NATIONAL AND STATE INITIATIVES TO PROMOTE HEALTH AND WELL-BEING
Jennifer Childress and Jill Dombrowski
Throughout the nation, Americans are experiencing declining levels of health. How is this determined?
What measurements are used and who measures them? What programs have been developed to address declining health levels? Partnerships and data are key to improving the health of Americans where we live, work, and play.
Healthy People: 1979–2020
Since 1979, theUS Department of Health and Human Services (HHS) has been setting ten-year national health objectives for Americans, called Healthy Peo- ple. By establishing benchmarks and monitoring prog- ress over time, Healthy People’s aims are to do the following:
• Encourage collaboration across communities and sectors.
• Empower individuals toward making informed health decisions.
• Measure the impact of prevention activities.
Since the 1980s, the HHS Healthy People initiatives have built on their predecessors and have addressed new areas of importance related to the health of the nation.
Given the comprehensiveness and pervasiveness of health, the development of Healthy People goals involve input from multiple sectors and stakeholders. Most recently, public health; health promotion and prevention experts;
LEARNING OBJECTIVES After reading this chapter, the student will be able to:
. Discuss the history of the Department of Health and Human Services’Healthy People initiative with an emphasis on Healthy People 2020.
. Describe the work of key federal government agencies to support research, share findings, and develop guidelines for healthy living.
. Identify government programs that promote health.
. Recognize key surveillance surveys and activities that monitor the health of the US population.
. Summarize state-level programs that use national guidelines to promote health.
federal, state, and local government officials; a consortium of more than two thousand organizations; and the general public were invited to provide feedback and input during the drafting of Healthy People 2020 objectives (US Department of Health and Human Services, 2010).
The goals identified in Healthy People 2020 are broad and include objectives for areas that were included in prior Healthy People goals, such as nutrition and physical activity, immunizations, cancer, heart disease, medical insurance coverage, mental health, environmental quality, and substance abuse. In addition, Healthy People 2020 has been expanded to include new areas of focus, such as global health; genomics; adolescent health; older adult health; lesbian, gay, bisexual, and transgender health;
and sleep health.
Healthy People 2020
The majority of deaths among Americans are the result of chronic diseases that are preventable through lifestyle behavior modifications. On December 2, 2010, Healthy People 2020 was released with the vision of a society in which all people live long, healthy lives (US Department of Health and Human Services, nd-a).
The mission of Healthy People 2020 is to do the following:
• Identify nationwide health improvement priorities.
• Increase public awareness and understanding of the determinants of health, disease, disability, and the opportunities for progress.
• Provide measurable objectives and goals that are applicable at the national, state, and local levels.
HISTORY OF HEALTHY PEOPLE
• 1979 surgeon general’s report, Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention
• Healthy People 1990: Promoting Health/Preventing Disease: Objectives for the Nation
• Healthy People 2000: National Health Promotion and Disease Prevention Objectives
• Healthy People 2010: Objectives for Improving Health US Department of
Health and Human Services (HHS) the US government’s principal agency tasked with protecting the health of all Americans and providing essential human services Healthy People ten-year national health objectives for Americans released by the US Department of Health and Human Services
• Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge.
• Identify critical research, evaluation, and data collection needs.
Healthy People 2020 has four overarching goals:
• Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
• Achieve health equity, eliminate disparities, and improve the health of all groups.
• Create social and physical environments that promote good health for all.
• Promote quality of life, healthy development, and healthy behaviors across all life stages.
Over the next ten years, progress toward these goals will be determined by the following four foundational health measures:
• General health status
• Health-related quality of life and well-being
• Determinants of health
• Health disparities
There are twenty-six leading health indicators within Healthy People 2020 organized under twelve topics. These indicators are being tracked, measured, and reported regularly throughout the decade to better evaluate the nation’s progress toward meeting Healthy People 2020 goals. These indicators represent a smaller set of objectives that reflect high-priority issues and associated actions to address them (see table 9.1).
HHS launched the Healthy People website (www.healthypeople.gov) to provide users access to information and resources particular to their needs (e.g., based on sex, age group, setting, population group, intervention agent, health condition, and prevention areas). Although the large number of indicators and associated data and information may seem overwhelming, HHS issued a special challenge for web application developers to create easy-to-use applications to quickly access these data. With easy access to relevant data, health professionals can better assist Americans where they live, work, and learn.
In June 2011, the US surgeon general’s office released the National Prevention Strategy, which is aimed at increasing the number of Americans
HEALTHYPEOPLE2020 245
Table 9.1 Healthy People 2020 Leading Health Indicators Access to Health Services
• Persons with medical insurance
• Persons with a usual primary care provider
...
Clinical Preventive Services
• Adults who receive a colorectal cancer screening based on the most recent guidelines
• Adults with hypertension whose blood pressure is under control
• Adult diabetic population with an A1c value greater than 9%
• Children aged nine to thirty-five months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, and PCV vaccines
...
Environmental Quality
• Air quality index exceeding 100
• Children aged three to eleven years exposed to secondhand smoke
...
Injury and Violence
• Fatal injuries
• Homicides
...
Maternal, Infant, and Child Health
• Infant deaths
• Preterm births
...
Mental Health
• Suicides
• Adolescents who experience major depressive episodes
...
Nutrition, Physical Activity, and Obesity
• Adults who meet current federal physical activity guidelines for aerobic physical activity and muscle- strengthening activity
•Adults who are obese
•Children and adolescents who are considered obese
•Total vegetable intake for persons aged two years and older
...
Oral Health
• Persons aged two years and older who used the oral health care system in past twelve months ...
Reproductive and Sexual Health
• Sexually active females agedfifteen to forty-four years who received reproductive health services in the past twelve months
• Persons living with HIV who know their serostatus
...
Social Determinants
• Students who graduate with a regular diploma four years after starting ninth grade
...
who are healthy at every stage of life. It includes comprehensive and evidence-based prevention strategies.
There are four strategic directions:
• Healthy and safe community environments
• Clinical and community preventive services
• Empowered people
• Elimination of health disparities There are seven targeted priorities:
• Tobacco-free living
• Preventing drug abuse and excessive alcohol use
• Healthy eating
• Active living
• Injury and violence free living
• Reproductive and sexual health
• Mental and emotional well-being (US Department of Health and Human Services, Office of the Surgeon General, National Prevention Council, 2011)
This federal initiative is a component of the Patient Protection and Affordable Care Act (ACA) and is focused on disease prevention. Some of the strategies for disease prevention are the same as those for health promotion, but the outcome measures may be different because the goals are different: preventing disease versus promoting and maintaining good health. Some of these measures may be based on secondary prevention;
therefore, the target populations may already have risk factors such as hypertension and obesity. For example, this chapter highlights healthy eating and active living interventions, but the focus of these strategies from the perspective of the National Prevention Strategy would be to avoid diseases or chronic health conditions such as CVD, stroke, and diabetes. The Substance Abuse
• Adolescents using alcohol or any illicit drugs during the past thirty days
• Adults engaging in binge drinking during the past thirty days
...
Tobacco
• Adults who are current cigarette smokers
• Adolescents who smoked cigarettes in the past thirty days
HEALTHYPEOPLE2020 247
emphasis then would be on behavior change to avoid disease, which may work for some populations but not others, such as adolescents, who are not concerned with development of disease when they are middle-aged.
US Department of Health and Human Services (HHS)
HHS is the United States government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves (US Department of Health and Human Services, nd-b). HHS works with state and local governments to provide health and human services through state or county agencies and through private-sector grantees. HHS programs are administered by eleven operating divisions, comprising eight agencies in the US Public Health Service and three human services agencies.
As a department within the federal government, the secretary of HHS sits on the president’s cabinet and is a presidential appointee. Every four years the secretary of HHS is responsible for updating afive-year strategic plan that defines the department’s missions and goals and the means by which progress will be measured. The most recent strategic plan
HHS STRATEGIC PLAN
• Promote high-value, safe, and effective health care.
• Secure and expand health insurance coverage.
• Eliminate health disparities.
• Promote prevention and wellness.
• Help Americans achieve and maintain healthy weight.
• Prevent and reduce tobacco use.
• Support the national HIV/AIDS strategy.
• Put children and youth on the path for successful futures.
• Promote early childhood health and development.
• Protect Americans’health and safety during emergencies and foster resilience in response to emergencies.
• Implement a twenty-first-century food safety system.
• Accelerate the process of scientific discovery to improve patient care.
• Promote program integrity, accountability, and transparency.
(2010–2015) is available on the HHS website and is designed to be a living, vital document that is updated frequently to reflect progress. The last update to the strategic plan was March 10, 2014 (US Department of Health and Human Services, 2014).
The organizational chart in figure 9.1 identifies the eleven operating divisions and eight agencies under HHS (www.hhs.gov). When visiting the HHS website, you can click on the organizational chart to be directed to the
The Executive Secretariat Secretary
Deputy Secretary Chief of Staff
Office of Intergovernmental and External Affairs (IEA) Office of Health Reform
(OHR)
Office of the Assistant Secretary for Administration
(ASA)
Program Support Center (PSC)
Administration for Children and Families
(ACF)
Centers for Medicare and Medicaid Services
(CMS)
Center for Faith-Based and Neighborhood Partnerships (CFBNP)
Office for Civil Rights (OCR)
Departmental Appeals Board (DAB)
Office of the General Counsel
(OGC)
Office of Global Affairs (OGA)*
Office of Inspector General
(OIG)
Office of Medicare Hearings and Appeals
(OMHA)
Office of the National Coordinator for Health Information Technology (ONC) Food and Drug
Administration (FDA)*
Health Resources and Services Administration
(HRSA)*
Administration for Community Living
(ACL)
Agency for Healthcare Research and Quality
(AHRQ)*
Agency for Toxic Substances and Disease
Registry (ATSDR)*
Centers for Disease Control and Prevention
(CDC)*
Indian Health Service (IHS)*
National Institutes of Health
(NIH)*
Substance Abuse and Mental Health Services
Administration (SAMHSA)*
Office of the Assistant Secretary for Financial
Resources (ASFR)
Office of the Assistant Secretary for Legislation (ASL)
Office of Minority Affairs
(OMA)*
Office of the Assistant Secretary for Health
(OASH)
Office of the Assistant Secretary for Planning
and Evaluation (ASPE) Office of the Assistant
Secretary for Preparedness and
Response (ASPR)*
Office of the Assistant Secretary for Public
Affairs (ASPA)
Figure 9.1 HHS Organizational Chart
Note:*Designates that it is a component of the US Public Health Service.
Source:US Department of Health and Human Services (nd-c).
US DEPARTMENT OFHEALTH ANDHUMANSERVICES(HHS) 249
division or agency website and view the sublayers that exist in addition to those pictured infigure 9.1.
HHS-operating divisions and agencies are tasked with carrying out initiatives to support Healthy People 2020 objectives, and the overall mission of HHS is to support and protect the health of Americans through research, public health, food and drug safety, grants, health insurance, and many other actions. Many of the initiatives discussed in this textbook fall under one of the entities of HHS circled in figure 9.1. Following are descriptions of some HHS agencies or divisions that are of particular interest in thefield of health promotion.
The Centers for Disease Control and Prevention (CDC)
The mission of theCenters for Disease Control and Prevention (CDC)is to collaborate to create the expertise, information, and tools that people and communities need to protect their health—through health promotion;
prevention of disease, injury, and disability; and preparedness for new health threats (Centers for Disease Control and Prevention, 2012a). Work- ing with partners throughout the nation and the world, the CDC seeks to accomplish its mission by doing the following:
• Monitoring health
• Detecting and investigating health problems
• Conducting research to enhance prevention
• Developing and advocating sound public health policies
• Implementing prevention strategies
• Promoting healthy behaviors
• Fostering safe and healthful environments
• Providing leadership and training
The CDC is composed of various centers, an institute, and offices to meet its mission, goals, and objectives, share resources, and effectively address public health concerns. On the CDC website, viewers may examine the plethora of health-related topics addressed. The CDC provides infor- mation, publications, multimedia, and tools to support experts, individuals, communities, and organizations as they act to address health concerns. The CDC strives to provide information through various mediums to its audi- ence; for example, in addition to print and online, information is available through podcast. To address a larger audience, many CDC resources are also available in Spanish.
Centers for Disease Control and Prevention (CDC) a federal agency under the US Department of Health and Human Services responsible for the public health of the nation; works to protect the public health and safety of people in the United States by tracking, detecting, and responding to threats
The following examples of CDC information sharing for seasonal influenza and smoking and tobacco use are demonstrative of the types of detailed information typically provided by the CDC.
Seasonal Influenza (Flu) Addressed by CDC
The CDC provides information to the general public regardingflu activity and surveillance. The website provides maps and information through the weekly FluView. Viewers can identify areas offlu outbreaks throughout the United States or customize the information to generate state-specific re- ports. Information includes the proportion of people visiting health care providers for influenza-like illness (ILI) (see figure 9.2), influenza-related
Figure 9.2 CDC FluView Webpage: ILI Activity Indicator Map
Source:Centers for Disease Control and Prevention (2014).
The CDC Influenza Application for Clinicians and Health Care Professionals (available in the App Store) provides information on the latest recommendations andflu activity updates, videos from subject matter experts, and products to print out and post in the workplace or distribute to patients.
US DEPARTMENT OFHEALTH ANDHUMANSERVICES(HHS) 251
mortality rates, the geographic spread of influenza, and hospitalizations related to influenza.
In addition to tracking influenza patterns, the CDC also provides information and facts regarding prevention and treatment of the flu.
Through the “Take 3” campaign, the CDC encourages three actions to prevent andfight theflu. The campaign outlines these three actions, along with steps and research supporting each one:
• Take time to get the flu vaccine.
• Take everyday preventive actions to stop the spread of germs.
• Takeflu antiviral drugs if your doctor prescribes them.
Smoking and Tobacco Use Addressed by the CDC
Another area of focus for the CDC is smoking and tobacco use. Similar to addressing influenza, the CDC provides resources to individuals and health professionals, as well as to communities, clinicians, teachers, and workplaces.
The State Tobacco Activities Tracking and Evaluation (STATE) system is an interactive application on the CDC website that houses and displays current and historical state-level data on tobacco use prevention and control. It uses data from the Behavioral Risk Factor Surveillance and Youth Risk Behavior Surveillance systems (discussed later in this chapter) to generate graphs and images. Figure 9.3 provides a webshot of the STATE home page.
Figure 9.3 STATE System Interactive Map: Behaviors—Cigarette Use—Adult Current Smokers—BRFSS
Source:Centers for Disease Control and Prevention (nd-a).
The CDC has developed the STATE system toolkit, which provides users with data for the United States and each state over multiple years, as well as state summaries. The site provides users with the ability to save copies of maps for presentations or reports (seefigure 9.4).
For individuals, the CDC provides information on the health conse- quences of smoking, secondhand smoke, and smokeless tobacco, as well as suggestions to help people quit smoking. The Tobacco-Free Sports Initiative Campaign is designed to help prevent and reduce the number of youth who use tobacco.
The Say It, Share It tobacco-free campaign (www.betobaccofree.gov), targeting teens, uses videos employing storytelling techniques to help prevent teens from smoking and using tobacco products. In addition, it leverages social media (Facebook, Twitter, and a widget) to reach teens.
Through its Healthier Worksite Initiative the CDC (2010b) has developed resources and toolkits to help employers implement tobacco-free campuses Figure 9.4 STATE System Toolkit
Source:Centers for Disease Control and Prevention (nd-b).
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and provide employees with information and resources to quit smoking. The information for employers is comprehensive, ranging from making an initial assessment, to planning (e.g., communications, timing, and policies), pro- moting, implementing, and evaluating their tobacco-cessation programs.
National Institutes of Health (NIH)
TheNational Institutes of Health (NIH)is the nation’s medical research agency, composed of twenty-seven institutes and centers supporting scien- tific studies with the theme of turning discovery into health (www.nih.gov).
Its mission is to
seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce the burdens of illness and disability. (National Institutes of Health, nd)
The NIH is the leading supporter of biomedical research in the world, with an impact that reaches beyond health to job creation and the US economy. The NIH states that the thirty-year increase in life expectancy of a baby born in the United States today, compared to one born in 1900, is due in large part to NIH research. The areas of research covered by NIH are broad, ranging from the lifelong impact of acute kidney injury, to wonders of the brain, to the landscape of genomics.
Clinical Center
The NIH Clinical Center is the home of NIH clinical research trials and is devoted entirely to clinical research. The Clinical Center facilitates the rapid translation of scientific observations and laboratory discoveries into medical approaches to diagnose, treat, and prevent disease. Findings from clinical trials are also communicated to the public through traditional news channels. Examples of recently successful clinical trial research projects include the HPV anticancer vaccine technology that led to thefirst FDA- approved vaccine against cancer (Intramural Research Program, nd) and a vaccine to protect against the Ebola virus infection, which was recently proven effective among monkeys and is now being tested in humans.
Chronic Disease Institutes
Health promotion professionals benefit from work conducted by the National Heart, Lung, and Blood Institute (NHLBI) (www.nhlbi.nih.gov) and the National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of
Health (NIH) a federal agency under the US Department of Health and Human Services; the primary medical research agency composed of twenty- seven institutes and centers supporting scientific studies with the theme of turning discovery into health