Age groups

18–24 years 31

25–44 years 34

45–64 years 42

65–74 years 51

75 years and older 65

*People aged 2 years and older.

†People aged 20 years and older.

‡People aged 40–59 years.

Source: Healthy People 2010 4

 and NHANES 1999–2000.

No leisuretime

physical

activity,

1997

Consumption

 of 3 or more

 servings of

vegetables

per day,*

1994–96

Breastfeeding

newborn

infant for

6 months,

1998

Obese

(BMI ≥ 30),†

1999–2000
68

PREVENTION STRATEGIES THAT WORK

chronic disease (e.g., elevated blood pressure or

serum cholesterol levels) prevent or postpone the

onset of disease by establishing more active lifestyles

and healthier eating habits. The goals of secondary

prevention are to help people who already have a

chronic disease cope with and control these

conditions and to prevent additional disability by

increasing their physical activity and establishing

more healthful eating patterns.

Socioecological Approach

To be most effective in the long run, public health

programs should focus on health promotion as well

as disease prevention. For example, by promoting

breastfeeding to pregnant women and new mothers

and supporting their efforts to breastfeed, public

health organizations can help children develop

healthy eating habits during infancy. Because

appropriate physical activity levels and healthy eating

behaviors should be instilled in childhood and

maintained throughout life, prevention efforts that

target older children and schools are equally

important, as are interventions for adults who are

inactive or have poor dietary habits even though they

have not yet developed chronic diseases. All

interventions should be appropriate to the target

audience, and different strategies may be required to

reach different segments of the population.

Interventions may address individuals, institutions,

communities, policies, or the environment and can

be effectively implemented in various settings, such

as schools, work sites, health care facilities, and

places of worship.

Whatever population segment is targeted by an

intervention, its members are also influenced by a

social network consisting of family members, friends,

colleagues, and acquaintances. Interventions have the

best chance of succeeding if they are directed at all

elements of this network simultaneously.20, 21

Increasingly, health promotion professionals are

recognizing the dynamic interplay between

individuals and their environments. Although

lifestyle choices are ultimately personal decisions,

they are made within a complex mix of social and

environmental influences that can make healthier

choices either more or less accessible, affordable,

comfortable, and safe.22-25

Research has shown that behavior change is more

likely to endure when a person’s environment is

simultaneously changed in a manner that supports

the behavior change.21, 26 Therefore, interventions

should address not only the intentions and skills of

individuals, but also their social and physical

environments, including the social networks and

organizations that affect them.27

Essential Strategies

Guidelines for Comprehensive Programs to Promote

Healthy Eating and Physical Activity

(www.astphnd.org) is a document designed to help

state and local health practitioners create

comprehensive nutrition, physical activity, and

obesity control programs.28 These guidelines provide

recommendations in seven major areas:

1) leadership, planning/management, and

coordination; 2) environmental, systems, and policy

change; 3) mass communications; 4) community

programs and community development; 5) programs

for children and adolescents; 6) health care delivery;

and 7) surveillance, epidemiology, and research.

To make the best use of scarce resources for

prevention, health agencies attempting to prevent

chronic disease should use strategies that focus on

highly prevalent risk factors that are modifiable

through behavior change. Following are four

behavior change strategies that meet this criterion.

Each strategy can target one or more Healthy People

2010 objectives.

• Promote increases in physical activity. Exercise

provides numerous health benefits and should be

promoted to the most sedentary subgroups of the

population.3

• Promote breastfeeding. Breastfed children have less

risk for acute diseases of infancy and early

childhood and a reduced risk of developing

childhood obesity.8

• Increase fruit and vegetable consumption. Higher

consumption of fruits and vegetables is associated
69

PROMOTING HEALTHY EATING AND PHYSICAL ACTIVITY FOR A HEALTHIER NATION

with lower incidence of several chronic diseases,

including cardiovascular disease and some

cancers.4

• Reduce television-viewing time. A reduction in the

length of time that children and adolescents watch

television may reduce the risk for obesity among

young people.29

Physical Activity Strategies

The Guide to Community Preventive Services

(www.thecommunityguide.org/pa) recommends

five population-based strategies for increasing a

population’s level of physical activity.30 These

strategies include ways to achieve Healthy People

2010 objectives that deal with moderate and

vigorous lifestyle activities for adults and young

people (Chapter 22).4

• Community-wide campaigns. Large-scale, highly

visible, multicomponent campaigns with messages

promoted to large audiences through diverse

media, including television, radio, newspapers,

movie theaters, billboards, and mailings.

• Individually targeted programs. Programs tailored

to a person’s readiness for change or specific

interests; these programs help people incorporate

physical activity into their daily routines by

teaching them behavioral skills such as setting

goals, building social support, rewarding

themselves for small achievements, solving

problems, and avoiding relapse.

• School-based physical education (PE). School

curricula and policies that require students to

engage in sufficient moderate to vigorous activity

while in school PE class. Schools can accomplish

this by increasing the amount of time students

spend in PE class or by increasing their activity

level during PE class.

• Interventions that provide social support for physical

activity in community settings. Interventions

designed to promote physical activity by helping

people create, strengthen, and maintain social

networks that support their efforts to exercise

more; examples include exercise buddy programs

and the establishment of exercise contracts or

walking groups.

• Interventions to provide people greater access to places

for physical activity. Examples include building

walking or biking trails and making exercise

facilities available in community centers or

workplaces.

NIH’s National Heart, Lung, and Blood Institute

(NHLBI) launched the Obesity Education Initiative

(OEI) in 1991 to encourage Americans to adopt

heart-healthy eating patterns and physical activity

habits that will help to prevent overweight and

obesity. The OEI also supports programs and

activities related to the Healthy People 2010

objectives for reducing the prevalence of overweight,

obesity, and physical inactivity. OEI’s two-pronged

strategy consists of a population approach, which

focuses on preventing overweight, obesity, and

physical inactivity in the general population, and a

high-risk approach, which targets people who are

experiencing, or are at high risk for, the adverse

health effects and medical complications associated

with overweight and obesity. For more information,

visit the OEI Web site at www.nhlbi.nih.gov/oei/

index.htm.

Strategies to Increase Fruit and Vegetable Consumption

High fruit and vegetable intake is associated with low

dietary fat intake, and dietary fat is associated with

both cancer and heart disease.5, 6 The Healthy People

2010 objectives related to fruit and vegetable

consumption (Chapter 19) include recommendations to consume at least three servings of

vegetables and two servings of fruit per day.4

Unfortunately, less than 25% of the U.S. population

consumes at least five servings of fruits or vegetables

a day. To increase fruit and vegetable consumption,

CDC, the National Cancer Institute (NCI), the

American Cancer Society (ACS), and three

Department of Agriculture agencies are collaborating

to expand federal support for the national 5 A Day

for Better Health Program. Resources to help health

organizations promote fruit and vegetable

consumption can be found at www.5aday.gov,

www.5aday.com, www.5aday.gov/pdf/

masimaxmonograph.pdf, and www.5aday.org/pdfs/

research/health_benefits.pdf.
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PREVENTION STRATEGIES THAT WORK

Nutrition and Your Health: Dietary Guidelines for

Americans (http://www.health.gov/dietaryguidelines)

serves as the principal federal policy document

related to dietary choices. This joint publication of

the Department of Health and Human Services and

the Department of Agriculture is intended to serve

the public in at least five ways:

• By helping consumers make dietary choices that

will promote their well-being and help them avoid

or postpone the onset of diet-related chronic

diseases.

• By assisting federal, state, and local agencies in

developing policies to guide the implementation

of feeding and educational programs.

• By helping state and local agencies devise and

implement regulatory policies and programs that

relate to food, nutrition, and health.

• By assisting health care providers in primary

disease prevention efforts.

• By guiding other domestic and international

organizations in the implementation of food,

nutrition, and health goals.

Strategies to Promote Breastfeeding

The Healthy People 2010 4 objective relating to

breastfeeding (Chapter 16) states: “Increase to 75%

the proportion of mothers who breastfeed their

babies in the early postpartum period, increase to

50% the proportion of mothers who breastfeed their

babies for at least 6 months, and increase to 25% the

proportion of mothers who breastfeed their babies

for at least 12 months.” Specific strategies to

promote breastfeeding are outlined in the HHS

Blueprint for Action on Breastfeeding, which can be

found at www.cdc.gov/breastfeeding/00binaries/

bluprntbk2.pdf. These strategies include

1) developing social support resources for

breastfeeding women, 2) training health care

professionals to promote breastfeeding among their

patients, 3) establishing maternity care practices and

policies that promote breastfeeding, and 4) establishing workplace programs and policies that

promote breastfeeding.

Strategies to Reduce Television Viewing Time

On average, U.S. children 2–17 years old spend

approximately 4.5 hours a day watching some kind

of electronic screen, with 2.5–2.75 hours of that

spent watching television.31, 32 National crosssectional surveys have shown a positive association

between the number of hours children watch

television and their risk of being overweight.29, 31, 32

This correlation probably has several causes:

television watching may displace calorie-burning

physical activity, children may eat more while

watching TV, television advertisements may induce

children to consume more high-calorie foods and

snacks, and TV viewing may reduce children’s

metabolic rate.33, 35-40 Based on data from young

people in grades 9–12, the Healthy People 2010

objective regarding TV watching (in Chapter 22)

states: “Increase to 75% the proportion of

adolescents who view television 2 or fewer hours

per school day.”4

Few studies have explored strategies for reducing

children’s TV viewing, and more testing and

development of such strategies is needed before firm

recommendations can be made. However, schoolbased programs have shown promise in helping to

reduce children’s TV viewing by providing means for

parents and children to monitor and budget the time

that children spend watching TV.37, 39

Interventions

Community-Based Programs

Community-based programs should use multiple

approaches to provide people with the knowledge,

skills, and attitudes necessary to eat a healthful diet

and be physically active. These programs should

work with local organizations to identify target

populations41-52 and should solicit full community

participation in a comprehensive approach that

addresses the physical, social, political, and cultural

environments affecting community members.
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PROMOTING HEALTHY EATING AND PHYSICAL ACTIVITY FOR A HEALTHIER NATION

Recommendations:

• Conduct community assessments to determine the

dietary and exercise habits of residents, identify

interventions that might help improve these

habits, and identify community resources and

potential partners that could help establish these

interventions.

• Coordinate efforts to achieve Healthy People 2010

objectives among various groups and agencies.

• Encourage representatives of the intended

population to participate in program planning,

design, implementation, and evaluation.

• Identify relevant population subgroups; attempt to

understand physical activity, nutrition, and obesity

from their point of view; and develop communitybased strategies and programs that are relevant and

acceptable to them.

• Educate the public and policy makers about the

importance of supportive environments.

• Promote broad social and environmental changes

that complement individual change efforts.

Examples of such activities include

• Promoting healthy food choices in

away-from-home sites such as restaurants;

fast-food outlets; school and work site

cafeterias; vending machines; and sports, arts,

and recreation venues.

• Encouraging restaurants to label heart-healthy

foods on menus and encouraging vending

machine operators to include a certain

percentage of choices low in fat, sodium,

and sugar.

• Coordinating community resources and

identifying consistent, convincing, culturally

appropriate, and scientifically sound nutrition

and physical activity messages delivered

through health professionals, grocery stores,

places of worship, schools, the media, parks

and recreational facilities and programs, food

service operations, and other pertinent

channels.

• Improving lighting and security in public

exercise areas such as walking paths (sidewalks,

trails) and bike paths.

• Involving the Department of Agriculture as a

key partner through programs such as WIC.

• Recruiting nontraditional partners such as food

producers and retailers, bicycle-pedestrian

coordinators, transportation planners, local

land/urban planners, trail coordinators,

violence-prevention advocates, and

neighborhood associations.

• Encouraging employers to adopt policies that

support physical activity and good nutrition,

such as offering flex-time and providing

healthy food options at work-site cafeterias.

• Demonstrating model physical activity and

healthy nutrition policies, procedures, and

practices at the work sites of agencies.

• Ensuring that the public health benefits of

both leisure-time and transportation-related

physical activity are conveyed to transportation

agencies, urban planners, building designers,

and officials responsible

for zoning and transportation-investment

decisions.

School-Based Programs for Children and Adolescents

Coordinated school health programs have the

potential to help young people adopt and maintain

healthy eating and physical activity behaviors53-56 and

possibly to prevent and control obesity and other

chronic diseases. Data from the National Health and

Nutrition Examination Surveys (NHANES) reveal

that the prevalence of obesity among U.S. children

6–19 years of age tripled in the past 20 years, to

slightly more than 15%.57,58 Information gathered

through the Youth Risk Behavior Surveillance

System (YRBSS) (www.cdc.gov/nccdphp/dash/yrbs/

index.htm) indicates that more than a third of young

people in grades 9–12 report not regularly engaging

in vigorous physical activity. Meanwhile, the

percentage that reported daily participation in school

physical education classes declined from 41.6% in

1991 to 32.2% in 1999.59
72

PREVENTION STRATEGIES THAT WORK

School-based programs should use a coordinated

school health model to

• Provide students with opportunities to engage in

healthy eating and physical activity behaviors.

• Help students develop the knowledge, skills, and

attitudes necessary to adopt and maintain these

behaviors.

• Integrate school-based physical activity and

nutrition programs with family and community

life.

Recommendations:

• Employ a full-time school health coordinator to

work collaboratively with the education

department on school health issues related to

nutrition and physical activity.

• Collaborate with the department of education to

employ a physical education/activity coordinator

at the department of education.

• Educate policy makers, health practitioners, and

the general public about the importance of

requiring daily physical education classes and

state-of-the-art nutrition education in the core

curriculum in kindergarten through 12th grade.

• Collaborate with the department of education to

provide support, training, and technical assistance

to help schools implement CDC school health

guidelines for promoting healthy eating60 and

physical activity61 and use the tools that support

the implementation of these guidelines (e.g., the

School Health Index62, 63 and Fit, Healthy, and

Ready to Learn64).

• Provide schools with the resources necessary to

educate faculty and students about healthy eating

and physical activity and implement curricula to

promote healthy eating and physical activity.

• Encourage communities and businesses to support

physical activity and nutrition programs for young

people.

• Provide support, training, and technical assistance

to help schools and community organizations

achieve the following:

• Create food service programs that are

consistent with USDA school meal program

regulations and physical education programs

that are consistent with the National Standards

for Physical Education.65

• Create a healthy school nutrition environment

in which appealing, healthy, and nutritious

choices are available whenever and wherever

food and beverages are offered to students.

• Provide before- and after-school extracurricular

physical activity opportunities such as physical

activity clubs, intramural activities, and

interscholastic sports.

• Integrate physical activity and healthy eating

into before- and after-school child care

programs (e.g., extended-day programs).

• Develop effective programs to increase the

number of students walking to and from

school.

• Develop and implement school health

councils, which include community

representation, to guide school health

programs.

• Develop and implement effective employee

health promotion programs and services.

• Evaluate school programs in healthy eating and

physical activity and make improvements

where needed.

Health Care Programs

One of the roles of health care programs is to provide

effective preventive services, including services

related to behavioral risk-factor modification.66 To

more effectively promote physical activity and

healthy eating in the communities they serve, health

care systems should collaborate with community

partners to create an integrated approach.

Recommendations:

• Work with health care systems to develop and use

evidence-based standards of practice for delivering

preventive services. At a minimum, health care

plans should have standards of practice for
73

PROMOTING HEALTHY EATING AND PHYSICAL ACTIVITY FOR A HEALTHIER NATION

assessing physical activity and nutrition and for

assessing the effectiveness of clinical interventions.

All children and adults enrolled in health care

plans should have access to appropriate primary

and secondary prevention care services related to

physical activity and nutrition.

• Work with health care systems to ensure that their

health care professionals are qualified to deliver

preventive services related to physical activity and

nutrition.67, 68

• Work with health care systems to develop and

evaluate prompts for counseling patients about

nutrition, physical activity, and body weight

regulation.

• Promote policies that either require or provide

incentives for health care systems to include

preventive services related to nutrition and

physical activity as part of their benefit packages.

Examples of policies that provide such incentives

include reimbursing providers for preventive care

and basing a health care system’s quality-of-care

rating at least in part on the quality of the

preventive care it provides.

• Help health care systems coordinate their

preventive care activities with community efforts

to promote physical activity and healthy nutrition.

The collaboration of the North Carolina

Prevention Partners (www.ncprevention

partners.org) illustrates how such a coordinated

effort might function.

• Work with health care systems to include

nutrition and physical activity indicators in the

surveillance data they collect. These indicators can

be used to evaluate the effectiveness of

interventions to increase physical activity or

improve nutrition among patients in the system.

Surveillance and Evaluation

Surveillance of a population’s dietary practices and

physical activity levels is necessary for quantifying

problems, understanding the scope of these

problems, identifying trends, targeting subgroups for

intervention, guiding planning, evaluating the

impact of interventions, informing the public, and

influencing public policy.69-79 Validated indicators of

nutrition and physical activity and the life stages for

which each is appropriate are shown in Table 2. This

list is partial and could be modified according to a

particular health department’s interests.

In addition, program-specific and community-level

indicators may be useful in targeting areas for

intervention and monitoring progress in meeting

specific program objectives. For example,

information about the food choices available at

various sites in a community could be useful in

planning community nutritional interventions.

Physical activity indicators could include policies

related to community use of school facilities after

school hours or required physical education classes

for high school students.

To establish or increase their capacity to carry out

dietary and physical activity surveillance, programs

should collect data on a regular basis and incorporate

existing surveys into their data collection efforts

whenever possible. Examples of such surveys include

the Behavioral Risk Factor Surveillance System

(BRFSS) [www.cdc.gov/nccdphp/brfss] for adults,

the YRBSS [www.cdc.gov/nccdphp/dash/yrbs/

index.htm] for adolescents, and the Pediatric

Nutrition Surveillance System (PedNSS)

[www.cdc.gov/nccdphp/dnpa/pdf/pednss.pdf] for

children in the WIC program. Programs should also

consider using state- or local-level surveys that

include nutrition and/or physical activity data.

Because surveillance data are so essential to the

success of programs, programs should 1) establish

standards for data analysis and timely reporting and

2) provide training and technical assistance to help

program personnel collect and analyze data.

Evaluations should describe how an intervention was

conducted (i.e., process evaluation) as well as how

successful it was in meeting its objectives (i.e.,

outcome evaluation). Because it is often not possible

to see a short-term change in the ultimate outcome

measure, program planners may need to identify

intermediate outcome measures. For example,
74

PREVENTION STRATEGIES THAT WORK

intermediate outcomes for a nutritional intervention

aimed at increasing fruit and vegetable consumption

might be increased awareness of the importance of

fruit and vegetable consumption. Even when

interventions have been implemented, evaluated, and

shown to be successful in a prior setting, ongoing

evaluation is essential to ensure that the program is

working well in the current setting.

Partnerships

Strategic partnerships that can serve the goals of all

partners are very important in leveraging limited

resources. Health departments and community

health centers can foster such partnerships by

developing coalitions that include local health

departments, other health care providers, and various

partners capable of providing or supporting

programs that promote better nutrition and greater

physical activity. These coalitions should be as

inclusive as possible and include both traditional

partners, such as hospitals and national health

organizations, and nontraditional partners, such as

restaurants, grocery stores, and transportation

agencies.

One example of a successful partnership is a

collaborative effort between the New York Division

of Public Health and the New York Academy of

Medicine that produced The Pocket Guide to Cases of

Medicine and Public Health Collaboration

(www.nyam.org/library/publications). Available in

both a print version and an on-line version, the

guide describes more than 400 instances of medical

and public health collaboration. Another example is

the North Carolina Prevention Partners project,

Building Alliances for Health Systems to Integrate

Table 2. Possible Surveillance Indicators for Nutrition and Physical Activity Programs

Measure Infants Youth Adults Older Adults

Weight and height X X X

(for calculating body mass index: BMI)

Daily fruit and vegetable consumption X X X

(at least 5 per day)

Occupational physical activity X

(at least 4 hours per work day in a nonsitting activity)

Nonoccupational physical activity X X

(at least 1.5 hours per week)

Moderate-intensity physical activities such as walking X X X

and gardening (at least 5 days/week and 30 minutes/day)

Vigorous-intensity physical activities such as some sports X X

and running (at least 3 days/week and 20 minutes/day)

Strengthening activities (at least 2 days per week) X X

Participation in physical education, sports, and other X

school-based activities

Television viewing time (less than 2 hours per weekday) X X X

Breastfeeding rates (initiation, 6 months) X

Birth weight X
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PROMOTING HEALTHY EATING AND PHYSICAL ACTIVITY FOR A HEALTHIER NATION

Preventive Care Services (BASIC) Benefits

(www.ncpreventionpartners.org). This Web-based

system coordinates and displays a variety of healthrelated information and programs that are relevant to

North Carolina.

Community coalitions are another type of partnership that proved useful in Missouri, where the

Bootheel Heart Health Program provided

community-based activities designed to help

residents of a rural, medically undeserved area of

southeastern Missouri decrease their risk for

cardiovascular disease by, among other things,

exercising more and eating more healthful foods.51, 52

Web sites for organizations that can serve as partners

for nutrition and physical activity programs are listed

in Table 3.

Strategic Plans

A strategic plan for promoting healthy diets and

physical activity should describe how the

comprehensive program will coordinate multiple

categorical programs that in any significant way

address nutrition, physical activity, or obesity

prevention. Key elements should include a

surveillance system for monitoring progress; a public

communication and education program focusing on

all segments of the population; coordination with

other programs and services (e.g., cardiovascular

health, diabetes, cancer control, minority health, and

aging/social services); and strategic partnerships with

state and local government entities, academic

institutions, and private organizations. Potential

partners for whom nutrition, physical activity, and

obesity prevention are relevant underlying issues

could include programs or organizations focusing on

diabetes, cardiovascular disease, neighborhood safety,

or livable communities. The plan should also

identify methods of working with government

leaders and establish the organizational support and

infrastructure necessary to promote policy-level

interventions such as making communities more

“activity friendly.”

Policy

In addition to convincing people to be more

physically active and eat a healthier diet, state and

community programs should work to create

environments, systems, and policies that

• Serve as passive inducements to being physically

active and eating a healthy diet.

• Eliminate barriers to being active and eating a

healthy diet.

• Provide explicit support, reinforcement, and

inducements to making healthy choices such as

taking stairs rather than riding elevators or eating

fruits or vegetables instead less healthy foods.

• Change cultural and organizational norms for

physical activity and body weight.

• Establish themselves as partners in planning and

decision-making on environmental and policy

issues that affect people’s eating and physical

activity habits.

Communications

Health communications efforts should have three

main goals: 1) to educate the public about the

importance of diet and exercise and motivate them

to eat healthier and engage in more physical activity,

2) to motivate relevant groups and policy makers to

create policies and environments that support

healthy eating and increased physical activity, and

3) to eventually change social norms related to eating

and activity. Potential audiences for communications

activities might include others within the agencies,

decision makers, health care providers, the general

public, specific segments of the population, policy

makers, the media, business leaders, and partners.

Because each audience will have different concerns

and “cultures,” health communicators will need to be

adept at defining their various audiences and at

designing culturally appropriate communications

strategies and messages for each. The CDCynergy

program (www.cdc.gov/cdcynergy) can assist

programs in planning communications activities.80

Because eating and exercise habits are complex
76

PREVENTION STRATEGIES THAT WORK

Table 3. Potential Partners for Comprehensive

Nutrition and Physical Activity Programs

Organization Web Site

American Academy of Pediatrics www.aap.org/

American Alliance for Health, Physical Education, Recreation and Dance www.aahperd.org

American Association of Public Health Physicians www.aaphp.org

American Cancer Society www.cancer.org

American College of Sports Medicine www.acsm.org

American College of Preventive Medicine www.acpm.org

American Council on Exercise www.acefitness.org

American Diabetes Association www.diabetes.org

American Dietetic Association www.eatright.org

American Heart Association www.americanheart.org

American Public Health Association www.apha.org

Association of Schools of Public Health www.asph.org

Association of Teachers of Preventive Medicine www.atpm.org

Centers for Disease Control and Prevention www.cdc.gov

Cooper Institute for Aerobics Research www.cooperinst.org

HHS Administration on Aging Division www.aoa.gov

HHS Office of Minority Health www.omhr.gov

Human Kinetics Publishers www.humankinetics.com

National Association for Community Health Centers www.nachc.com

National Association for Health and Fitness www.physicalfitness.org

National Heart, Lung, and Blood Institute www.nhlbi.nih.gov

National Cancer Institute www.cancernet.nci.hig.gov

National Institute of Diabetes, Digestive, and Kidney Diseases www.niddk.nih.gov

National Park Service: Rivers, Trails, and Conservation Assistance Program www.nps.gov/rtca

National Recreation and Park Association www.nrpa.org

President’s Council on Physical Fitness and Sports www.fitness.gov

Prevention Research Centers www.cdc.gov/prc

Society for Public Health Education www.sophe.org

Society for Nutrition Education www.sne.org

U. S. Department of Agriculture www.usda.gov

U. S. Department of Education www.ed.gov

U. S. Department of Energy www.energy.gov

U. S. Department of Transportation www.dot.gov

U. S. Food and Drug Administration www.fda.gov

YMCA of the United States www.ymca.net
77

PROMOTING HEALTHY EATING AND PHYSICAL ACTIVITY FOR A HEALTHIER NATION

behaviors linked to larger social, cultural, political,

economic, and environmental factors, health

communications activities should be part of a larger

plan that addresses these other factors. Social

marketing provides a useful framework for such a

broad approach to health communications.

Resources on social marketing can be found at

http://socialmarketing-nutrition.ucdavis.edu/

home.htm, www.turningpointprogram.org/Pages/

socialmkt.html, and www.hc-c.gc.ca/hppb/

socialmarketing.

Health communications messages should be as

specific as possible (e.g., “Eat 5 a Day” rather than

“Eat a Healthy Diet”). Because members of the

general public cannot be expected to know what

terms like “healthy diet” and “moderate physical

activity” mean, program planners and health

communicators should determine how their

audiences perceive such concepts and define them

more clearly if research shows this to be necessary.

Research should include formative research (e.g.,

focus groups), pretesting of concepts and messages,

and monitoring during the implementation of the

program.

The Weight-Control Information Network (WIN) is

a national service of NIH’s National Institute of

Diabetes and Digestive and Kidney Diseases. WIN

was established in 1994 to raise awareness and

provide up-to-date, science-based information on

obesity, physical activity, weight control, and related

nutritional issues to health professionals, people who

are overweight or obese, the media, Congress, and

the general public. WIN Notes, WIN’s newsletter,

features information on obesity and weight control

research, new initiatives and programs, professional

organizations, and materials and resources available

from WIN and other organizations and agencies.

Other publications include brochures, fact sheets,

article reprints, conference and workshop

proceedings, and materials developed by NIDDK on

obesity and nutrition. For more information, see

www.niddk.nih.gov/health/nutrit/win.htm.

The California Nutrition Network (www.dhs.ca.gov/

cpns/network/index.html) offers an example of how

states can design appropriate materials for specific

populations. For several years, this group has

produced social marketing campaigns that focus on

the dietary habits of various target populations.

Professional Development

Staff should be familiar with recent scientific research

related to nutrition and physical activity, as well as

with current guidelines about what constitutes

healthful dietary and physical activity behaviors. At a

minimum, those who work with surveillance data

should be familiar with current technology related to

the measurement of these behaviors and associated

environmental indicators. Those who work with

programs may require training on behavioral and

environmental motivators, program development

and partnering strategies, program evaluation, social

marketing, and communications. Networking with

members of nutrition and physical activity programs

in other states is another way for program personnel

to stay abreast of new developments in their field.

Examples of training opportunities in physical

activity include the Physical Activity and Public

Health Courses. This series includes the 6-day Public

Health Practitioner’s Course on Community

Interventions, the 8-day postgraduate Research

Directions & Strategies course conducted annually

by the University of South Carolina, and the

national 5 A Day training conducted twice yearly by

NCI and CDC. Various national organizations also

offer opportunities for professional development in

areas related to physical activity and nutrition. Such

organizations include the American College of Sports

Medicine; the American Alliance of Health, Physical

Education, Recreation and Dance; the Society for

Public Health Education; the Society for Nutrition

and Education; the American Public Health

Association; the Social Marketing for Public Health

Conference; and the American Dietetic Association.

The Web site of CDC’s Division of Nutrition and

Physical Activity (www.cdc.gov/nccdphp/dnpa)

provides information on CDC-funded research and

practices in these areas. CDC also offers monthly
78

PREVENTION STRATEGIES THAT WORK

nutrition and physical activity teleconferences.

National training resources on obesity include health

care provider training by the Centers for Obesity

Research and Education (www.uchsc.edu/core/

index.htm) and weight management training for

dietitians provided by the Commission on Dietetic

Registration (www.cdrnet.org/whatsnew/

certificateofTraining.htm).

Challenges Ahead

Although the dietary practices of Americans have

changed substantially in the past 20 years, none of

these changes has yet been causally linked to the

obesity epidemic. Thus the development of effective

evidence-based strategies to prevent and treat obesity

through dietary changes remains a high priority. In

addition, although obesity has been negatively

correlated with physical activity levels and

breastfeeding history and positively correlated with

time spent watching television, we have only limited

information about the best way to translate these

findings into effective public health strategies. Thus

further research and continued monitoring of

existing interventions are essential in these areas as

well. Furthermore, as health departments attempt to

coordinate the efforts of various categorical programs

promoting physical activity and healthful diets, new,

more effective strategies are likely to emerge.

Web-Based Resources

Public Health Policy

www.healthypeople.gov: Provides updated

information on Healthy People 2010 objectives,

leading health indicators, and national and state

programs.

www.cdc.gov/nccdphp/sgr/sgr.htm: The Surgeon

General’s Report on Physical Activity and Health

(1996).

www.surgeongeneral.gov/topics/obesity: The Surgeon

General’s Call To Action To Prevent and Decrease

Overweight and Obesity. Provides updated

information on strategies to reduce the burden

caused by obesity.

www.nns.nih.gov: National Nutrition Summit.

Provides highlights of accomplishments in the areas

of food, nutrition, and health since the landmark

1969 White House Conference on Food, Nutrition,

and Health and identifies continuing challenges and

emerging opportunities for the nation in these areas;

focuses on nutrition and lifestyle issues affecting

people of all ages, particularly those related to the

nation’s epidemic of overweight and obesity.

www.cdc.gov/nccdphp/publicat.htm: A source for

various government publications relevant to physical

activity and health.

http://odphp.osophs.dhhs.gov: Provides information

on public health policies and reports and on the Best

Practices Initiative of HHS’s Office of Disease

Prevention and Health Promotion.

Surveillance, Evaluation, and Research

www.cdc.gov/nccdphp/brfss: Provides Behavioral

Risk Factor Surveillance System data, including state

and national summaries as well as copies of current

and past questionnaires.

www.cdc.gov/nccdphp/dash/yrbs/index.htm:

Provides Youth Risk Behavior Survey data as well as

copies of current and past questionnaires.

www.cdc.gov/nccdphp/dnpa/pnss.htm: Provides

information collected by the Pediatric Nutrition

Surveillance System, including data collected from

health, nutrition, and food assistance programs for

infants and children.

www.cdc.gov/nccdphp/dnpa/physical/handbook/

index.htm: Physical Activity Evaluation Handbook.

Provides tools for state and local agencies and

community-based organizations that are evaluating

physical activity programs.

For additional information on how to conduct

evaluations of health programs, see www.cdc.gov/
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PROMOTING HEALTHY EATING AND PHYSICAL ACTIVITY FOR A HEALTHIER NATION

eval.

Interventions and Program Development

http://thecommunityguide.org/pa/ Guide to

Community Preventive Services. Provides

recommendations for effective, evidence-based

strategies.

www.cdc.gov/nccdphp/dnpa/kidswalk/

kidswalk_guide.htm: Includes information on how

communities can implement the Kids Walk to

School Program.

www.paceproject.org: Patient-centered Assessment

and Counseling for Exercise and Nutrition. Provides

information on physician counseling techniques for

physical activity and nutrition programs.

www.cdc.gov/nccdphp/dnpa/pahand.htm: Provides

access to For Promoting Physical Activity: A Guide for

Community Action.

www.cdc.gov/nccdphp/dnpa: The Web site of CDC’s

Division of Nutrition and Physical Activity.

www.cdc.gov/nccdphp/dash/SHI/index.htm: The

Web site of CDC’s School Health Index.

www.state.hi.us/doh/legrpts2002/

tspact_259sec27.pdf: The Web site of the Healthy

Hawaii Initiative, which provides examples of

community health improvement strategies in the

areas of tobacco use prevention and control, physical

activity, and nutrition.

www.nhlbi.nih.gov/guidelines/obesity/

ob_home.htm: This web site provides the Clinical

Guidelines on the Identification, Evaluation, and

Treatment of Overweight and Obesity in Adults from

the National Heart, Lung, and Blood Institute.

www.ihs.gov/MedicalPrograms/Nutrition. The Web

site of the Indian Health Services’ National

Nutrition and Dietetics Training program.

www.astphnd.org: Nutrition and Physical Activity

Work Group’s Guidelines for Comprehensive Programs

to Promote Healthy Eating and Physical Activity.

http://thecommunityguide.org/pa: A systematic

review of the effectiveness of selected populationbased interventions designed to increase levels of

physical activity from the Task Force on Community

Preventive Services.

www.cdc.gov/breastfeeding/00binaries/

bluprntbk2.pdf: HHS Blueprint for Action on

Breastfeeding, 2000.

www.cdc.gov/nccdphp/dnpa/pep.htm: Personal

Energy Plan (PEP), a 12-week self-directed work site

program.

Communications and Social Marketing

www.cdc.gov/cdcynergy/: The Web site for

CDCynergy, an interactive CD ROM that guides

the user through the communications planning

process.

www.hsc.usf.edu/CFH/ntcsm/: An on-line training

course in social marketing from the University of

South Florida.

http://www.niddk.nih.gov/health/nutrit/win.htm:

The Web site of NIH’s Weight Control Information

Network.

Partnerships, Alliances, and Coalitions

www.dhs.ca.gov/cpns/index.htm: Describes

nutrition-related partnering opportunities in

California.

www.ncpreventionpartners.org: Describes how

North Carolina used various partnerships to pursue

public health goals.

www.cdc.gov/prc/glance: A CDC Web site that lists

current Prevention Research Centers and describes

some of the projects they have engaged in.
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41. Centers for Disease Control and Prevention.

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53. Sallis JF, McKenzie TL, Alcaraz JE, Kolody B,

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physical activity and fitness in elementary school

students. Am J Public Health 1997;87:1328-34.

54. Luepker RV, Perry CL, McKinlay SM, et al.

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dietary patterns and physical activity. The Child

and Adolescent Trial for Cardiovascular Health

(CATCH). JAMA 1996;275:768-76.

55. Marx E, Wooley SF, Northrop D, editors.

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57. Troiano RP, Flegal KM, Kuczmarski RJ, et al.

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58. Ogden CL, Flegal KM, Carroll MD, Johnson

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79. Peterson KE, Chen LC. Defining undernutrition

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85

ADVANCING TOBACCO CONTROL THROUGH

EVIDENCE-BASED PROGRAMS

TABLE OF CONTENTS

Overview

Burden

Healthy People 2010 Objectives

National Leadership

Surveys

Research

Programs

Prevention Opportunities

Community Programs to Reduce Tobacco Use

Chronic Disease Control Programs to Reduce the Burden of Tobacco-Related Diseases

School Programs

Enforcement

Statewide Programs

Counter-Marketing

Cessation Programs

Surveillance and Evaluation

Administration and Management

Technical Resources

General Planning Resources

School Programs Core Resources

Enforcement Core Resources

Statewide Programs Core Resources

Counter-Marketing Core Resources

Cessation Core Resources

Surveillance and Evaluation Core Resources

Administration and Management Core Resources

References

87

5

ADVANCING TOBACCO CONTROL THROUGH

EVIDENCE-BASED PROGRAMS

Overview

In the Surgeon General’s report, Reducing Tobacco

Use, former U.S. Surgeon General David Satcher

noted that “Our lack of greater progress in tobacco

control is more the result of our failure to implement

proven strategies than it is the lack of knowledge

about what to do.”1 The report provides a complete

analysis of five major approaches to reducing tobacco

use: educational, clinical, regulatory, economic, and

comprehensive. The authors of the report concluded

that the comprehensive approach, which involves the

synergistic coordination of the other major

approaches, has been most successful in reducing

tobacco use, and that statewide comprehensive

approaches were particularly effective. They

estimated that if the strategies shown to be effective

were fully implemented, the rates of tobacco use,

both among young people and among adults, could

be cut in half by 2010.2 In an independent analysis,

the Institute of Medicine (IOM) also concluded that

comprehensive state tobacco control programs can

reduce rates of smoking and save lives.3

The conclusions of the Surgeon General’s report and

the IOM report are thus consistent: comprehensive

statewide tobacco control programs work.

Recommended strategies for implementing such

programs can be found in Reducing Tobacco Use

(www.cdc.gov/tobacco)2 and Best Practices for

Comprehensive Tobacco Control Programs

(www.cdc.gov/tobacco)4 from the Centers for Disease

Control and Prevention (CDC) and on the Web sites

of the Task Force on Community Preventive Services

(www.thecommunityguide.org)5

 and the Surgeon

General (www.surgeongeneral.gov/tobacco/

smokesum.htm).6 The proven strategies discussed in

these sources provide a strong foundation for action

at the state and local levels. Possible funding sources

for comprehensive state tobacco control programs

include money from the settlement of the states’

lawsuits against the tobacco industry, state excise tax

revenues, general state funds, and federal and private

sources.

Burden

Tobacco use is the single most preventable cause of

death and disease in the United States. Each year, it

causes more than 440,000 deaths and costs the

nation approximately $75 billion in medical

expenses and $81.9 million in productivity losses.7

Tobacco use is associated with cancer, heart disease,

chronic obstructive pulmonary disease, and stroke—

4 of the 5 leading causes of death in the United

States. In 2000, an estimated 46.5 million U.S.

adults (23.3%) were current smokers. The prevalence

of smoking was higher among men (25.7%) than

among women (21.0%). Among racial/ethnic

groups, Asians (14.4%) and Hispanics (18.6%) had

the lowest prevalence of adult cigarette use, and

American Indians/Alaska Natives had the highest

rates (36%) (Table 1).8 Although nearly 70% of

adult smokers want to quit smoking completely, only

a small fraction are successful in any given year

because of the highly addictive nature of tobacco

use.9

Smoking rates among children and youth are

perhaps even more disturbing than rates among

adults. For example, rates among U.S. high school

students increased significantly from approximately

28% in 1991 to 35% in 1999,10 while 15% of

middle school students currently use some form of

tobacco (cigarettes, smokeless tobacco, cigars, pipes,
88

PREVENTION STRATEGIES THAT WORK

bidis, or kreteks).11 Overall, white teens are taking up

smoking at higher rates than are black and Hispanic

teens.11 Although recent studies indicate that

U.S. teen smoking rates may have leveled or begun

to decline,12 they are still substantially above the

goals articulated in Healthy People 2010.13

Tobacco products other than conventional cigarettes

have also had catastrophic effects on users’ health.

The use of smokeless tobacco has been associated

with leukoplakia and oral cancer, as well as with the

early indicators of these conditions, peridontal

degeneration and soft tissue lesions; regular cigar use

has been associated with cancers of the lungs, larynx,

oral cavity, and esophagus; and the use of bidis

(small, brown, often flavored tobacco cigarettes from

India that are hand-rolled in tendu or tenburni leaf

and secured with a string at one end) has been

associated with heart disease and cancers of the

mouth, pharynx and larynx, lung, esophagus,

stomach, and liver. Although bidis were virtually

unheard of in this country until quite recently, their

popularity among young people has grown

alarmingly: as of 2000, 2.4% of middle school

students and 4.1% of high school students reported

smoking bidis.

Men (n=13,986) Women (n=18,388) Total (n=32,374)

Characteristic % (95% CI †) % (95% CI) % (95% CI)

Race/Ethnicity§

White, non-Hispanic 25.9 (+ 1.0) 22.4 (+ 0.8) 24.1 (+0.7)

Black, non-Hispanic 26.1 (+ 2.5) 20.9 (+ 1.7) 23.2 (+1.5)

Hispanic 24.0 (+ 2.1) 13.3 (+ 1.6) 18.6 (+1.3)

American Indian/Alaska Native¶ 29.1 (+11.0) 42.5 (+11.0) 36.0 (+8.0)

Asian** 21.0 (+ 4.6) 7.6 (+ 2.8) 14.4 (+2.8)

Education††

0–12 (no diploma) 33.2 (+ 2.2) 23.6 (+ 1.7) 28.2 (+1.4)

<8 26.1 (+ 3.1) 14.2 (+ 2.2) 20.0 (+1.9)

9–11 37.6 (+ 3.5) 30.8 (+ 2.7) 33.9 (+2.2)

12 40.1 (+ 6.8) 25.3 (+ 5.1) 32.7 (+4.4)

GED§§ diploma 50.1 (+ 6.2) 44.3 (+ 5.7) 47.2 (+4.3)

12 (diploma) 31.7 (+ 1.9) 23.5 (+ 1.4) 27.2 (+1.2)

Associate degree 21.9 (+ 2.8) 20.4 (+ 2.4) 21.1 (+1.8)

Some college 25.8 (+ 2.1) 21.6 (+ 1.7) 23.5 (+1.3)

Undergraduate degree 14.2 (+ 1.7) 12.4 (+ 1.5) 13.2 (+1.1)

Graduate degree 9.1 (+ 1.8) 7.5 (+ 1.6) 8.4 (+1.2)

Age group (yrs)

18–24 28.5 (+ 2.7) 25.1 (+ 2.4) 26.8 (+1.8)

25–44 29.7 (+ 1.4) 24.5 (+ 1.1) 27.0 (+0.9)

45–64 26.4 (+ 1.5) 21.6 (+ 1.3) 24.0 (+1.0)

>65 10.2 (+ 1.3) 9.3 (+ 1.0) 9.7 (+0.8)

Poverty status¶¶

At or above 25.4 (+ 1.0) 20.4 (+ 0.9) 22.9 (+0.7)

Below 35.3 (+ 3.2) 29.1 (+ 2.3) 31.7 (+1.9)

Unknown 23.6 (+ 1.8) 19.5 (+ 1.4) 21.4 (+1.1)

Total 25.7 (+ 0.8) 21.0 (+ 0.7) 23.3 (+0.5)

Table 1. Percentage of persons aged 18 years and older who were current smokers,*

by selected characteristics—National Health Interview Survey, United States, 2000

* Smoked >100 cigarettes during their lifetime and reported at the time of interview smoking every day or some days. Excludes 301 respondents

for whom smoking status was unknown.

† Confidence interval.

§ Excludes 287 respondents of unknown, multiple, and other racial/ethnic categories.

¶ Wide variances among estimates reflect limited sample sizes.

** Does not include Native Hawaiians and Other Pacific Islanders.

†† Persons aged >25 years. Excludes 305 persons with unknown years of education.

§§ General Educational Development.

¶¶ The 1999 poverty thresholds from the Bureau of the Census were used in these calculations.
89

ADVANCING TOBACCO CONTROL

Smoking also poses health risks for nonsmokers as

well as for those who smoke. Nearly 9 of 10

nonsmoking Americans are exposed to

environmental tobacco smoke (ETS), which has

been associated with lung cancer and heart disease

among nonsmoking adults and with serious

respiratory problems among children. In addition,

substantial evidence now indicates that ETS

exposure is also associated with low birthweight and

sudden infant death syndrome.

The consequences of tobacco use have become a

global concern. The World Health Organization

(WHO) estimates that about 4 million people die

every year of tobacco-related diseases and that

without effective international tobacco control

programs, the annual death toll will increase to as

many as 10 million by 2030, including 7 million

among people in developing countries.

Healthy People 2010 Objectives

Tobacco use is one of the 28 focus areas of Healthy

People 2010 . For more information on the tobaccorelated objectives in Healthy People 2010, visit

www.healthypeople.gov.

National Leadership

Reducing rates of tobacco use requires a partnership

between the federal government and states. Several

federal agencies have conducted studies whose results

can provide a foundation for state action, including

the National Institutes of Health (NIH), the Centers

for Disease Control and Prevention (CDC), the

Substance Abuse and Mental Health Services

Administration (SAMHSA), and the Agency for

Health Care Policy and Research (AHCPR). These

and other federal entities have produced and

disseminated important information about the

extent of tobacco use, the impact of tobacco use, and

the effectiveness of various interventions to reduce

tobacco use.

Surveys

Federally supported surveys of tobacco use include

the Behavioral Risk Factor Survey, the National

Health Interview Survey, the Youth Risk Behavior

Survey, and the Youth Tobacco Survey conducted

through CDC; the tobacco use supplement to the

current population survey being conducted by the

Bureau of Census, with support from NIH and

CDC; the Monitoring the Future Study conducted

through NIH; and the National Household Survey

on Drug Abuse conducted through SAMHSA.

Research

The federal government also has sponsored research

on the health impact of tobacco use, the

determinants of tobacco use, and interventions to

reduce tobacco use. Most of this research has been

supported by NIH’s National Cancer Institute

(NCI); however, research into tobacco use has also

been supported by other federal entities, including

the National Institute on Drug Abuse, the National

Institute of Child Health and Development, and

the National Heart, Lung, and Blood Institute.

Besides supporting disease-specific research, NCI

has supported smoking-prevention and smokingcessation intervention studies, including mass media

and school trials and large-scale demonstration

projects such as COMMIT and ASSIST. CDC also

supports applied research through its Prevention

Research Centers; this research focuses on

identifying population segments disproportionately

affected by tobacco use and on reducing or

eliminating these disparities.

Programs

In addition to providing research and survey data

that can help states design and implement tobacco

control programs, various federal entities also

directly support state programs. For example,

SAMHSA implements the Synar regulation to

reduce youth access to tobacco products through

state-level compliance activities; AHCPR has

published clinical practice guidelines on smoking

cessation and has worked with a variety of health

care organizations to ensure that the guidelines are

implemented; and CDC supports several programs

to prevent and reduce tobacco use, including the

National Tobacco Control Program, which in FY
90

PREVENTION STRATEGIES THAT WORK

1999 funded efforts in all states and territories and

the District of Columbia to establish core tobacco

use prevention and reduction programs. CDC has

also developed several educational and media

programs that can be used in tobacco control

efforts, including the Media Campaign Resource

Center, which makes high-quality antismoking

advertising materials available for use by states and

organizations.

Private organizations are also playing an increasing

role in tobacco control. The Robert Wood Johnson

Foundation/American Medical Association’s

SmokeLess States program, for example, directly

funds policy-focused interventions and approaches

by private, nonprofit organizations. The American

Legacy Foundation, an independent national public

health foundation, is another important source of

funding for state tobacco control programs. Created

by the 1998 Master Settlement Agreement between

participating states and the tobacco industry, the

foundation aims to reduce rates of tobacco use and

ETS exposure, reduce disparities in access to

prevention and cessation services, and increase

smoking-cessation rates. Although numerous

national organizations have undertaken critical

activities to curb tobacco use, the success of tobacco

control interventions will ultimately depend on the

state and local agencies that devise and implement

them.

Following is a list of some of the national

organizations that can aid in state and local tobacco

control efforts:

Action on Smoking and Health: www.ash.org

Advocacy Institute: www.advocacy.org

American Cancer Society: www.cancer.org

Americans for Nonsmokers’ Rights:

www.no-smoke.org

American Heart Association: www.americanheart.org

American Legacy Foundation:

www.americanlegacy.org

American Lung Association: www.lungusa.org

Agency for Healthcare Research and Quality:

www.ahrq.org

Campaign for Tobacco-Free Kids:

www.tobaccofreekids.org

Environmental Protection Agency: www.epa.gov

National Cancer Institute: www.nci.nih.gov

CDC: www.cdc.gov/tobacco

Robert Wood Johnson Foundation/American

Medical Association SmokeLess States program:

www.ama-assn.org/ama/pub/category/3230.html

Substance Abuse and Mental Health Services

Administration: www.samhsa.gov

Prevention Opportunities

Data from California and Massachusetts show that

comprehensive tobacco control programs can

substantially reduce tobacco use, and in the case of

California, reduce rates of death from lung cancer

and cardiovascular disease. CDC recommends that

such programs have four main goals:

• To prevent the initiation of tobacco use among

young people (primary prevention).

• To help current smokers quit (secondary

prevention).

• To eliminate ETS exposure among nonsmokers

(primary and secondary prevention).

• To identify population groups disproportionately

affected by tobacco use and eliminate these

disparities (primary and secondary prevention).

Comprehensive tobacco control programs should

attempt to create “environments” in which smoking

is discouraged or banned. The primary way of doing

this is by supporting legislative, regulatory, and

voluntary organizational restrictions on the use of

tobacco, such as on how it is sold, priced, and

promoted, and where tobacco products are allowed

to be used. These “environmental change” efforts

should be supported by tobacco use prevention,

treatment, and cessation programs and efforts to

prevent people from being exposed to environmental

tobacco smoke.
91

ADVANCING TOBACCO CONTROL

Comprehensive tobacco control programs should

serve as a model for “cultural inclusiveness” and

“cultural competency” by addressing the specific

concerns of various population segments, including

racial and ethnic minorities and other groups at high

risk for tobacco-related diseases. They should also

attempt to increase awareness of the disproportionate

toll that tobacco use exacts from minorities and to

convince minority advocacy groups to include

tobacco control as part of their agendas.

Comprehensive tobacco control programs should

attempt to partner with any group with overlapping

interests that can help them reach their goals, from

national nongovernmental health organizations such

the American Cancer Society, to federal agencies

such as CDC or NIH, to groups representing

specific local constituencies such as a PTA chapter or

minority advocacy group. Partnering with local

groups or community leaders is essential, especially

in areas with predominantly minority populations,

since these local groups and leaders can help state

program officials design interventions or educational

campaigns that target local residents in a culturally

appropriate manner.

Best Practices for Comprehensive Tobacco Control

Programs4

 recommends ways in which states can

establish tobacco control programs that are

comprehensive, sustainable, and accountable. Its

recommendations are based largely on analyses of

existing state programs, especially on those in

California and Massachusetts, which were funded

with revenue from state tobacco excise taxes.

Although the document includes recommended

funding ranges for various program components,

state officials are of course responsible for funding

decisions and, in making them, will have to

determine what their most pressing needs are and

what funds are available.

Best Practices identifies the following nine categories

of programs that should be part of any

comprehensive state-level tobacco control program:

I. Community Programs to Reduce Tobacco Use

Local community programs offer a wide range of

prevention activities, including engaging youth in

developing and implementing tobacco control

interventions; developing partnerships with local

organizations; conducting educational programs for

young people, parents, enforcement officials,

community and business leaders, health care

providers, school personnel, and others; and

promoting both governmental and nongovernmental

policies that promote clean indoor air, restrict access

to tobacco products, foster insurance coverage for

smoking-cessation treatment, and support other

program objectives.

II. Chronic Disease Control Programs to Reduce the

Burden of Tobacco-Related Diseases

Even if current tobacco use stopped, the

accumulated effects of smoking would cause disease

among past users for decades to come. Therefore,

any comprehensive tobacco control program should

encompass programs to prevent tobacco-related

diseases and to detect them as early as possible,

including cardiovascular disease prevention

programs, asthma prevention programs, oral health

programs, and cancer registries.

III. School Programs

School program activities include implementing

CDC’s Guidelines for School Health Programs to

Prevent Tobacco Use and Addiction,

14 which call for

tobacco-free policies, teacher training, parental

involvement, cessation services, the implementation

of curricula shown to be effective, and the

coordination of school-based tobacco control efforts

with those of local community coalitions and

statewide media and educational campaigns.

IV. Enforcement

To be effective, tobacco control policies must be

vigorously enforced, particularly policies that

restrict minors’ access to tobacco and those that

restrict smoking in public places. State enforcement

efforts should be coordinated with those of the

Food and Drug Administration (FDA) and the
92

PREVENTION STRATEGIES THAT WORK

Substance Abuse and Mental Health Services

Administration (SAMHSA). California and

Massachusetts have addressed enforcement issues by

making enforcement a required activity for all

recipients of community program grants. Florida

has taken a more centralized approach by having

state alcoholic beverage control officers conduct

compliance checks with the help of locally recruited

youth in all regions of the state.

V. Statewide Programs

State tobacco control programs can support local

programs by providing technical assistance in

conducting program evaluations, using the media to

discourage tobacco use, implementing smoke-free

policies, and reducing minors’ access to tobacco.

Statewide organizations representing population

segments disproportionately affected by tobacco use

can be particularly helpful in devising and

implementing interventions targeting those groups

VI. Counter-Marketing

As its name indicates, counter-marketing is used to

counter the marketing efforts of tobacco companies

as well as subtler social forces (such as youth peer

pressure) that encourage smoking. Countermarketing can take many forms, including paid

television, radio, billboard, and print

advertisements; the use of media advocacy and

other public relations techniques such as press

releases, local antismoking events, and health

promotion activities; and efforts to reduce tobacco

industry sponsorship and promotion of various

events (often by helping to arrange for replacement

sponsors). Counter-marketing activities can be used

to promote smoking cessation and discourage

smoking initiation, as well as to garner public

support for tobacco control interventions. Countermarketing campaigns should be a primary activity

in all states with comprehensive tobacco control

programs.

VII. Cessation Programs

Smoking-cessation programs can yield significant

health and economic benefits. Effective cessation

strategies include brief advice by medical providers,

counseling, and pharmacotherapy. Smokingcessation activities of comprehensive state tobacco

control programs should include establishing

population-based treatment programs such as

telephone cessation helplines; working to ensure

that treatment for tobacco use is covered under

both public and private insurance; and eliminating

cost barriers to treatment for underserved

populations, particularly the uninsured.

Treating Tobacco Use and Dependence,6

 a Public

Health Service-sponsored Clinical Practice

Guideline, updates the 1996 Smoking Cessation,

Clinical Practice Guideline No. 18 that was

sponsored by AHCPR. The original guideline

reflected the scientific research literature published

between 1975 and 1994. This guideline was

written in response to new, effective clinical

treatments for tobacco dependence that have been

identified since 1994, and these treatments promise

to improve the rates of successful tobacco cessation.

A variety of supporting materials are also available,

including a quick reference guide for clinicians and

consumer materials in English and Spanish. For

more information, see www.surgeongeneral.gov/

tobacco.

VIII. Surveillance and Evaluation

Tobacco-use surveillance involves monitoring

people’s tobacco-related behaviors, attitudes, and

long-term health outcomes at regular intervals.

Tobacco control programs should use such

surveillance activities to measure both local and

statewide progress toward meeting short-term and

intermediate objectives.

Through coordinated surveillance and evaluation

activities, tobacco control programs can

demonstrate their accountability, monitor the

implementation of program elements, and measure

their impact over various periods of time. Logic

models can help them to plan and report on these

surveillance and evaluation activities, as well as to

use surveillance and evaluation results to
93

ADVANCING TOBACCO CONTROL

demonstrate the effectiveness of program activities

to decision makers and to show program

stakeholders what the program can accomplish over

a given period of time (Figure 1).

An Introduction to Program Evaluation for

Comprehensive Tobacco Control Programs15 from

CDC recommends that tobacco control programs

divide their evaluation efforts into the following six

steps:

Step 1: Engage stakeholders.

Step 2: Describe the program.

Step 3: Focus the evaluation design.

Step 4: Gather credible evidence.

Step 5: Justify conclusions.

Step 6: Ensure that evaluation findings are used, and

share lessons learned.

To ensure the comparability of evaluation data from

state tobacco control programs throughout the

country, states should consider using surveillance

systems compatible with the Behavioral Risk Factor

Surveillance System (BRFSS), the Youth Risk

Behavior Survey (YRBS), the Adult Tobacco Survey

(ATS), and the Youth Tobacco Survey (YTS). States

can modify these existing systems to meet their

specific needs, either by adding additional questions

or survey modules, by sampling more extensively to

capture local-level data, or by focusing surveillance

efforts on populations with high rates of tobacco

use or tobacco-related illnesses. In addition, states

can combine traditional surveillance with the

collection of data on “environmental indicators”

such as state and local tobacco policies, pro-tobacco

efforts, and taxes on tobacco products; use

information from a variety of sources in program

planning; and disseminate surveillance and

evaluation findings in forms most appropriate for

specific groups of program stakeholders.

Although state agencies should develop the capacity

to manage and conduct surveillance and evaluation

activities, they should also, when possible, partner

with organizations capable of helping them with

these activities, including universities, various health

organizations, and local groups that can help them

reach populations disproportionately affected by

tobacco use.

IX. Administration and Management

To be effective, tobacco control programs will need

a strong management structure to coordinate

program components, involve multiple state and

local agencies (e.g., health, education, law

enforcement) and levels of local government, and

partner with statewide voluntary health

organizations and community groups. In addition,

their administration and management systems must

be able to prepare and implement contracts and

monitor program spending and program activities.

The management team of tobacco control programs

should include people with expertise in program

development, coordination, and management; fiscal

management, including management of funding to

state and local partners; leadership development;

tobacco control and tobacco use prevention

content; cultural competence; public health policy,

including analysis, development, and

implementation; community outreach and

mobilization; training and technical assistance;

health communications, including countermarketing; the strategic use of both free and paid

media messages; strategic planning; gathering and

analyzing data (surveillance); and evaluation

methods.

Technical Resources

General Planning Resources

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

and Health Promotion. Preventing Heart Disease

and Stroke: Addressing the Nation’s Leading Killers,

At A Glance 2003 (www.cdc.gov/nccdphp/aag/

aag_cvd.htm).

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

and Health Promotion, Cardiovascular Health

Program (www.cdc.gov/nccdphp/cvh/index.htm).
94

PREVENTION STRATEGIES THAT WORK

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and

Health. Smoking-Attributable Mortality, Morbidity,

and Economic Costs (SAMMEC) Computer

Software and Documentation, 1996.

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and

Health. Tobacco Information and Prevention Source:

Health Consequences (www.cdc.gov/nccdphp/

tobacco/hlthcon.htm).

Centers for Disease Control and Prevention,

National Center for Environmental Health.

National Asthma Control Program. Reducing Costs

and Improving Quality of Life, At A Glance 2002

(www.cdc.gov/nceh/airpollution/asthma/ataglance/

asthmaAAG.pdf).

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and

Health. Making Your Workplace Smokefree: A

Decision Maker’s Guide. Atlanta: U.S. Department

of Health and Human Services, 1996

(www.cdc.gov/tobacco/research_data/

environmental/etsguide.htm).

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

Targeted to disparate populations

Countermarketing

Policy and

regulatory

action

Community

mobilization

Decreased

smoking 

Reduced exposure

to ETS

State

programs

Federal

programs

Community

and national

partners

Knowledge and

attitude change

Adherence to and

enforcement of bans,

regulations,

and policies

Exposure to

pro-health

messages 

School-based

prevention

and education

curricula

Creation of 

smoking bans,

regulations,

and policies

Reduced tobaccorelated morbidity

and mortality

Decreased

tobacco-related

disparity

Increased

cessation among

youth

and adults

Increased

environments with

no smoking

Reduced initiation

among youth

Outcomes

Inputs Activities Outputs Short-term Intermediate Long-term

Figure 1. Logic Model for Tobacco Use Prevention and Control
95

ADVANCING TOBACCO CONTROL

and Health Promotion. Oral Health: Preventing

Cavities, Gum Disease, and Mouth and Throat

Cancer, At A Glance 2003 (www.cdc.gov/nccdphp/

aag/aag_oh.htm).

School Programs Core Resources

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention and

Health Promotion, Division of Adolescent and

School Health. Health Bibliography: Effective SchoolBased Tobacco Prevention Programs: Recommendations

and Syntheses. 2002.

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention and

Health Promotion. Guidelines for School Health

Programs to Prevent Tobacco Use and Addiction. 1994

(www.cdc.gov/nccdphp/dash/guidelines/

nutptua.htm).

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention and

Health Promotion. Guidelines for School Health

Programs: Preventing Tobacco Use and Addiction,

Overview. 2000.

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention and

Health Promotion. School Health Index for Physical

Activity, Healthy Eating, and a Tobacco-Free Lifestyle.

2002 (www.cdc.gov/nccdphp/dash/SHI/index.htm).

National Association of State Boards of Education.

Fit, Healthy, and Ready to Learn. A School Health

Policy Guide. 2000 (www.nasbe.org).

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention and

Health Promotion. School Health Policies and

Programs Study Fact Sheet: Tobacco Use Prevention.

2001.

Drug Strategies, Inc. Making the Grade: A Guide to

School Drug Prevention Programs. Washington, DC:

Drug Strategies, Inc. 1999

(www.drugstrategies.org).

Enforcement Core Resources

California Environmental Protection Agency

(CalEPA). Health Effects of Exposure to

Environmental Tobacco Smoke. Sacramento:

CalEPA, Office of Environmental Health and

Hazard Assessment, 1997.

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and

Health. Making Your Workplace Smokefree: A

Decision Maker’s Guide. Atlanta: U.S. Department

of Health and Human Services, 1996

(www.cdc.gov/tobacco/research_data/

environmental/etsguide.htm).

DiFranza JR, Celebucki CC, Seo HG. A model for

the efficient and effective enforcement of tobacco

sales laws. Am J Public Health 1998;88:1100–1.

Food and Drug Administration. Regulations

restricting the sale and distribution of cigarettes and

smokeless tobacco products to protect children and

adolescents—final rule. Fed Regist 1996;61:41,314–

75.

Institute of Medicine. Growing Up Tobacco Free:

Preventing Nicotine Addiction in Children and

Youths. Washington, DC: National Academy Press,

1994.

Substance Abuse and Mental Health Services

Administration. Final regulations to implement

section 1926 of the Public Health Service Act

regarding the sale and distribution of tobacco

products to individuals under the age of 18. Fed

Regist 1996;13:1492–1500.

Substance Abuse and Mental Health Services

Administration. Synar Regulation: Tobacco Outlet

Inspection—Guidance. Rockville, MD: SAMHSA,

Center for Substance Abuse Prevention, 1997.

U.S. Department of Health and Human Services.

Preventing Tobacco Use Among Young People: A

Report of the Surgeon General. Atlanta: U.S.
96

PREVENTION STRATEGIES THAT WORK

Department of Health and Human Services, Public

Health Service, 1994.

U.S. Environmental Protection Agency (USEPA).

Respiratory Health Effects of Passive Smoking: Lung

Cancer and Other Disorders. Washington, DC:

USEPA, Office of Research and Development,

Office of Air and Radiation, 1992. Publication No.

EPA/600/6–90/006F.

Statewide Programs Core Resources

California Department of Health Services. A Model

for Change: The California Experience in Tobacco

Control. Sacramento: California Department of

Health Services, 1998.

California Department of Health Services.

California Tobacco Control Project Showcase: A

Compendium of Abstracts. Sacramento: California

Department of Health Services, 1998.

Counter-Marketing Core Resources

Cummings KM, Clark H. The Use of CounterAdvertising as a Tobacco Use Deterrent and Analysis

of Pending Federal Tobacco Legislation. Washington,

DC: Advocacy Institute, Health Science Analysis

Project, 1998.

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and

Health, Media Campaign Resource Center. Media

Campaign Resource Books and Video Catalogs. Vol. I,

1995, and Vol. II, 1998 (www.cdc.gov/tobacco/

mcrc).

Wallack L, Dorfman L, Jernigan D, Themba M.

Media Advocacy and Public Health. Newbury Park,

CA: SAGE Publications, 1993.

Cessation Core Resources

Agency for Health Care Policy and Research.

Smoking Cessation: Clinical Practice Guideline, No.

18, Information for Specialists. Washington, DC:

AHCPR, 1996. AHCPR Publication No. 96–0694.

American Medical Association. How to Help

Patients Stop Smoking, Guidelines for Diagnosis and

Treatment of Nicotine Dependence. Chicago:

American Medical Association, Division of Health

Science, 1994. Publication No. AA41: 93–668.

National Cancer Institute. How to Help Your

Patients Stop Smoking: A National Cancer Institute

Manual for Physicians. Bethesda, MD: NIH, 1991.

NIH Publication No. 93–3064.

National Cancer Institute. How to Help Your

Patients Stop Using Tobacco: A National Cancer

Institute Manual for the Oral Health Team.

Bethesda, MD: NIH, 1993. NIH Publication No.

93–3191.

National Heart, Lung, and Blood Institute. Nurses:

Help Your Patients Stop Smoking. Bethesda, MD:

DHHS, PHS, NIH, 1993. NIH Publication No.

92–2962.

U.S. Preventive Services Task Force. Guide to

Clinical Preventive Services, 2nd ed. Baltimore:

Williams & Wilkins, 1996.

Surveillance and Evaluation Core Resources

MacDonald G, Starr G, Schooley M, Yee SL,

Klimowski K, Turner K. Introduction to Program

Evaluation for Comprehensive Tobacco Control

Programs. Atlanta: Centers for Disease Control and

Prevention, 2001 (www.cdc.gov/tobacco/

evaluation_manual/contents.htm).

Yee SL, Schooly M. Surveillance and Evaluation

Data Resources for Comprehensive Tobacco Control

Programs. Atlanta: Centers for Disease Control and

Prevention, 2001 (www.cdc.gov/tobacco/

surveillance_manual/contents.htm).

Independent Evaluation Consortium. Final Report

of the Independent Evaluation of the California

Tobacco Control Prevention and Education Program:

Wave I Data, 1996–1997. Rockville, MD: The

Gallup Organization, 1998.
97

ADVANCING TOBACCO CONTROL

Pierce JP, Gilpin EA, Emery SL, et al. Tobacco

Control in California: Who’s Winning the War? An

Evaluation of the Tobacco Control Program, 1989–

1996. La Jolla, CA: University of California–San

Diego, 1998.

Substance Abuse and Mental Health Services

Administration, Center for Substance Abuse

Prevention. Reducing Tobacco Use Among Youth:

Community-Based Approaches—A Guideline.

Washington, DC: U.S. Department of Health and

Human Services, Substance Abuse and Mental

Health Services Administration, Center for

Substance Abuse Prevention, 1997. DHHS

Publication No. 97–3146.

Stanford Center for Research in Disease Prevention.

Tell Your Story: Guidelines for Preparing an

Evaluation Report. Palo Alto, CA: California

Department of Health Services, Tobacco Control

Section, 1998.

Windsor, R. Evaluation for Health Promotion,

Health Education, and Disease Prevention Programs,

2nd ed. Mountain View, CA: Mayfield Publishing

Company, 1994.

Administration and Management Core Resources

California Department of Health Services. A Model

for Change: the California Experience in Tobacco

Control. Sacramento: California Department of

Health Services, 1998.

References

1. Centers for Disease Control and Prevention.

Reducing Tobacco Use: A Report of the Surgeon

General: At A Glance. Atlanta: U.S. Department

of Health and Human Services, 2000.

2. Centers for Disease Control and Prevention.

Reducing Tobacco Use: A Report of the Surgeon

General. Atlanta: U.S. Department of Health

and Human Services, 2000.

3. Institute of Medicine. State Programs Can Reduce

Tobacco Use. Washington, DC: National

Research Council, 2000.

4. Centers for Disease Control and Prevention. Best

Practices for Comprehensive Tobacco Control

Programs—August 1999. Atlanta: U.S.

Department of Health and Human Services,

1999.

5. Hopkins D, Fielding J, Task Force on

Community Preventive Services, editors. The

Guide to Community Preventive Services:

Tobacco use prevention and control-reviews,

recommendations, and expert commentary. Am J

Prev Med 2000;20(2S).

6. Fiore MC, Bailey WC, Cohen SJ, et al. Treating

Tobacco Use and Dependence. Clinical Practice

Guideline. Rockville, MD: U.S. Department of

Health and Human Services, Public Health

Service, 2000.

7. Centers for Disease Control and Prevention.

Annual smoking-attributable mortality, years of

potential life lost, and economic costs—United

States, 1995–1999. MMWR Morb Mortal Wkly

Rep 2002;51(14):300–3.

8. Centers for Disease Control and Prevention.

Cigarette smoking among adults—United States,

2000. MMWR Morb Mortal Wkly Rep

2002;51(29);642–5.

9. Substance Abuse and Mental Health Services

Administration (SAMHSA). Summary of

Findings from the 2000 National Household

Survey on Drug Abuse. NHSDA Series H-13.

Rockville, MD: U.S. Department of Health and

Human Services, 2001. DHHS Pub. No. (SMA)

01-3549. Available at www.samhsa.gov/news/

click3_frame.html.

10. Centers for Disease Control and Prevention.

Trends in cigarette smoking among high school

Students—United States, 1991–1999. MMWR

Morb Mortal Wkly Rep 2000;49(33).

11. Centers for Disease Control and Prevention.

Youth tobacco surveillance, 2000. MMWR

Surveill Summ 2001;50(SS-4).

12. Centers for Disease Control and Prevention.

Trends in cigarette smoking among high school

students—United States, 1999-2001. MMWR

Morb Mortal Wkly Rep 2002;51(19):409-12.
98

PREVENTION STRATEGIES THAT WORK

13. U.S. Department of Health and Human

Services. Healthy People 2010 (conference

edition, in two volumes). Washington, DC: U.S.

Department of Health and Human Services,

2000.

14. Centers for Disease Control and Prevention.

Guidelines for school health programs to prevent

tobacco use and addiction. MMWR Recomm Rep

1994;43(RR-2).

15. MacDonald G, Starr G, Schooley M, Yee SL,

Klimowski K, Turner K. Introduction to Program

Evaluation for Comprehensive Tobacco Control

Programs. Atlanta: Centers for Disease Control

and Prevention, 2001.
99

BUILDING A HEALTHIER FUTURE

THROUGH SCHOOL HEALTH PROGRAMS

TABLE OF CONTENTS

The Critical Need for Effective School Health Programs

Healthy People 2010

Promising Practices for School Health Programs

1. Coordinate Multiple Components and Use Multiple Strategies.

2. Coordinate the Activities of Health and Education Agencies and Other Organizations Working to

Improve the Health of Young People.

3. Implement the School Health Guidelines.

4. Use a Program Planning Process to Achieve Health Promotion Goals.

Eight Priority Actions for Improving the Health of Young People

Priority 1. Monitor Critical Health-Related Behaviors Among Young People and the Effectiveness of

School Policies and Programs in Promoting Health-Enhancing Behaviors and Better Health.

Priority 2. Establish and Maintain Dedicated Program-Management and Administrative-Support

Systems.

Priority 3. Build Effective Partnerships Among State-Level Governmental and Nongovernmental

Agencies and Organizations.

Priority 4. Establish Policies to Help Local Schools Effectively Implement Coordinated School Health

Programs and the School Health Guidelines.

Priority 5. Establish a Technical-Assistance and Resource Plan that Will Provide Local School Districts

with the Help They Need to Effectively Implement School Health Guidelines.

Priority 6. Implement Health Communications Strategies to Inform Decision Makers and the Public

About the Role of School Health Programs in Promoting Health and Academic Success Among

Young People.

Priority 7. Develop a Professional Development Plan for School Officials and Others Responsible for

Establishing Coordinated School Health Programs and Implementing the School Health

Guidelines.

Priority 8. Establish a System for Evaluating and Continuously Improving State and Local School

Health Programs.

National Leadership

Challenges Ahead

References

101

6

BUILDING A HEALTHIER FUTURE

THROUGH SCHOOL HEALTH PROGRAMS

The Critical Need for Effective School

Health Programs

In the United States, 53 million young people attend

nearly 129,000 schools for about 6 hours of classroom time each day for up to 13 of the most

formative years of their lives.1

 More than 95% of

young people aged 5–17 years are enrolled in school.

Because schools are the only institutions that can

reach nearly all youth, they are in a unique position

to improve both the education and health status of

young people throughout the nation.

Supporting school health programs to improve the

health status of our nation's young people has never

been more important. Many of the health challenges

facing young people today are different from those of

past decades. Advances in medications and vaccines

have largely reduced the illness, disability, and death

that common infectious diseases once caused among

children. Today, the health of young people, and the

adults they will become, is critically linked to the

health-related behaviors they choose to adopt.

Certain behaviors that are often established during

youth contribute markedly to today's major causes

of death, such as heart disease, cancer, and injuries.

These behaviors include

• Using tobacco.

• Eating unhealthy foods.

• Not being physically active.

• Using alcohol and other drugs.

• Engaging in sexual behaviors that can cause HIV

infection, other sexually transmitted diseases, and

unintended pregnancies.

• Engaging in behaviors that can result in violence

or unintentional injuries.

Three of these behaviors—tobacco use, unhealthy

eating, and inadequate physical activity—contribute

to chronic diseases such as cardiovascular disease,

cancer, and type 2 diabetes. These behaviors are

typically established during childhood and adolescence, and recent trends have been alarming. Young

people are clearly at risk, as the following data show:

• Every day, nearly 5,000 young people try their

first cigarette.2

• In 2001, only 32% of high school students

participated in daily physical education classes,

compared with 42% of students in 1991.3

• Seventy-nine percent of young people do not eat

the recommended five servings of fruits and

vegetables each day.4

• Each year, more than 900,000 adolescents become

pregnant,5,6 and about 3 million become infected

with a sexually transmitted disease.7

Rigorous studies in the 1990s showed that health

education in schools can reduce the prevalence of

health-risk behaviors among young people.

• Studies using a multiple-session school curriculum

based on the social influences model and delivered

to sixth- and seventh-grade students achieved

significant reductions in smoking among these

students through the ninth grade.8

• The prevalence of obesity decreased among girls

in grades 6–8 who participated in a school-based

intervention program.9
102

PREVENTION STRATEGIES THAT WORK

• Middle/junior high school students enrolled in the

school-based Life Skills Training Program were less

likely than other students to use tobacco, alcohol,

or marijuana, and these effects lasted through the

12th grade (www.lifeskillstraining.com).10

Healthy People 2010

Healthy People 2010 outlines 467 national health

objectives, of which 107 are directed specifically

toward adolescents and young adults (i.e., 10- to

24-year-olds). Among these 107 objectives, 21 are

identified as "critical" on the basis of two criteria:

1) they involve critical health outcomes or behaviors

that contribute to them, and 2) state-level data

necessary to measure progress in meeting the

objective are available or soon will be.4

Promising Practices for School Health

Programs

This document describes promising practices

that states and communities should consider

when planning school-based policies and

programs to help young people avoid

behaviors that increase their risk for obesity

and chronic disease, especially tobacco use,

unhealthy eating, and inadequate physical

activity. These promising practices

incorporate four key concepts.

1. Coordinate Multiple Components and Use

Multiple Strategies.

Modern school health programs

integrate the efforts and resources of

education, health, and social service

agencies to provide a comprehensive

set of programs and services to

promote health and prevent chronic

diseases and their risk factors among

young people. Such school health

programs systematically coordinate the

following eight components: 1) health

services; 2) health education; 3) efforts to

ensure healthy physical and social environments; 4) nutrition services; 5) physical

education and other physical activities; 6)

counseling, psychological, and social services; 7)

health programs for faculty and staff; and 8)

collaborative efforts of schools, families, and

communities to improve the health of students,

faculty, and staff (Figure 1).

A coordinated school health program provides a

framework for school districts and schools to use in

organizing and managing school health initiatives. It

Counseling,

Psychological

& Social

Services

Health

Education

Health

Promotion

for Staff

Healthy School

Environment

Health

Services

Nutrition

Services

Family/

Community

Involvement

Physical

Education

The 8 Components of a Coordinated School Health Program

Figure 1. A Coordinated School Health

Program (CSHP)

Resources

• Building Business Support for School Health

Programs. 1999. National Association of State

Boards of Education. Available from

www.nasbe.org/HealthySchools.
103

BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS

also provides an organizational framework for

agencies to use in planning and coordinating school

health initiatives, synchronizing comparable public

health and school health programs, and efficiently

using multiple funding sources to improve the health

and education of young people.

2. Coordinate the Activities of Health and Education

Agencies and Other Organizations Working to Improve

the Health of Young People.

Health and education agencies share the common

goal of improving and protecting the health and

well-being of young people, so collaboration should

be encouraged at all levels. It is important to build a

state-level structure that supports the implementation of a coordinated approach to school health.

Bringing together key resources, programs, and

decision makers within a supportive structure

demonstrates that school health programs are a

priority and models a collaborative structure for

those involved in implementing school health

programs at the local level. State health and education agencies that do not have a school health

coordinator position should be encouraged to

establish one to facilitate communication and

coordination of programs among key players.

3. Implement the School Health Guidelines.

Developed by the Centers for Disease Control and

Prevention (CDC) after an exhaustive review of

published research and with input from academic

experts and national, federal, and voluntary

organizations interested in child and adolescent

health, these school health guidelines offer specific

recomendations to help states, districts, and schools

implement school health programs and policies that

have been found to be most effective in promoting

healthy behaviors among young people.

The school health guidelines emphasize multiple

strategies to prevent tobacco use, promote physical

activity and healthy eating, and reduce rates of

obesity among young people. The guidelines also

identify priorities for state decision makers to

consider. Recommendations address policy development, curriculum development and selection,

instructional strategies, environmental changes,

direct interventions, professional development,

family and community involvement, program

evaluation, and linkages among components of a

coordinated school health program.

A number of tools have been developed that can

help schools implement the school health guidelines.

These include the following:

• School Health Index for Physical Activity, Healthy

Eating, and a Tobacco-Free Lifestyle: A SelfAssessment and Planning Guide. This tool from

CDC enables schools to identify strengths and

weaknesses of health promotion policies and

programs; develop an action plan for improving

student health; and involve teachers, students,

parents, and the community in promoting healthenhancing behaviors and better health.

• Fit, Healthy, and Ready to Learn: A School Health

Policy Guide. This policy guide from the National

Association of State Boards of Education provides

direction on establishing an overall policy framework for school health programs and specific

school policies to promote physical activity and

healthy eating and discourage the use of tobacco.

The guide is designed for use by states, school

Resources

• Guidelines for School Health Programs to

Prevent Tobacco Use and Addiction. MMWR

1994;43(RR-2). Available at www.cdc.gov/

nccdphp/dash/guidelines.

• Guidelines for School and Community

Programs to Promote Lifelong Physical Activity

Among Young People. MMWR 1997;46

(RR-6). Available at www.cdc.gov/nccdphp/

dash/guidelines.

• Guidelines for School Health Programs to

Promote Lifelong Healthy Eating. MMWR

1996;45(RR-9). Available at www.cdc.gov/

nccdphp/dash/guidelines.
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PREVENTION STRATEGIES THAT WORK

districts, and individual schools, both public

and private.

• Changing the Scene: A Guide to Local Action. This

kit from the U.S. Department of Agriculture

(USDA) promotes discussion of healthy school

nutrition environments at the local, state, and

national levels. Tools within the kit will help

school administrators, teachers, parents, school

food-service professionals, and community and

business leaders to work together to support

changes in the school nutrition environment.

4. Use a Program Planning Process to Achieve Health

Promotion Goals.

The exact nature of coordinated school health

programs depends on the unique needs of the school

population and on the resources available to the

school and community. Having a program planning

process in place is critical for program improvement

and long-range planning. This process, which should

involve all stakeholders, includes defining priorities

on the basis of a population's unique needs, determining what resources are available, developing a

strategic plan based on realistic goals and measurable

objectives, and establishing processes for determining

whether these goals and objectives are met and for

continuously improving the program.11

Eight Priority Actions for Improving the Health of

Young People

In the remainder of this chapter, we discuss the

following eight priority actions that states can take to

improve the health and academic outcomes of their

young people.

1. Monitor critical health-related behaviors among

young people and the effectiveness of school

policies and programs in promoting healthenhancing behaviors and better health.

2. Establish and maintain dedicated programmanagement and administrative-support systems

at the state level.

3. Build effective partnerships among state-level

governmental and nongovernmental agencies

and organizations.

4. Establish policies to help local schools effectively

implement coordinated school health programs

and the school health guidelines.

5. Establish a technical-assistance and resource plan

that will provide local school districts with the

help they need to effectively implement the school

health guidelines.

6. Implement health communications strategies to

inform decision makers and the public about the

role of school health programs in promoting

health and academic success among young people.

7. Develop a professional-development plan for school

officials and others responsible for establishing

coordinated school health programs and implementing the school health guidelines.

8. Establish a system for evaluating and continuously

improving state and local school health policies

and programs.

Priority 1. Monitor Critical Health-Related Behaviors

Among Young People and the Effectiveness of School

Policies and Programs in Promoting Health-Enhancing

Behaviors and Better Health.

Conduct a statewide assessment of critical health-risk behaviors

and the policies and programs designed to discourage them.

School health programs should be based on highquality data describing the health-risk behaviors of

young people and the characteristics of the policies

and programs already in place to address those

behaviors. The Council of State and Territorial

Epidemiologists has approved the following set of

adolescent health-risk indicators for inclusion in the

National Public Health Surveillance System:12

• Cigarette smoking.

• Smokeless tobacco use.

Resources

• Step by Step to Comprehensive School Health:

The Program Planning Guide. ETR Associates.

Available at www.etr.org/pub.

• Step by Step to Health-Promoting Schools. ETR

Associates. Available at www.etr.org/pub.
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS

• Consumption of fewer than five servings of fruits

or vegetables daily.

• Lack of vigorous and moderate physical activity.

• At risk for being overweight.

• Overweight.

• Alcohol use.

• Binge drinking.

To obtain continuous, high-quality, comparable data

for each indicator and other measures of chronic

disease risk factors, states can conduct a Youth Risk

Behavior Survey (YRBS) every 2 years among

representative samples of 9th- through 12th-grade

students. States can supplement the YRBS data with

data from the Youth Tobacco Survey (YTS) or other

surveys assessing relevant health-related behaviors

and their determinants among young people. States

conducting the YRBS, YTS, or other school-based

surveys can receive technical assistance from CDC in

selecting the sample and implementing the survey,

thus reducing the burden that multiple school-based

surveys can place on schools.

To evaluate the effectiveness of school health policies

and programs, states can develop School Health

Education Profiles every 2 years by surveying

representative samples of middle/junior high and

senior high schools. These surveys provide

information on local education and health policies,

including tobacco-use-prevention policies, nutritionrelated policies, violence-prevention policies, health

education, and physical education and physical

activity programs.

States should create a framework for coordinating

state-level data-gathering and data-analysis activities

and establish ongoing processes for selecting samples,

collecting data, interpreting results, writing reports

for state and local decision makers, and sharing data

with agencies and organizations interested in

improving the health of young people. Results from

the YRBS and the profiles can be disseminated to

key decision makers in both the public health and

education sectors, such as state and local health

officers, education administrators, school board

members, legislators, and parents.

YRBS and School Health Education Profiles data can

be used to describe the extent and type of health-risk

behaviors among students, raise public awareness of

these behaviors, set program goals, develop health

education programs, monitor health education

policies and programs, support professional

development, and support health-related legislation.

States can also participate in national surveys that

measure health-risk behaviors among young people,

such as the National Youth Risk Behavior Survey, or

that measure school health policies and programs,

such as the School Health Policies and Programs

Study (SHPPS). These surveys provide national data

that can be compared with state-level data.

Resources

• Youth Risk Behavior Surveillance System (YRBSS): Information about the YRBSS is available at

www.cdc.gov/yrbs.

• School Health Policies and Programs Study (SHPPS): Information about SHPPS and sample questionnaires

are available at www.cdc.gov/shpps.

• Handbook for Conducting Youth Risk Behavior Surveys (YRBS). Centers for Disease Control and

Prevention, 2000. Contact CDC at 770-488-6170.

• PC Sample/PC School: Survey TA Sampling Software. Centers for Disease Control and Prevention, 2000.

Contact CDC at 770-488-6170.

• Handbook for Developing School Health Education Profiles (SHEP). Centers for Disease Control and

Prevention, 2000. Contact CDC at 770-488-6170.
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PREVENTION STRATEGIES THAT WORK

As an example of how state survey data can be used,

every 2 years the Montana Office of Public Instruction distributes the Montana School Health Education

Profile: The Status of Health Education in Montana

Schools to state leaders, parents, and others interested

in school health education. This document is used to

set policy and establish priorities for improving

health education programs. For more information,

contact the Montana Department of Education at

406-444-1963.

Support local-level assessments of school health policies

and programs.

States can support local assessments of school health

policies and programs to determine their strengths

and weaknesses and to identify the resources needed

to successfully implement priority school health

guidelines. The information can be useful to local

school and community leaders in developing a strategic plan for improving the health and education

of youth.

The School Health Index for Physical Activity, Healthy

Eating, and a Tobacco-Free Lifestyle: A Self-Assessment

and Planning Guide can help school officials assess

the strengths and weaknesses of the eight

components of their school health program and of

other policies and programs related to

chronic disease prevention, establish priorities for

improving programs, and monitor changes in

processes and outcomes.

State health and education agencies should also

provide technical assistance and resources to support

local-level assessment and assist schools in analyzing

and using assessment results gathered through the

School Health Index or other instruments.

Priority 2. Establish and Maintain Dedicated ProgramManagement and Administrative-Support Systems.

State and local agencies collectively build the support

systems to plan, implement, and evaluate fully

functioning coordinated school health programs. By

coordinating the allocation of new resources and

using existing resources more efficiently, state

agencies can help schools to meet the health needs of

students and their families. To build a state-level

infrastructure that supports coordinated school

health programs, health and education agencies must

work with other relevant state agencies such as social

services, mental health, and environmental health, as

well as with nongovernmental organizations in the

state. The heads of state government agencies must

commit to supporting the process of infrastructure

development. These leaders should focus on the

following when developing infrastructure.

• Personnel and Organizational Involvement:

State and local leaders of school health programs

should identify the relevant agencies and the

personnel responsible for implementing school

health-related policies and programs and should

help to coordinate the delivery and use of

resources for multiagency programs related to

school health.

• Authorization and Funding: State and local

leaders should also 1) identify laws, directives,

policies, and mandates that authorize school

health programs and promote the implementation

of school health guidelines at the local level and

suggest new ones that may be needed; 2) obtain

the funding needed to support school health

programs and ensure that the funding can be used

in flexible ways; and 3) establish interagency

agreements to facilitate collaborative program

planning and to provide resources for local school

health programs.

The search for funding sources can be complicated because coordinated school health programs

cover many content areas and health problems. In

Resources

• School Health Index for Physical Activity,

Healthy Eating, and a Tobacco-Free Lifestyle: A

Self-Assessment and Planning Guide. Atlanta:

U.S. Department of Health and Human

Services, Centers for Disease Control and

Prevention, 2000. Available at www.cdc.gov/

nccdphp/dash/SHI/index.htm.
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS

addition, funding sources and application

protocols change substantially from year to year.

The Healthy Youth Funding Database from CDC

provides access to an array of current information

on federal, state, and private-sector funding. The

easy-to-use database offers examples of how states

use federal funds to support adolescent and school

health programs.

• Technical Assistance and Resources: State and

local agency leaders should develop processes for

identifying, developing, and disseminating

resources for supporting coordinated school health

programs and implementing the school health

guidelines at the school and district levels. They

should identify existing human, data, technological, and material resources that could be used

to enhance school health programs; obtain

additional resources if they are needed; coordinate

the use of professional development resources to

improve statewide training networks; and

coordinate the support provided by external

partners, including institutions of higher

education and philanthropic agencies.

• Communications and Linkages: State and local

leaders must establish and strengthen linkages that

will 1) build the state's capacity to assist in the

local implementation of school health guidelines

and coordinated school health programs, 2)

strengthen collaborations among relevant partners,

and 3) facilitate advocacy for school health

programs. They should also establish

communications networks to promote broadbased decision making, to ensure that state-level

policies and programs are adopted at the local

level, and to promote the effective use of local

school and district resources to enhance school

health programs.

In addition to focusing on these important

organizational supports, health and education leaders

must help state and local school health-related staff

develop the skills they need to effectively organize

and manage school health programs. The

Coordinated School Health Program Infrastructure

Development: Process Evaluation Manual can help

build the necessary support for coordinated school

health programs and institutionalize this support at

the state and local levels.

State agencies in Wisconsin and Rhode Island have

completed assessments of their organizational

capacity and leadership for school health and are

using the results to strengthen their infrastructure

for school health. California created a consensus

document, Blueprint for Action, to set directions for

state school health programs.

Priority 3. Build Effective Partnerships Among StateLevel Governmental and Nongovernmental Agencies

and Organizations.

Reducing health-risk behaviors among young people

is a complex effort that requires cooperation and

collaboration among many partners at the state,

regional, and local levels. At the state level, structures

for intra-agency, interagency, and community

partnerships must be developed.

Build coordination and planning within state agencies.

State departments of health can foster the intraagency coordination of programs that address the

needs of young people (e.g., maternal and child

health, chronic disease, cardiovascular health, physical activity, nutrition, tobacco control) to ensure

Resources

• Coordinated School Health Program

Infrastructure Development: Process Evaluation

Manual. Atlanta: U.S. Department of Health

and Human Services, Centers for Disease

Control and Prevention, 1997. Available at

www.cdc.gov/nccdphp/dash/publications/

index.htm.

Resources

• Healthy Youth Funding Database. CDC.

Available at www.cdc.gov/nccdphp/shpfp/

index.asp.
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PREVENTION STRATEGIES THAT WORK

that these programs, which are often delivered in

both community and school settings, are connected

and efficient.

Similarly, state departments of education can foster

the intra-agency coordination of programs such as

Safe and Drug-Free Schools, health education,

physical education, food services, health services, and

counseling and psychological services. In short, state

departments of both health and education should

strive to build structures that foster intra-agency

collaboration and planning. Such internal partnerships allow agencies to use resources more efficiently,

improve communication among staff involved with

complementary programs, and, as a result,

strengthen the programs themselves.

Promote collaboration among state agencies.

To reduce duplication of effort and maximize the use

of limited state resources, leaders of state agencies

should establish a school health interagency program

committee. This committee's primary role would be

to coordinate the management and implementation

of multiple school health-related programs across

agencies. State agencies can develop agreements

(e.g., memoranda of understanding) that include

jointly prepared plans for coordinating administrative responsibilities and activities among agencies.13

The interagency collaboration can be coordinated

and jointly led by school health leaders from the

state education and health agencies. Other members

of this committee might include representatives from

state agencies that address social services, justice,

mental health, agriculture, substance abuse, parks

and recreation, labor, economic development, and

transportation, as well as representatives from the

governor's office.

Such an interagency committee should not be

limited to agency leaders. It should include the

program staff who are responsible for promoting

the implementation of school health guidelines and

strengthening the delivery of services through local

school health programs. The committee may take

on a variety of roles and responsibilities, including

the following:14

• Improve communication, planning, coordination,

and collaboration among state agencies engaged

in ongoing activities relevant to the health and

academic achievement of young people.

• Identify needs and strategies for improving state

leadership of school health programs.

• Identify and implement state policies and programs to facilitate quality school health programs.

Resources

• Final Report: Comprehensive School Health

Program Infrastructure Needs Assessment.

Providence: Rhode Island Department of

Education and Department of Health, 1996.

Available at www.health.state.ri.us/disprev/

hshk/home.htm.

• Supporting School Health: An Initial Assessment

of Infrastructure for Comprehensive School

Health, Student Services, Prevention and

Wellness Programs. Phase One, DPI Status and

Dynamics. Madison, WI: Wisconsin

Department of Public Instruction, 1995.

• Building Infrastructure for Coordinated School

Health: California’s Blueprint. Sacramento:

California Department of Education, 2000.

Available at www.cde.ca.gov.

Resources

• Schools and Health: Our Nation’s Investment.

Institute of Medicine. Washington, DC:

National Academy of Science Press, 1997:

247-52.

• Coordinated School Health Program

Infrastructure: Process Evaluation Manual.

Atlanta: U.S. Department of Health and

Human Services, Centers for Disease Control

and Prevention, 1997. Available at

www.cdc.gov/nccdphp/dash/publications/

index.htm.
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS

• Coordinate federal, state, and philanthropic

funding for school health programs awarded to

state agencies.

• Help identify successful school health programs

and disseminate information about them to school

health officials throughout the state.

• Help coordinate health programs in private,

voluntary, and postsecondary institutions.

• Prepare reports and make policy recommendations

to relevant state officials.

Strong working relationships between state agencies

are evident in Tennessee and Oregon. In Tennessee,

for example, the state commissioners of education

and health issued a joint statement on school health

that resulted in the formation of a working group

with members from each agency. As a result of this

group's efforts, the agencies executed a memorandum

of agreement that established a permanent working

relationship between the two agencies and addressed

all components of the Tennessee Coordinated School

Health Program.

The Oregon Coordinated School Health Initiative is

steered by the Blueprint Working Group, which is

responsible for guiding the development of the

Coordinated School Health Blueprint for Action.

This 5-year strategic plan will outline the priority

state and local actions to

• Build infrastructure for coordinated school

health programs.

• Strengthen the components of coordinated

school health programs.

• Address key health-risk behaviors among

children and adolescents.

The Blueprint Working Group is made up of state

agency program coordinators responsible for the

various components of a coordinated school health

program and for reducing health-related risk factors

among children and adolescents. Members of the

working group from the Oregon Department of

Education include the coordinated school health

program director, an HIV prevention specialist, the

director of federal programs, a physical education

specialist, a child nutrition programs specialist, the

juvenile corrections director, a school counseling

specialist, and a safe and drug-free schools specialist.

Members from the the Oregon Department of

Health include the coordinated school health

program director, the adolescent health manager, the

YRBS coordinator, and staff from the following

programs: tobacco, cardiovascular health, schoolbased health, immunization, environmental health,

family planning/teen pregnancy prevention, and

asthma. The working group also includes

representatives from the Oregon Office of Alcohol

and Drug Abuse Program, including staff from the

Governor's Council on Alcohol Tobacco and Other

Drugs, and the Youth Development Director from

the Oregon Commission on Children and Families.

Establish a state school health coordinating council.

To expand access to school health resources and

coordinate efforts of the larger community interested

in improving the health of students, states can

establish a school health coordinating council.10

This council can include representatives from the

interagency program committee; health and

education leadership organizations such as the state

school boards association; nongovernmental

organizations such as the American Cancer Society;

and associations representing health education,

physical education, health care providers, postsecondary institutions, businesses, and community

health coalitions, as well as parents and students.

States should establish policies and guidelines that

will clearly define the roles and responsibilities of the

school health coordinating council in establishing

priorities for state school health programs. These

roles and responsibilities could include the following:

• Developing statewide consensus on key issues

related to school health programs and policies and

communicating these issues to the interagency

program committee.

• Showcasing effective and innovative coordinated

school health programs for multiple audiences,

including the state legislature.
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PREVENTION STRATEGIES THAT WORK

• Conveying a clear vision of the role of school

health programs in improving the health and

academic achievement of students. Councils

might convey this vision by developing consensus

statements about the correlations between

participation in such programs and academic

success, by identifying and reducing the barriers

to collaboration among state organizations

concerned with the health and well-being of

children and adolescents, or by integrating

programs across agencies and organizations.

• Proposing appropriate state policies and legislation

and helping school districts and schools implement

the school health guidelines by disseminating

resources such as the School Health Index.

The Rhode Island School Health Advisory Council

was formed as a primary partner in the state's

comprehensive school health initiative, Healthy

Schools! Healthy Kids! The council comprises

approximately 150 members representing various

constituency groups concerned with changing health

priorities, including representatives from state

government, the state chapter of the American

Academy of Pediatrics, hospitals, schools, community groups, colleges and universities, and various

heart, lung, and cancer associations. The council

developed Rhode Island's Healthy Schools! Healthy

Kids! Plan for Comprehensive School Health and

continues to implement the recommendations in the

plan and to help identify new and emerging health

priorities in school health.

Priority 4. Establish Policies to Help Local Schools

Effectively Implement Coordinated School Health

Programs and the School Health Guidelines.

States use laws, policy statements, and administrative

regulations to articulate their expectations and

recommendations for school health programs and

the important role that schools have in improving

the health of young people.14 State and local agency

leaders can establish policies to support local

implementation of the school health guidelines and

programs. In addition, state education and health

agencies can provide model implementation policies

to local school districts. This option is especially

important in states that have minimal legislative

mandates for school health. Model policies should be

developed in cooperation with the state's board of

education and association of school boards.

The National Association of State Boards of

Education (NASBE), in cooperation with the

National School Boards Association (NSBA), has

developed Fit, Healthy, and Ready to Learn, a school

health policy guide that translates the school health

guidelines into model policy language.15This

document can help guide policy development at the

state, district, and school levels. It also contains a

wealth of information that can guide state health

leaders through the process of creating educational

policy.

State school health policies typically are enacted or

adopted by either the state legislature, the state board

of education, or state commissions. Some regulations

that have the force of policy can be adopted by the

state education agency, which typically is also

responsible for implementing state school health

policies. The state health department can provide

data and testimony to help guide the development of

state school health policies. Following are some of

the issues that these state-level policies can address.

The formation of school health councils and placement of school

health coordinators at the district level.

Some school boards delegate oversight authority on

specified health-related issues to a school health

Resources

• Fit, Healthy, and Ready to Learn: A School

Health Policy Guide. National Association of

State Boards of Education. Washington, DC:

NASBE, 1999. Available at www.nasbe.org/

HealthySchools/nasbepubs.mgi.

• Changing the Scene, Improving the School

Nutrition Environment: A Guide to Local

Action. U.S. Department of Agriculture, Food

and Nutrition Service, 2000. Available at

www.fns.usda.gov/tn/Healthy/changing.html.
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS

coordinating council that includes parents and

community representatives. This council might

operate as a standing committee of the board or as a

distinct body. It might simply be an advisory body or

might have authority to enhance program coordination among staff members working in the various

school health components. When such a council is

active and has real influence, it is a natural forum for

involving outside professionals—such as physicians,

law enforcement officers, media representatives, and

university faculty members—with the school district.

Virginia and Texas require districts to have school

health councils.

The size of a superintendent's staff depends on the

size and the resources of the district. A district may

or may not have school health program coordinators

who provide guidance and technical assistance to

school personnel. If they are present, such staff

members are natural points of contact for outside

professionals who want to work with schools.

Instructional delivery and curricula content.

State education agencies and local school districts

may use the National Health Education Standards,

which are based on health education theory and

practice, to establish curriculum frameworks and

standards. These standards provide a framework for

decisions about which lessons, strategies, activities,

and types of assessment to include in a health

education curriculum. Health education curricula

based on the national standards can foster universal

health literacy, which the Joint Committee on

National Health Education Standards defines as the

ability to obtain, interpret, and understand basic

health information and services and to use such

information and services to improve one's health.

Student and staff performance standards.

State boards of education, state school boards

associations, and public health boards can set

learning standards for health education and physical

education. These standards can serve as the basis for

local school health education and physical education

programs and the development of performance

standards for teachers. Many states have developed

student performance standards that are either based

on or aligned with national health- and physicaleducation standards.

Specifications for a healthy school nutrition environment.

State boards of education can adopt policies that

limit the number of times that students have access

to food and beverages in vending machines at school

or that set specific nutritional quality standards for

the types of food and beverages available on campus,

including those in vending machines. In West

Virginia, the state board of education adopted a

Resources

• Improving School Health: A Guide to the Role of

the School Health Coordinator. Atlanta:

American Cancer Society, 1999. Available at

www.schoolhealth/info.

• Improving School Health: A Guide to School

Health Councils. Atlanta: American Cancer

Society, 1998. Available at www.schoolhealth/

info.

• Promoting Healthy Youth, Schools, and

Communities: A Guide to Community-School

Health Advisory Councils. Des Moines: Iowa

Department of Public Health, 1999. Available

at www.idph.state.ia.us/fch/fam_serv/

advisory.htm.

Resources

• National Health Education Standards:

Achieving Health Literacy. Joint Committee on

National Health Education Standards.

Atlanta: American Cancer Society, 1995.

Available at www.aahperd.org/aahe/

natl_health_education_standards.html.

• Moving into the Future: National Standards for

Physical Education. National Association for

Sports and Physical Education. Washington,

DC: NASPE, 1995. Available at

www.aahperd.org/naspe/publicationsnationalstandards.html.
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nutrition policy for the types of foods available in

school vending machines that is one of the strongest

in the nation.

Tobacco-free schools.

A tobacco-free environment is one in which tobacco

use is prohibited on school property, including

buildings, grounds, and vehicles, and at schoolsponsored events on and off school property. This

rule applies to students, staff members, and visitors.

Policies that ensure a tobacco-free environment can

be adopted at the school, district, or state level. At

the state level, these policies are generally enacted as

law by the state legislature, but some states have

empowered their state boards of education with the

authority to mandate policies that affect districts and

schools. States with tobacco-free school policies

include Alabama, Arizona, Arkansas, California,

Colorado, Hawaii, Mississippi, New Mexico, New

York, Ohio, Texas, Utah, Washington, and West

Virginia.

Procedures for monitoring and enforcing tobaccofree schools policy can also be established at the

local or state level. For example, a state department

of education may require districts to report tobaccouse violations; a local school board might require a

progressive discipline plan for student policy

violations that begins with an educational

intervention. The National Association of State

Boards of Education and a number of state and

local education and health agencies have produced

guidelines for implementing tobacco-free school

policies.

Quality professional development of school health staff.

State boards of education can set professional development requirements for school health program staff

and other personnel who implement health programs

in schools. For example, Maine decided to focus on

middle school students as part of its efforts to reduce

tobacco addiction rates among teens and young

adults. All of the state's middle school teachers were

offered professional development in Life Skills

Training, a program to help teens develop healthy

personal and social skills. Since the program began in

1997, smoking among Maine high school students

Resources

• School Health: Findings from Evaluated

Programs. 2nd ed. U.S. Department of

Health and Human Services, Office of

Disease Prevention and Health Promotion.

Washington, DC: HHS, 1998.

• Safe and Drug-Free Schools Program. Principles

of Effectiveness. U.S. Department of

Education. Federal Register. Vol. 63, No.

104, 1998:29902–6. June 1, 1998. Available

at www.ed.gov/legislation/FedRegister/

announcements/1998-2.

• Exemplary and Promising Safe, Disciplined,

and Drug-Free Schools Programs. U.S.

Department of Education, Office of Special

Educational Research and Improvement and

Office of Reform Assistance and Dissemination. Washington, DC: DoE, 2001.

• Health Framework for California Public

Schools Kindergarten Through Grade Twelve.

California Department of Education.

Sacramento: California DoE, 1994.

Resources

• Fit, Healthy, and Ready to Learn: A School

Health Policy Guide. National Association of

State Boards of Education. Washington, DC:

NASBE, 1999. Available at www.nasbe.org/

HealthySchools/fithealthy.mgi.

• Creating and Maintaining a Tobacco-Free School

Policy. Partnership for a Tobacco-Free Maine.

Augusta, ME: Department of Human Services.

2000. Available at www.tobaccofreemaine.org.

• Tobacco-Free School Policy Guide. Available from

the Office of Public Instruction, P.O. Box

202501, Helena, MT 59620-2501.

• Guidelines for Implementation of West Virginia

Board of Education Policy 2422.5A: Tobacco

Control. Available from the West Virginia

Department of Education, 1900 Kanawaha

Blvd. East, Charleston, WV 25305-0330.
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS

has dropped more than 20%. Increases in the state

excise tax and new community-based programs also

contributed to this decrease. (For more information

about the importance of professional development,

see Priority 7.)

Priority 5. Establish a Technical-Assistance and Resource

Plan that Will Provide Local School Districts with the

Help They Need to Effectively Implement School Health

Guidelines.

To advance state policies and support the local

implementation of priority school health policies

and programs that are consistent with the school

health guidelines, state and local agencies can

develop and implement a plan for providing

technical assistance and resources to school districts

and schools. State education and health agencies

must develop the capacity to help schools improve

their school health programs and provide school

personnel with the tools they need to help reduce

tobacco use, increase physical activity, and support

healthy eating patterns among students. State and

local health and education agency leaders can

• Establish criteria to help local schools develop,

assess, and select effective curricula; institute

processes for identifying and reviewing potential

programs based on these established criteria; and

develop strategies for disseminating information

about selected programs to teachers and

community members.

• Develop and disseminate guidelines and resources

to assist school districts in establishing school

health councils.

• Identify and promote the use of resources for

developing school health policy and for planning

and assessing school health programs (e.g., CDC's

School Health Index; NASBE's Fit, Healthy, and

Ready to Learn; and USDA's Changing the Scene)

and make these resources available to local school

districts. For example, in Georgia, the DeKalb

County Board of Education and Board of Health

have collaborated to promote the use of the School

Health Index in DeKalb's elementary schools. In

the 2001–2002 school year, 17 schools completed

the index, including the action plans, and

8 schools received funding from a variety of

Board of Health programs. Funded activities

include the following:

• Hiring certified physical education teachers

for the first time.

• Developing walking clubs.

• Establishing wellness programs for school

staff members.

• Purchasing exercise equipment for students

to use.

• Developing fitness stations on the school

campus for use by students, staff members,

and the community.

• Providing professional development for

teachers.

• Offering healthier choices in the school

vending machines.

Resources

• Moving into the Future: National Standards

for Physical Education. National Association

for Sports and Physical Education.

Washington, DC: NASPE, 1995. Available

at www.aahperd.org/naspe/publicationsnationalstandards.html.

• National Health Education Standards:

Achieving Health Literacy. Joint Committee

on National Health Education Standards.

Atlanta: American Cancer Society, 1995.

Available at www.aahperlth_education_

standards.htm.

• Keys to Excellence: Standards of Practice for

Nutrition Integrity. American School Food

Service Association. Alexandria, VA:

ASFSA, 1995. Available at www.asfsa.org.

(Search “Keys to Excellence.”)

• Scope and Standards for Professional School

Nursing Practice. National Association of

School Nurses, Inc., and American Nurses

Association. Washington, DC: American

Nurses Publishing. 2001. Available at

www.nasn.org and at www.ana.org.
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PREVENTION STRATEGIES THAT WORK

• Identify community-resource personnel and

programs that complement school health policies

and make these available to local school districts

to foster community-school partnerships.

• Identify national standards and guidelines for

health education, physical education, school

nutrition programs, and school health services

and convey this information to local school

districts to facilitate effective policy and program implementation.

• Establish technical-assistance communication

networks (e.g., e-mail networks) or refer school

health staff to existing national technicalassistance communication networks. For example,

the Maine Department of Education, through its

Maine's Learning Results, has developed a

technical-assistance plan to strengthen state and

local efforts to improve student learning, define

professional development needs, update local

curricula and instructional practices, and assess

student achievement. It also provided additional

resources to improve school health programs

through its publications, communications

networks, and technical assistance.

• Identify a contact or lead person in every school

to receive regular school health communications

and resources.

• Identify appropriate media campaign materials

and resources that can help local health agencies

and school districts promote positive health

messages and programs for youth.

• Respond to requests for technical assistance and

information from local school health staff or

strengthen regional technical-assistance systems to

support local needs.

• Communicate school health-related findings from

the Community Guide to Preventive Services, which

features systematic reviews of published studies

conducted by the Task Force on Community

Preventive Services. In one such review, the Task

Force found that physical education classes are

effective in improving both physical activity levels

and physical fitness among school-aged children.

On the basis of these findings, the Task Force

issued a strong recommendation to implement

programs that increase the amount of time that

students spend in school-based physical education

classes.

State and local health and education agencies can

establish frameworks for allocating funds to support

local school health policies and programs that are

consistent with the intent of state policies and

appropriations. For example, in response to legislation that appropriated health protection funds to

the Massachusetts Department of Education, the

agency developed specific assurance documents that

established school health councils and coordinators

in the districts that received these funds. The education agency also provided technical assistance to

help local coordinators implement a comprehensive,

interdisciplinary Pre-K–12 health education and

human services program.

Resources

• Health Protection Fund. Massachusetts

Department of Education. Available at

www.doe.mass.edu. (Search “Health

Protection Fund.”)

Resources

• State of Maine Guidelines for Coordinating

School Health Programs. Maine Department of

Education. Available at www.mainecshp.com.

Resources

• Community Guide to Preventive Services.

Available at www.thecommunityguide.org.

Resources

• CDC’s Youth Media Campaign. Available at

www.verbnow.com.
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS

Priority 6. Implement Health Communications Strategies

to Inform Decision Makers and the Public About the Role

of School Health Programs in Promoting Health and

Academic Success Among Young People.

State and local agencies need to build support at

both the state and local levels for school-based

programs to reduce tobacco use, increase physical

activity, and improve eating behaviors among

students. As an important part of this effort, state

and local health and education agencies can develop

and implement a school health communications plan

to promote the value of school health programs

among legislative leaders, state and local government

policy makers (including health and education

leaders), local school leaders, business leaders,

parents, students, and other community members.

Such a plan should foster communication among

state-level partners working to improve school health

programs and increase the flow of information and

resources between the state and local levels.

For example, the Oregon Department of Education

formed an external communications work group to

develop and implement an awareness campaign to

promote coordinated school health programs among

local decision makers and gatekeepers (e.g., school

board members, school administrators, county

commissioners). The campaign has stressed the links

between students' educational outcomes and their

physical, social, and emotional health and the critical

role that school health programs can play in

improving these outcomes. This work group includes

representatives from a wide variety of state partners

interested in school health, including the Oregon

Association for Health, Physical Education,

Recreation and Dance; the Oregon School Health

Education Coalition; the Oregon Dairy Council; the

Oregon Partnership (alcohol-use prevention); the

Northwest affiliate of the American Cancer Society;

the Oregon School Nurses Association; and Children

First for Oregon (a Kids Count affiliate). As a result

of the work group's efforts, in many districts, school

health councils have been formed to plan the

implementation of school health programs.

Priority 7. Develop a Professional-Development Plan for

School Officials and Others Responsible for Establishing

Coordinated School Health Programs and Implementing

the School Health Guidelines.

Professional development is critical to the effective

implementation of the school health guidelines and

coordinated school health programs.13 Any state plan

for reducing the risk for chronic disease among

young people should include a comprehensive plan

for teaching the skills that state and local decision

makers, school staff, parents, and community members will need to support and implement a coordinated school health program. This development plan

should address the specific training needs of the

various target groups and should be informed by

literature from the field of professional development

and training. States and communities can provide or

support professional-development training in a

variety of ways:

• Through a cadre of trainers who can provide and

model interactive professional development and

who are themselves provided with ongoing

support, training, and feedback.

• Through multiple delivery systems, such as

scheduled workshops, materials centers, interactive Web sites, and district mentoring programs.

• By providing funds for professional-development

events and materials.

• By providing support staff to manage the logistics

of training.

Resources

• Building Business Support for School Health

Programs. National Association of State

Boards of Education, 1999. Available at

www.nasbe.org/Educational_Issues/

Safe_Healthy.html.

• School Health Starter Kit: For Motivated

People Who Want to Get Others Involved.

Washington, DC: Council of Chief State

School Officers, 1999. Available at

www.publications.ccsso.org.
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PREVENTION STRATEGIES THAT WORK

• Through marketing strategies to create awareness

of and encourage participation in professional

development and training.

Plans should specify the target audience for each

professional-development event and should include

learning and performance objectives. Insofar as

possible, participants in these events should develop

action plans that describe how they will incorporate

their newly acquired knowledge and skills into

their professional responsibilities. Professionaldevelopment events should be evaluated by the

quality of those plans and how well they are

implemented.

Professional-development events may be needed for

school personnel, such as health and physical

education teachers, nurses, school counselors, food

service directors, and administrators. Others who

require professional development may include school

board members; parents; health educators in state

health departments; health department staff who

work with youth-focused, community-based

organizations; parks and recreation staff; business

leaders; clergy; and social services and juvenile justice

staff. Depending upon the work plan and desired

outcomes, professional development could include

awareness sessions, skill-building training, topical

events, or customized offerings for teachers and

school health coordinators.

Opportunities for professional development to

support school health programs are available through

Resources

• Strategies for Professional Development in

Cooperative Agreements with State Education

Agencies, Local Education Agencies, and

National Non-Governmental Organizations.

Available at www.cdc.gov/nccdphp/dash.

• Wood FH, Thompson SR. Assumptions

about staff development based on research

and best practice. Journal of Staff

Development 1993;14(4):52-57.

Education Resources

• American School Food Service Association

(ASFSA): www.asfsa.org

• Association for Supervision and Curriculum

Development (ASCD): www.ascd.org

• American Association for Health Education

(AAHE): www.aahperd.org/aahe

• National Association for Sport and Physical

Education (NASPE): www.aahperd.org/

naspe

• American School Counselor Association

(ASCA): www.schoolcounselor.org

• National Association of School Nurses

(NASN): www.nasn.org

• National Association of School Psychologists

(NASP): www.nasponline.org

• Society of State Directors of Health, Physical

Education and Recreation (SSDHPER):

www.thesociety.org

Public Health Resources

• American Public Health Association

(APHA): www.apha.org

• Association of State and Territorial Chronic

Disease Program Directors (ASTCDPD):

www.chronicdisease.org

• Association of State and Territorial Directors

of Health Promotion and Public Health

Education (ASTDHPPHE):

www.astdhpphe.org

• Society of Public Health Educators

(SOPHE): www.sophe.org

Federal Resources

• U.S. Department of Agriculture (USDA):

www.usda.gov

• U.S. Department of Health and Human

Services, Centers for Disease Control and

Prevention (CDC): www.cdc.gov

• Health Resources and Services

Administration (HRSA): www.hrsa.gov

• The President’s Council on Physical Fitness

and Sports: www.fitness.gov
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS

a variety of venues, including national and state-level

conferences and other continuing education opportunities offered by professional organizations.

National health organizations also offer specialized

opportunities for professional development, such as

those offered at the American Cancer Society's

School Health Coordinator Leadership Institute.

Several states have replicated the institute or are

planning to do so. For more information, contact

the American Cancer Society, Children and Youth

Initiatives, at 404-982-3672.

Other venues for professional development include

professional-preparation programs offered by

institutions of higher education, professional

journals, on-line courses, and list servs. States should

develop systems to provide follow-up support to

participants after the professional-development

events have concluded. Such support could be

provided through booster sessions, peer counseling,

networking groups, or ongoing sequential training.

CDC has developed Training Tracker, a database

program that enables agencies and organizations to

track their various training and professionaldevelopment activities over time. Training Tracker

will store data useful for planning and evaluating

professional-development events.

State and local health and education agencies should

support policies and identify funding that will

advance the development of a statewide,

comprehensive professional-development plan. In

general, state agencies should designate staff to both

develop this plan and ensure its implementation at

the state and school-district levels. However, if

professional-development events are typically

delivered at the regional level, it might be more

Resources

• Training Tracker: A Computer-Based Training

Tool. (E-mail request for information to

nccddashtracker@cdc.gov.)

appropriate for regional, county, or local education

agency staff to develop their own plans.

Priority 8. Establish a System for Evaluating and

Continuously Improving State and Local School Health

Policies and Programs.

Program evaluation is an essential ongoing organizational practice in public health and education. The

results of such evaluations not only measure a

program's success in meeting its goals but also

provide information for planning future program

activities. Agencies need to develop clear plans,

inclusive partnerships, and feedback systems that

foster learning and ongoing improvement. Routine,

practical evaluations that provide information for

management and improve program effectiveness

should be a part of education and public health

programs at both the state and local levels.

Program evaluation helps program officials to

better understand their programs' needs and assets,

to establish priorities, and to use their resources

more effectively.

As an agency develops its program goals, objectives,

and implementation plans, it should also develop

procedures for measuring its success in meeting these

goals and objectives. Evaluations can be used to assess

the following four aspects of program activities:

1. The development and implementation of healthrelated education policies.

2. The provision of professional development

activities for decision makers and education and

public health agency staff.

3. The development and implementation of effective

curricula and programs for students.

4. The establishment of sufficient capacity to develop

and implement program activities and collaborate

with other organizations.

Agencies can perform two kinds of evaluations:

process evaluations and outcome evaluations. Process

evaluations require accurate and organized records of

program activities and are central to the ability of
118

PREVENTION STRATEGIES THAT WORK

program staff to effectively monitor and report on

their activities. By delineating the who, what, when,

and where of program activities, process evaluations

allow agency staff to assess whether these activities

met their goals and objectives. Agency staff can also

use process evaluations to chart and report on activities across time in a very systematic and cost-effective

manner. Because a basic understanding of the process

of program activities is critical to evaluating their

outcomes, education and public health agencies

should conduct process evaluations annually.

Outcome evaluations are used to assess the impact of

program activities on their participants, including

changes in their knowledge, attitudes, skills, and

behaviors both immediately following program

activities and over the long term.

Evaluation results are only valuable when they are

used to develop and improve program activities.

Evaluation results may be communicated to national,

state, and local education and public health agencies; to school districts and individual schools;

to community-based organizations; and to

community members.

State agencies should develop evaluation resources,

tools, and a technical assistance process to help local

agencies evaluate their program activities. Agencies

may want to consider enlisting the help of postsecondary institutions or of independent evaluators

or evaluation firms. However, the respective roles

and duties of agency staff and hired evaluators must

be clearly outlined, and evaluators and agency staff

must agree on the purpose, methods, and procedures

of evaluations.

There are four commonly accepted standards for

evaluation: utility, feasibility, propriety, and accuracy.

Utility refers to the usefulness of evaluation results.

Evaluations with good utility specify the amount and

type of information collected, make clear the values

used in interpreting collected data, and present

findings in a clear and timely way. Feasibility refers to

the extent that evaluations employ practical, nondisruptive procedures, take into account the differing

political interests of those involved, and use resources

prudently. Propriety is a measure of how well the

rights of those affected by the evaluation are

respected. Evaluations with good propriety have

protocols and other agreements to ensure that the

welfare of human subjects is protected, that the

findings are disclosed in a complete and balanced

fashion that reflects multiple perspectives, and that

conflicts of interest are addressed in an open and fair

manner. Accuracy is a measure of how well evaluation

results reflect reality. Accurate evaluations describe

the program activities and their contexts, articulate

the purpose and methods of the evaluation, employ

systematic procedures to gather valid and reliable

information, apply appropriate methods of analysis

and synthesis, and produce impartial reports

containing justified conclusions.

Resources

• Framework for program evaluation in public

health. MMWR 1999;48(RR-11). Available at

www.cdc.gov/eval/framework.htm.

• Collins J, Rugg D, Kann L, Pateman B,

Banspach S, Kolbe L. Evaluating a national

program of school-based HIV prevention.

Evaluation and Program Planning 1996;19(3):

209–18.

• MacDonald G, Starr G, Schooley M, Yee SL,

Klimowski K, Turner K. Introduction to

Program Evaluation for Comprehensive Tobacco

Control Programs. Atlanta: CDC, 2001.

• Handbook for Evaluating HIV Education.

Atlanta: CDC, 1992. Available at

www.cdc.gov/nccdphp/dash/publications/

index.htm.

• Coordinated School Health Program

Infrastructure Development Process Evaluation

Manual. Atlanta: CDC, 1997. Available at

www.cdc.gov/nccdphp/dash/publications/

index.htm.

• Physical Activity Evaluation Handbook.

Atlanta: CDC, 2002. Available at

www.cdc.gov/nccdphp/dnpa/physical/

handbook/index.htm.
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS

Administration (HRSA) in 1994 to encourage the

development of new, comprehensive, full-time,

school-based primary care programs that serve

children at high risk for health problems through

treatment and services such as counseling, mental

and dental health services, nutrition, and health

education. HSHC funds 76 organizations,

including community health centers, local health

departments, hospitals, private, nonprofit health

providers, and university medical centers, to establish

new school-based health centers. The program has

established a number of collaborative linkages with

other government agencies and private organizations

that enable the school-based centers to strengthen

the quality of care that they provide. For more

information, visit the HSHC Web site:

bphc.hrsa.gov/programs/HSHCProgramInfo.htm.

HRSA also supports the National Adolescent Health

Information Center (NAHIC), which is based

within the University of California, San Francisco’s

Division of Adolescent Medicine, Department of

Pediatrics, and Institute for Health Policy Studies.

NAHIC’s goal is to improve the health of

adolescents by serving as a national resource for

adolescent health information and research and to

assure the integration, synthesis, coordination and

dissemination of adolescent health-related

information. In all of its activities, NAHIC

emphasizes the needs of special populations who are

more adversely affected by the current changes in the

social environment for youth and their families. For

more information, visit the NAHIC Web site at

http://youth.ucsf.edu/nahic.

Challenges Ahead

Because every child needs sound preparation for a

healthy future, school health programs should be

established in all U.S. schools. Convincing children

and adolescents to adopt behaviors that reduce their

risk for chronic diseases is a continual challenge and

should be a goal of all public health programs.

Achieving this goal requires that state leaders in

public health and education accept the opportunity

National Leadership

Collaborative strategies are necessary to promote

healthy communities, healthy schools, and healthy

children within our nation. In recognition of the

need for sustained and coordinated federal efforts to

strengthen and improve the education and health of

school-age children and youth, the U.S. Departments of Education, Health and Human Services,

and Agriculture established the Interagency Committee on School Health in 1994. The committee,

which meets twice each year, is co-chaired by the

Assistant Secretary for Health in the Department of

Health and Human Services, the Assistant Secretary

for Elementary and Secondary Education in the

Department of Education, and the Under Secretary

of Food, Nutrition and Consumer Affairs in the

Department of Agriculture. Committee members

represent the Department of Defense, the Department of Justice, the Environmental Protection

Agency, the Indian Health Service, the Bureau of

Indian Affairs, and the Consumer Product Safety

Commission, as well as the Departments of Education, Agriculture, and Health and Human Services.

The National Coordinating Committee on School

Health (NCCSH) was established in 1994 by the

Secretaries of the Departments of Education and

Health and Human Services. Shortly after NCCSH

was created, the Department of Agriculture added its

support. The NCCSH was formed to link federal

departments with national nongovernmental organizations to support quality coordinated school health

programs in our nation's schools. Its responsibilities

include providing national leadership for the promotion of quality school health programs; improving

communications, collaboration, and information

sharing among national organizations; identifying

local, state, and federal barriers to the development

and implementation of effective school health programs; and collecting and disseminating information

that can help to improve the effectiveness of these

programs. Membership has grown to approximately

75 national organizations.

Healthy Schools, Healthy Communities (HSHC)

was established by the Health Resources and Services
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PREVENTION STRATEGIES THAT WORK

9. Gortmaker SL, Wiecha J, Sobol AM, Dixit S,

Fox MK, Laird N. Reducing obesity via a schoolbased interdisciplinary intervention among

youth: Planet Health. Arch Pediatr Adolesc Med

1999;153(4):409–18.

10. Botvin GJ, Baker E, Dusenbury L, Botvin EM,

Diaz T. Long-term follow-up results of a randomized drug abuse prevention trial in a white

middle-class population. JAMA 1995;273(14):

1106–12.

11. Allensworth DD. Improving the health of youth

through a coordinated school health programme.

Promot Educ 1997;4(4):42–7.

12. Indicators for chronic disease surveillance.

Available at http://cdi.hmc.psu.edu. Accessed

August 18, 2002.

13. Sweeney DB, Nichols P. The state role in

coordinated school health programs. In: Marx E,

Wooley S, editors. Health is Academic: A Guide to

Coordinated School Health Programs. New York:

Teachers College Press, 1998:244–68.

14. Institute of Medicine. Schools and Health: Our

Nation's Investment. Washington, DC: National

Academy Press, 1997.

15. National Association of State Boards of

Education (NASBE). Fit, Healthy, and Ready to

Learn: A School Health Policy Guide. Washington,

DC: NASBE, 1999.

16. Centers for Disease Control and Prevention.

School Health Policy and Programs Study 2000.

J Sch Health 2001;71(7):251–350.

and responsibility to effectively implement and

improve school health programs.

References

1. Snyder T, Hoffman C, editors. Digest of

Education Statistics 2001. Jessup, MD: National

Center for Education Statistics, 2002: Table 2

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