Module 8: Program Planning Essentials and Models
Thursday, March 16, 2017
12:43 PM
Program Planning
MAP-IT: A Guide to Using Healthy People 2020 in Your Community
Healthy People is based on a simple but powerful model:
• Establish national health objectives.
• Provide data and tools to enable states, cities, communities, and individuals across the Nation to
combine their efforts to achieve them.
Use the MAP-IT framework to help:
• Mobilize partners.
• Assess the needs of your community.
• Create and implement a plan to reach Healthy People 2020 objectives.
• Track your community’s progress.
Are you working to achieve Healthy People 2020 objectives?
Healthy People 2020 is looking for real stories from organizations implementing programs to improve
our Nation’s health. Share your story!
A Framework for Implementation
No two public health interventions are exactly alike. But most interventions share a similar path to
success: Mobilize, Assess, Plan, Implement, Track.
Otherwise known as MAP-IT, this framework can be used to plan and evaluate public health
interventions to achieve Healthy People 2020 objectives. Whether you are a seasoned public health
professional or new to the field, the MAP-IT framework will help you create your own path to a
healthy community and a healthier Nation.
Use these tools and resources as a reference. Each of the 5 MAP-IT sections includes questions to
ask and answer, a brief overview, Healthy People 2020 tools, and links to related resources.
Choose 1 of the steps below to get started:
From <https://www.healthypeople.gov/2020/tools-and-resources/Program-Planning>
Mobilize
Healthy People 2020 Tools:
• Brainstorm: Potential Partners [PDF – 83KB]
• Organizing a Coalition [PDF – 70KB]
Questions to Ask and Answer:
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What is the vision and mission of the coalition?
Why do I want to bring people together?
Who should be represented?
Who are the potential partners (organizations and businesses) in my community?
Start by mobilizing key individuals and organizations into a coalition.
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Start by mobilizing key individuals and organizations into a coalition.
Look for partners who have a stake in creating healthy communities and who will contribute to the
process. Aim for broad representation.
Next, identify roles for partners and assign responsibilities.
This will help to keep partners engaged in the coalition. For example, partners can:
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Facilitate community input through meetings, events, or advisory groups.
Develop and present education and training programs.
Lead fundraising and policy initiatives.
Provide technical assistance in planning or evaluation.
Field Notes: Minnesota
Minnesota formed the Minnesota Health Improvement Partnership, a group of individuals representing a
broad sector of both public and private organizations, including members from local departments of health.
This group was charged with the responsibility to develop Healthy Minnesotans: Public Health Improvement
Goals for 2004.
Resources to Help You Mobilize:
• Increasing Participation and Membership
• The Community Toolbox
• Chapter 1: Our Model for Community Change and Improvement
• Chapter 4: Getting Issues on the Public Agenda
• Chapter 5: Choosing Strategies to Promote Community Health and Development
• Chapter 7: Encouraging Involvement in Community Work
• Chapter 16: Group Facilitation and Problem-Solving
• Chapter 21: Enhancing Support, Incentives, and Resources
• Chapter 23: Modifying Access, Barriers, and Opportunities
• Chapter 27: Cultural Competence in a Multicultural World
• Chapter 30: Principles of Advocacy
Toolkits
• Creating and Maintaining Partnerships
• Increasing Participation and Membership
• Enhancing Cultural Competence
From <https://www.healthypeople.gov/2020/tools-and-resources/program-planning/Mobilize>
Assess
Healthy People 2020 Tools:
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• Brainstorm: Community Assets [PDF – 82 KB]
• Exercise: Prioritizing Issues [PDF – 70 KB]
Questions to Ask and Answer:
• Who is affected and how?
• What resources do we have?
• What resources do we need?
Assess both needs and assets (resources) in your community.
This will help you get a sense of what you can do, versus what you would like to do.
Work together as a coalition to set priorities.
What do community members and key stakeholders see as the most important issues? Consider
feasibility, effectiveness, and measurability as you determine your priorities.
Start collecting state and local data to paint a realistic picture of community needs.
The data you collect during the assessment phase will serve as baseline data. Baseline data provide
information before you start a program or intervention. They allow you to track your progress.
Dig Deeper: Getting at the Roots of the Issue
Social Determinants of Health
Start a dialogue about the underlying causes of poor health or quality of life in your community. How
do the 5 social determinants of health discussed in Healthy People relate to your issue(s)?
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Healthy People 2020 Approach to Social Determinants of Health
A “place-based” organizing framework, reflecting five (5) key areas of social determinants of health
(SDOH), was developed by Healthy People 2020.
These five key areas (determinants) include:
Economic Stability
Education
Social and Community Context
Health and Health Care
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• Health and Health Care
• Neighborhood and Built Environment
Goal
Create social and physical environments that promote good health for all.
Overview
Health starts in our homes, schools, workplaces, neighborhoods, and communities. We know that
taking care of ourselves by eating well and staying active, not smoking, getting the recommended
immunizations and screening tests, and seeing a doctor when we are sick all influence our health. Our
health is also determined in part by access to social and economic opportunities; the resources and
supports available in our homes, neighborhoods, and communities; the quality of our schooling; the
safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social
interactions and relationships. The conditions in which we live explain in part why some Americans
are healthier than others and why Americans more generally are not as healthy as they could be.
Healthy People 2020 highlights the importance of addressing the social determinants of health by
including “Create social and physical environments that promote good health for all” as one of the four
overarching goals for the decade.1 This emphasis is shared by the World Health Organization, whose
Commission on Social Determinants of Health in 2008 published the report, Closing the gap in a
generation: Health equity through action on the social determinants of health.2 The emphasis is also
shared by other U.S. health initiatives such as the National Partnership for Action to End Health
Disparities 3 and the National Prevention and Health Promotion Strategy.4
The Social Determinants of Health topic area within Healthy People 2020 is designed to identify ways
to create social and physical environments that promote good health for all. All Americans deserve an
equal opportunity to make the choices that lead to good health. But to ensure that all Americans have
that opportunity, advances are needed not only in health care but also in fields such as education,
childcare, housing, business, law, media, community planning, transportation, and agriculture. Making
these advances involves working together to:
• Explore how programs, practices, and policies in these areas affect the health of individuals, families,
and communities.
• Establish common goals, complementary roles, and ongoing constructive relationships between the
health sector and these areas.
• Maximize opportunities for collaboration among Federal-, state-, and local-level partners related to
social determinants of health.
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Understanding Social Determinants of Health
Social determinants of health are conditions in the environments in which people are born, live, learn,
work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life
outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments
and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.”5 In
addition to the more material attributes of “place,” the patterns of social engagement and sense of
security and well-being are also affected by where people live. Resources that enhance quality of life
can have a significant influence on population health outcomes. Examples of these resources include
safe and affordable housing, access to education, public safety, availability of healthy foods, local
emergency/health services, and environments free of life-threatening toxins.
Understanding the relationship between how population groups experience “place” and the impact of
“place” on health is fundamental to the social determinants of health—including both social and
physical determinants.
Examples of social determinants include:
Availability of resources to meet daily needs (e.g., safe housing and local food markets)
Access to educational, economic, and job opportunities
Access to health care services
Quality of education and job training
Availability of community-based resources in support of community living and opportunities for
recreational and leisure-time activities
Transportation options
Public safety
Social support
Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a
community)
Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
Residential segregation
Language/Literacy
Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
Culture
Examples of physical determinants include:
Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
Built environment, such as buildings, sidewalks, bike lanes, and roads
Worksites, schools, and recreational settings
Housing and community design
Exposure to toxic substances and other physical hazards
Physical barriers, especially for people with disabilities
Aesthetic elements (e.g., good lighting, trees, and benches)
By working to establish policies that positively influence social and economic conditions and those that
support changes in individual behavior, we can improve health for large numbers of people in ways
that can be sustained over time. Improving the conditions in which we live, learn, work, and play and
the quality of our relationships will create a healthier population, society, and workforce.
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the quality of our relationships will create a healthier population, society, and workforce.
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Each of these five determinant areas reflects a number of critical components/key issues that make
up the underlying factors in the arena of SDOH.
Economic Stability
Poverty
Employment
Food Insecurity
Housing Instability
Education
High School Graduation
Enrollment in Higher Education
Language and Literacy
Early Childhood Education and Development
Social and Community Context
Social Cohesion
Civic Participation
Discrimination
Incarceration
Health and Health Care
Access to Health Care
Access to Primary Care
Health Literacy
Neighborhood and Built Environment
Access to Foods that Support Healthy Eating Patterns
Quality of Housing
Crime and Violence
Environmental Conditions
This organizing framework has been used to establish an initial set of objectives for the topic area as
well as to identify existing Healthy People objectives (i.e., in other topic areas) that are complementary
and highly relevant to social determinants. It is anticipated that additional objectives will continue to be
developed throughout the decade.
In addition, the organizing framework has been used to identify an initial set of evidence-based
resources and other key tools/examples of how a social determinants approach is or may be
implemented at a state and local level.
Back to Top
Emerging Strategies To Address Social Determinants of Health
A number of tools and strategies are emerging to address the social determinants of health, including:
Use of Health Impact Assessments to review needed, proposed, and existing social policies for their
likely impact on health6
Application of a “health in all policies” strategy, which introduces improved health for all and the
closing of health gaps as goals to be shared across all areas of governmen
1. How does the physical environment affect the health of your community (for example:
water and air quality, availability of safe walking paths or sidewalks, housing standards)?
2. How does access to health services affect the health of your community?
3. How do biology and genetics affect the health issue you are trying to address?
4. How does the social environment affect the health of your community (for example:
income level, education level, unemployment, language)?
5. How does individual behavior affect the health issue you are trying to address?
Are there interventions and/or strategies you can adopt to effect change at the root level, ultimately
improving the health of your community?
Field Notes: Kansas
Kansas determined priority health issues through its Healthy Kansas 2000 Steering
Committee, which evaluated health data, sought expert opinions, invited public
comments, and conducted an opinion survey of residents. Kansas used a
consensus method to limit the scope of its objectives to 7 priority health areas and
4 disease risk factors. The 7 priority health areas were alcohol and drug abuse,
cancer, heart disease, HIV and other sexually transmitted diseases, infectious
diseases and immunizations, injuries and violence, and maternal and infant health.
The 4 risk factors were lack of access to preventive care, tobacco use, poor
nutrition, and lack of physical activity.
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Other Resources:
• Community Health Assessment and Group Evaluation (CHANGE) Action Guide (Center for
Disease Control and Prevention, 2010)
• The Community Toolbox
• Chapter 3: Assessing Community Needs and Resources
• Chapter 8: Developing a Strategic Plan
• Chapter 17: Analyzing Community Problems and Solutions
• Chapter 18: Deciding Where to Start
Toolkits
• Assessing Community Needs and Resources
• Analyzing Problems and Goals
From <https://www.healthypeople.gov/2020/tools-and-resources/program-planning/Assess>
Plan
Healthy People 2020 Tools:
• Defining Terms: Vision, Goal, Objective, Strategy [PDF – 407 KB]
• Potential Health Measures [PDF – 85 KB]
• Setting Targets for Objectives [PDF – 100 KB]
Questions to Ask and Answer:
• What is our goal?
• What do we need to do to reach our goal? Who will do it?
• How will we know when we have reached our goal?
A good plan includes clear objectives and concrete steps to achieve them.
The objectives you set will be specific to your issue or community; they do not have to be exactly the
same as the ones in Healthy People 2020.
Consider your intervention points.
Where can you create change?
Think about how you will measure your progress.
How will you know if you are successful?
When setting objectives, remember to state exactly what is to be achieved.
What is expected to change, by how much, and by when? Make your objectives challenging, yet
realistic.
Remember: Objectives need a target. A target is the desired amount of change (reflected by a
number or percentage). A target needs a baseline (where you are now—your first data point).
Making Connections: Achieving Healthy People 2020
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Making Connections: Achieving Healthy People 2020
Although your objectives are specific to your state or community, it’s important to understand how
they support Healthy People 2020. After all, the work you do in your community is part of a larger
movement to create a healthier Nation.
Your Objective: Reduce the annual number of new cases of diagnosed diabetes in Franklin County.
Target: 9.0 new cases were 1,000 population aged 18 to 65.
Baseline: 10.0 new cases per 1,000 population aged 18 to 65.
Healthy People Objective: D1: Reduce the annual number of new cases of diagnosed diabetes in
the population.
Target: 7.2 new cases per 1,000 population aged 18 to 84.
Baseline: 8.0 new cases of diabetes per 1,000 population aged 18 to 84 occurred in the past 12
months, as reported in 2006-08 (age adjusted to the year 2000 standard population).
Target-setting method: 10% improvement
Data source: National Health Interview Survey (NHIS), CDC/NCHS
So you’ve set your objective, identified measures, set your target, and established your baseline.
Now, how will you reach your objective? You need some strategies. Start by searching for best
practices and other tested interventions. Engage coalition members in a strategy brainstorm.
Field Notes: Rhode Island
To achieve its year 2000 objectives, the Rhode Island Department of Health
initiated the Worksite Wellness Council of Rhode Island, which focused on
increasing health promotion and disease prevention activities in work sites, where
most adults spend the majority of their time. The State Wellness Council entered
into an agreement with the Wellness Council of America (WELCOA) to make
Rhode Island the first Well State in the United States. Through this agreement,
Rhode Island aims to have 20% of its workforce in WELCOA-certified Work Well
Sites.
Other Resources:
• State Program Evaluation Guides: Writing SMART Objectives (Centers for Disease Control and
Prevention [CDC], 2008)
• State Program Evaluation Guides: Developing and Using a Logic Model (CDC, 2008)
• The Community Toolbox
• Chapter 8: Developing a Strategic Plan
• Chapter 9: Developing and Organizational Structure for the Initiative
• Chapter 14: Core Functions in Leadership
• Chapter 19: Choosing and Adapting Community Interventions
• Chapter 42: Getting Grants and Financial Resources
Toolkits
• Developing a Framework or Model of Change
• Developing Strategic and Action Plans
• Improving Organizational Management and Development
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• Improving Organizational Management and Development
• Building Leadership
• Writing a Grant Application for Funding
From <https://www.healthypeople.gov/2020/tools-and-resources/program-planning/Plan>
Implement
Healthy People 2020 Tools:
• Communication Plan Template [PDF – 70 KB]
• Coalition Self Assessment [PDF – 128 KB]
Questions to Ask and Answer:
• Are we following our plan?
• What can we do better?
First, create a detailed workplan that lays out concrete action steps, identifies who is
responsible for completing them, and sets a timeline and/or deadlines.
Make sure all partners are on board with the workplan.
Next, consider identifying a single point of contact to manage the process and ensure that
things get done.
Be sure to share responsibilities across coalition members. Do not forget to periodically:
• Bring in new partners for a boost of energy and fresh ideas.
• Check in with existing partners often to see if they have suggestions or concerns.
Get the word out: develop a communication plan.
Convene kick-off events, activities, and community meetings to showcase your accomplishments
(and partners).
Field Notes: North Carolina
North Carolina has established the Office of Healthy Carolinians, which is responsible for
keeping their Healthy People initiative on track. Staff are available to North Carolina counties
for support and training, particularly coalition building. There is also a governor’s task force
that certifies counties in the Healthy Carolinians project. The counties do an assessment and
then implement an action plan.
Other Resources:
• Pink Book—Making Health Communication Programs Work (National Cancer Institute, 2002)
• The Community Toolbox
• Chapter 6: Communications to Promote Interest
• Chapter 10: Hiring and Training Key Staff of Community Organizations
• Chapter 11: Recruiting and Training Volunteers
• Chapter 12: Providing Training and Technical Assistance
• Chapter 24: Improving Services
• Chapter 25: Changing Policies
• Chapter 26: Changing the Physical and Social Environment
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• Chapter 26: Changing the Physical and Social Environment
• Chapter 43: Managing Finances
• Chapter 45: Social Marketing of Successful Components of the Initiative
Toolkits
• Influencing Policy Development
• Developing an Intervention
• Implementing a Social Marketing Effort
• Sustaining the Work or Initiative
From <https://www.healthypeople.gov/2020/tools-and-resources/program-planning/Implement>
Track
Healthy People 2020 Tools:
• Measuring Progress [PDF – 178 KB]
Questions to Ask and Answer:
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Are we evaluating our work?
Did we follow the plan?
What did we change?
Did we reach our goal?
Plan regular evaluations to measure and track your progress over time.
Consider partnering with a local university or state center for health statistics to help with data
tracking. Some things to think about when you are evaluating data over time:
• Data Quality: Be sure to check for standardization of data collection, analysis, and structure of
questions.
• Limitations of Self-Reported Data: When you are relying on self-reported data (such as exercise
frequency or income), be aware of self-reporting bias.
• Data Validity and Reliability: Watch out for revisions of survey questions and/or the development
of new data collection systems. This could affect the validity of your responses over time. (Enlist a
statistician to help with validity and reliability testing.)
• Data Availability: Data collection efforts are not always performed on a regular basis.
Do not forget to share your progress—and successes—with your community.
If you see a positive trend in data, issue a press release or announcement.
Field Notes: New Jersey
For its 1996 and 1999 updates to the State’s year 2000 objectives, New Jersey’s statistical and program
staff assessed progress and analyzed trends. Based on their trend analysis, staff categorized each objective
and sub-objective as “likely to be achieved,” “unlikely to be achieved,” or “uncertain.”
Other Resources:
• State Program Evaluation Guides: Developing an Evaluation Plan (Centers for Disease Control
and Prevention, 2008)
• The Community Toolbox
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• The Community Toolbox
• Chapter 36: Introduction to Evaluation
• Chapter 37: Operations in Evaluating Community Interventions
• Chapter 38: Some Methods for Evaluating Comprehensive Community Initiatives
• Chapter 39: Using Evaluation to Understand and Improve the Initiative
Toolkit
• Evaluating the Initiative
From <https://www.healthy
The Public Health System
Public health systems are commonly defined as “all public, private, and voluntary entities that
contribute to the delivery of essential public health services within a jurisdiction.” This concept
ensures that all entities’ contributions to the health and well-being of the community or state are
recognized in assessing the provision of public health services.
The public health system includes
• Public health agencies at state and local levels
• Healthcare providers
• Public safety agencies
• Human service and charity organizations
• Education and youth development organizations
• Recreation and arts-related organizations
• Economic and philanthropic organizations
• Environmental agencies and organizations
From <https://www.cdc.gov/nphpsp/essentialservices.html>
people.gov/2020/tools-and-resources/program-planning/Track>
The 10 Essential Public Health Services
Figure 2: The 10 Essential Public Health Services
The 10 Essential Public Health Services describe the public health activities that all communities
should undertake and serve as the framework for the NPHPS instruments. Public health systems
should
Monitor health status to identify and solve community health problems.
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1. Monitor health status to identify and solve community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships and action to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the provision of health care when
otherwise unavailable.
8. Assure competent public and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10. Research for new insights and innovative solutions to health problems.
From <https://www.cdc.gov/nphpsp/essentialservices.html>
CORE FUNCTIONS AND THE PUBLIC HEALTH SYSTEM
Definition of Public Health:
“What we as a society do collectively to assure the conditions in which people can be
healthy”
Institute of Medicine Report “The Future of Public Health,” 1988
Exercise
Watch this video to learn more about public health’s role in improving the health status of the
United States to in one generation.
Consider the following questions: (click on the question to see the answer)
• Do you think that this video is effective?
• What is missing in this video?
P5 - A Public Health Approach
Five key elements in a public health approach to addressing population health issues:
1. Populations
Target for intervention: the country as a whole; a specific state, county, city, neighborhood
or specific group such as people at risk or with a particular disease
2. Prevention
Prevention Levels
○ Primary
○ Secondary
○ Tertiary
Prevention Strategies
High-risk: focuses on identifying the relatively small number of individuals who are at
high risk in order to reduce their risk factor(s) and subsequent development of
disease
Population-based: focuses on changing behavior in large numbers of people, most of
whom have low or no risk at present, in order to prevent the development of risk
factors and disease
3. Partnerships
○ Activities undertaken within the formal structure of government
○ Associated efforts of private and voluntary organizations and individuals
4. Priorities
Resources are limited, therefore priorities must be established
5. Public Health Workforce
○ A competent public health and personal health care workforce requires:
▪ Providing education and training for personnel
▪ Licensing professionals and certifying facilities including regular verification and
inspection follow-ups
▪ Continuing quality improvement and life-long learning within all
licensure/certification programs
▪ Partnering with professional training programs to assure community-relevant
learning experiences
▪ Assuring continuing education in management and leadership for
administrators and executives
Public Health Obligations of Government
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Prevent epidemics and the spread of disease
Protect against environmental hazards
Prevent injuries
Promote and encourage healthy behaviors
Respond to disasters and assist communities in recovery
Assure the quality and accessibility of health services
Core Functions of Government in Public Health
• Assessment—identification of problems
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• Assessment—identification of problems
• Policy Development—mobilization of necessary efforts and resources
• Assurance—vital conditions are in place so that crucial services can be received
Assessment
1. Monitor health status to identify community health problems
2. Diagnose and investigate health problems and health hazards in the community
Policy Development
3. Inform, educate and empower people about health issues
4. Mobilize community partnerships to identify and solve health problems
5. Develop policies and plans that support individual and community health efforts
Assurance
6. Enforce laws and regulations that protect health and ensure safety
7. Link people to needed personal health services and assure the provision of health care
when otherwise unavailable
8. Assure a competent public health and personal health care workforce
9. Evaluate effectiveness, accessibility and quality of personal and population-based health
services
Assessment—Policy Development--Assurance
10. Research for new insights and innovative solutions to health problems
The Public Health System
• THE SYSTEM BACKBONE: Governmental Public Health Infrastructure
• Community
• Health care delivery system
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• Health care delivery system
• Employers and Business
• The Media
• Academia (public health and health sciences)
Partnerships are expanding in public health and the system is growing more complex as we
tackle new problems.
Public health systems are commonly defined as “all public, private, and voluntary entities that
contribute to the delivery of essential public health services within a jurisdiction.” This concept
ensures that all entities’ contributions to the health and well-being of the community or state are
recognized in assessing the provision of public health services.
The public health system includes:
• Public health agencies at state and local levels
• Healthcare provider
• Public safety agencies
• Human service and charity organizations
• Education and youth development organizations
• Recreation and arts-related organizations
• Economic and philanthropic organizations
• Environmental agencies and organizations
EFFECTIVENESS-BASED PROGRAM PLANNING
Beginning in the 1980s and continuing to today, program planning and implementation has been
driven by performance accountability. This stems from the fact that many public health and
human service programs are funded by tax dollars. Performance accountability has also been
embraced by many private sector organizations such as foundations, non-profits and the United
Way. Government and private sector funding sources want to know if the programs they support
work and if they do not, funds can be redirected.
Effectiveness-based Program Planning has two foci:
Effectiveness: measurable changes occurring in organizations, communities or systems
as a result of receiving services
Program: prearranged set of activities designed to achieve defined goals and objectives
Program Planning: Stepwise Process
Program planning is a stepwise process that includes several critical elements.
1. Determine Need
Review quantitative data (morbidity and mortality reports, survey data, information from
available utilization databases such as Medicare and Medicaid, insurers, health care
agencies, assessing existing resources)
Review qualitative data (information from key stakeholders, focus groups, public forums)
2. Establish a framework for action-Goals and Objectives
Goals
Characteristics of goals:
○ Goals provide a sense of programmatic direction
○ Goals are not necessarily achievable
○ Goals should fit within the mission of the organization that offers the program*
▪ * This is very important to consider since most programs are not funded at a
level that allows programs to be freestanding.
Examples of Goals
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○ 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
Objectives
Outcome Objectives identify results (ends) to be achieved by program, such as
reduction in incidence and prevalence of the problem in the target population
Process Objectives identify manner (means) in which results will be achieved,
identify milestone necessary to achieve outcome objectives, such as offering weekly
screening, referral and follow-up programs for a year that will reach 5000 individuals
Characteristics of Objectives:
○ Objectives should be written in clear, unambiguous terms (behavioral language)
○ Objectives should Identify expected results
○ Objectives should identify measurable results
○ Objectives should identify time frame within which results will be achieved
○ Objective should identify achievable results based on technology, knowledge and
resources
○ Objectives should identifies parties responsible for results
Example of an Outcome Objective:
Mental Health and Mental Disorders
By 2020, increase the proportion of persons with co-occurring substance abuse and
mental disorders who receive treatment for both disorders by 10% from 3.0% to
3.3%.
Baseline: 3.0 percent of persons with co-occurring substance abuse and mental
disorders received treatment for both disorders in 2008
Target: 3.3 percent
Target-Setting Method: 10 percent improvement
Data Source: National Survey on Drug Use and Health (NSDUH), SAMHSA
Activities
Specific tasks that must be completed to achieve process objectives
Common Activities:
○ Health communications
○ Media advocacy
○ Policy actions
○ Initiatives at work, school, health care settings
Characteristics of Potential Activities:
○ Effectiveness—evidence that when properly applied, activity can contribute to
attaining the objective
○ Reach—potential for activity to reach a large portion of the target population
○ Acceptability—extent to which the target population, general public and relevant
agencies finds the activity socially and culturally acceptable
○ Cost—extent to which the activity is economically feasible
○ Public support—extent to which the activity has potential for engendering positive
public opinion, support for the initiative or public health and prevention in general
3. Develop Evaluation Plan during program planning
○ Types of Evaluation:
○ Formative/Process—ongoing evaluation to determine if the program is doing what it
set out to do (focus on process objectives)
○ Summative/Outcome—evaluation at conclusion of program to assess
accomplishments (focus on outcome objectives)
From <https://cf.son.umaryland.edu/NRSG780/module8/subtopic2.htm>
PROGRAM PLANNING MODELS
A wide range of evidence-based program planning models are available to assist you in
developing frameworks for community-based population health programs. Using program
planning models typically speeds the planning process and assists in identifying essential
elements for program success.
This module will highlight three models:
1. MAP-IT, the model for implementing Healthy People 2020
2. Logic models
3. PRECEDE/PROCEED developed by Drs. Larry Green and Marshall Kreuter
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3. PRECEDE/PROCEED developed by Drs. Larry Green and Marshall Kreuter
There are many others that may assist you including the Communities That Care Model that
specifically focused on preventing youth from problem behaviors, the Community Readiness
Model that is issue specific and the Healthy Cities/ Healthy Communities Model, a citizen driven
framework used extensively in international settings.
MAP-IT: A framework for planning and evaluating public health interventions in a community
MAP-IT has five steps:
1. Mobilize individuals and organizations that care about the health of your community into a
coalition.
2. Assess the areas of greatest need in your community, and the strengths and resources
that you can tap into to address those areas.
3. Plan your approach: start with a vision of where you want to be as a community; add
strategies and action steps to help achieve that vision.
4. Implement your plan using concrete action steps that can be monitored and will make a
difference.
5. Track your progress over time.
How do you use MAP-IT?
1. Mobilize
○ Consider what you want coalition partners to do and how the coalition might be
organized
○ Brainstorm potential partners
○ Recruit coalition members
○ Create a vision for the coalition
2. Assess
○ Collect locally available data about resources and needs
○ Collect information from public and archival sources.
○ Determine what issues are most important to community residents and key
stakeholders
○ Identify community assets, including people, skills, capacity and capacity building,
space, organizations and institutions, knowledge, funds, etc.
○ Based on data and community priorities, prioritize needs by consensus
○ Establish baseline data
3. Plan
○ Choose the issue(s) the initiative will work on
○ Set clear objectives
○ For each objective, develop an action plan that includes:
▪ A strategy and tactics
▪ A timeline with reasonable time targets for each phase of the strategy
▪ The responsible parties and their roles and tasks
▪ Indicators and/or other measures of progress
4. Implement
○ Identify an individual or organization to serve as the coordinating point for the
implementation of the initiative.
○ Make sure that everyone involved knows what’s going on and what everyone else is
doing
○ Use the media and other channels to inform the community about the work of the
initiative
5. Track
○ Start your evaluation and monitoring at the very beginning of your initiative, if
possible
○ Set up a system for gathering data
○ Consider:
▪ Data Quality
▪ Limitations of self-reported data
▪ Data validity and reliability
▪ Data availability
○ Organize and analyze data on a regular basis, so that you can make appropriate
adjustments in your work as time goes on
○ Share progress and successes with the community
MAP-IT: Additional Resources
• Healthy People 2020, a collaboration between several different organizations with the mission of
setting objectives for the health of the nation. They provide the MAP-IT framework for
Implementation, as well as many other useful pages, including:
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Implementation, as well as many other useful pages, including:
• Organizing a Coalition: Provides a list of important questions to consider before organizing a
•
•
•
•
coalition, in a printable format that allows you to fill out answers to the questions and/or distribute
them to a planning group.
Potential Partners: A checklist that will help you think of all possibilities for potential partners for
your effort.
Prioritizing Issues: An exercise that will assist you in determining which issues it is most
important for your effort to undertake.
Community Assets: A checklist to assist you in determining community assets that are
available.
Measuring Progress: Helpful formulas for quantitatively measuring your progress.
Logic Model
Basically a logic model is a systematic and visual way to present and share your understanding
of the relationships among the resources you have to operate your program, the activities you
plan, and the changes or results you hope to achieve.
When read from left to right, logic models describe program basics over time from planning
through results. Reading a logic model means following the chain of reasoning or “If…then…”
statements which connect the program’s parts. The figure below shows how the basic logic
model is read.
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The purpose of a logic model is to provide stakeholders with a road map describing the
sequence of related events connecting the need for the planned program with the program’s
desired results. Mapping a proposed program helps you visualize and understand how human
and financial investments can contribute to achieving your intended program goals and can lead
to program improvements.
PRECEDE/PROCEED MODEL
PRECEDE/PROCEED: A community-oriented participatory model for creating successful
community health promotion interventions. It was among the first and is an internationally
recognized program planning model for public health.
PRECEDE/PROCEED is designed to prioritize behavioral and environmental objectives
• Identify risk factors
• Differentiate between behavioral and environmental risk factors
• Focus on the factors most likely to achieve program objectives
• Determine the importance of risk factors
• Determine the potential for changeability
• Identify what is most important and most changeable
• Set objectives--who, what, how much, when
PRECEDE-PROCEED: 9 Phases
Five Diagnostic Phases:
1. Social Assessment
2. Epidemiologic Assessment
3. Behavioral and Environmental Assessment
4. Educational and Organizational/Educational Assessment
5. Administrative and Policy Diagnosis
Four Implementation and Evaluation Phases:
1. Implementation
2. Process Evaluation
3. Impact Evaluation
4. Outcome Evaluation
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Additional Planning Models
The Community Tool box is a global resource for free information on essential skills for
building healthy communities. It offers more than 7,000 pages of practical guidance in
creating change and improvement.
The Community Tool Box offers practical resources for your work:
• How-to Guidance – table of contents
• Toolkits
• Troubleshooting guide
• Evidence-based practices – promising approaches
Check out the Community Tool Box at http://ctb.ku.edu/en
From <https://cf.son.umaryland.edu/NRSG780/module8/subtopic3.htm>
Introduction to Logic Models Chapter One defines logic models and explains their usefulness to program
stakeholders. You will learn the relevance of this state-of-the-art tool to program planning, evaluation,
and improvement. Effective program evaluation does more than collect, analyze, and provide data. It
makes it possible for you – program stakeholders – to gather and use information, to learn continually
about and improve programs that you operate in or fund. The W.K. Kellogg Foundation believes
evaluation – especially program logic model approaches – is a learning and management tool that can
be used throughout a program’s life – no matter what your stake in the program. Using evaluation and
the logic model results in effective programming and offers greater learning opportunities, better
documentation of outcomes, and shared knowledge about what works and why. The logic model is a
beneficial evaluation tool that facilitates effective program planning, implementation, and evaluation.
The What and Why of the Logic Model
The WHAT: Logic Model Definition Basically, a logic model is a systematic and visual way to present and
share your understanding of the relationships among the resources you have to operate your program,
the activities you plan, and the changes or results you hope to achieve.
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The most basic logic model is a picture of how you believe your program will work. It uses words and/or
pictures to describe the sequence of activities thought to bring about change and how these activities
are linked to the results the program is expected to achieve.
Logic Model Development Guide A program logic model is a picture of how your program works – the
theory and assumptions underlying the program. ...This model provides a road map of your program,
highlighting how it is expected to work, what activities need to come before others, and how desired
outcomes are achieved (p. 35). W.K. Kellogg Foundation Evaluation Handbook (1998) Chapter 1
Resources/ Inputs Activities Outputs Outcomes Impact 1 2 3 4 5 Your Planned Work Your Intended
Results The Basic Logic Model components shown in Figure 1 above are defined below. These
components illustrate the connection between your planned work and your intended results. They are
depicted numerically by steps 1 through 5. YOUR PLANNED WORK describes what resources you think
you need to implement your program and what you intend to do.
1. Resources include the human, financial, organizational, and community resources a program has
available to direct toward doing the work. Sometimes this component is referred to as Inputs.
2. Program Activities are what the program does with the resources. Activities are the processes, tools,
events, technology, and actions that are an intentional part of the program implementation. These
interventions are used to bring about the intended program changes or results.
YOUR INTENDED RESULTS include all of the program’s desired results (outputs, outcomes, and impact).
3. Outputs are the direct products of program activities and may include types, levels and targets of
services to be delivered by the program.
4. Outcomes are the specific changes in program participants’ behavior, knowledge, skills, status and
level of functioning. Short-term outcomes should be attainable within 1 to 3 years, while longer-term
outcomes should be achievable within a 4 to 6 year timeframe. The logical progression from short-term
to long-term outcomes should be reflected in impact occurring within about 7 to 10 years.
5. Impact is the fundamental intended or unintended change occurring in organizations, communities or
systems as a result of program activities within 7 to 10 years. In the current model of WKKF grantmaking
and evaluation, impact often occurs after the conclusion of project funding.
The term logic model is frequently used interchangeably with the term program theory in the evaluation
field. Logic models can alternatively be referred to as theory because they describe how a program
works and to what end (definitions for each employed by leading evaluation experts are included in the
Resources Appendix). The What: How to “Read” a Logic Model When “read” from left to right, logic
models describe program basics over time from planning through results. Reading a logic model means
following the chain of reasoning or “If...then...” statements which connect the program’s parts. The
figure below shows how the basic logic model is read. Page 2 Logic Model Development Guide Most of
the value in a logic model is in the process of creating, validating, and modifying the model … The clarity
of thinking that occurs from building the model is critical to the overall success of the program (p. 43).
W.K. Kellogg Foundation Handbook (1998)
Chapter 1 Figure 2. How to Read a Logic Model. The WHY: Logic Model Purpose and Practical Application
The purpose of a logic model is to provide stakeholders with a road map describing the sequence of
related events connecting the need for the planned program with the program’s desired results.
Mapping a proposed program helps you visualize and understand how human and financial investments
can contribute to achieving your intended program goals and can lead to program improvements. A
logic model brings program concepts and dreams to life. It lets stakeholders try an idea on for size and
apply theories to a model or picture of how the program would function. The following example shows
how the logic model approach works. (If you are familiar with logic models, you may wish to skip ahead
to the section entitled “Why Use A Logic Model?”) Page 3 Logic Model Development Guide Sample
Factors influencing the trip: • Family members’ school and work schedules • The holidays • Winter
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Factors influencing the trip: • Family members’ school and work schedules • The holidays • Winter
weather • Frequent Flier availability Sample Activities: • Creating/checking family schedules • Gathering
holiday flight and FF information • Getting airport transportation • Notifying Iowa relatives An Example:
We are proposing an inexpensive family trip from Charleston, South Carolina, to Des Moines, Iowa, to
visit relatives during December school holidays. The seasonal trip we dream of taking from Charleston to
Des Moines is the “program.” Basic assumptions about our trip “program” are: • We want to visit
relatives between 12/10/00 and 1/5/01 while the children are out of school. • We will fly from South
Carolina to Iowa because it takes less time than driving and because frequent flier (FF) miles are
available. • Using frequent flier miles will reduce travel costs. We have to determine the factors
influencing our trip, including necessary resources, such as, the number of family members, scheduled
vacation time, the number of frequent flier miles we have, round trip air reservations for each family
member, and transportation to and from our home to the airport. The activities necessary to make this
happen are the creation of our own family holiday schedule, securing our Iowa relative’s schedule,
garnering air line information and reservations and planning for transportation to and from the airport.
Resources/ Inputs Activities Outputs Outcomes Impact Certain resources are needed to operate your
program If you have access to them, then you can use them to accomplish your planned activities If you
accomplish your planned activities, then you will hopefully deliver the amount of product and/or service
that you intended If you accomplish your planned activities to the extent you intended, then your
participants will benefit in certain ways If these benefits to participants are achieved, then certain
changes in organizations, communities, or systems might be expected to occur 1 2 3 4 5 Your Planned
Work Your Intended Results In this example, the results of our activities – or outputs – are mostly
information, such as family schedules, flight schedules, and cost information based on the time frame of
the trip. This information helps identify outcomes or immediate goals. For instance, if we make
reservations as soon as possible, we are able to find flights with available frequent flier slots and
probably have more options for flights that fit within the time frame. Knowing this, our outcomes
improve – reservations made well in advance result in flight schedules and airline costs that suit our
timeline and travel budget. Longer-term impact of our trip is not an issue here, but might be projected
as continued good family relationships in 2010. Using a simple logic model as a trip-planning tool
produced tangible benefits. It helped us gather information to influence our decisions about resources
and allowed us to meet our stated goals. Applying this process consistently throughout our trip planning
positions us for success by laying out the best course of action and giving us benchmarks for measuring
progress – when we touch down in Charlotte and change planes for Cincinnati, we know we’re on
course for Des Moines. Typical logic models use table and flow chart formats like those presented here
to catalogue program factors, activities, and results and to illustrate a program’s dimensions. Most use
text and arrows or a graphic representation of program ideas. This is what our trip planning “program”
could look like in logic model format. It was easy to organize travel plans in a flow chart, but we could
also choose to organize and display our thinking in other ways. A logic model does not have to be linear.
It may appear as a simple image or concept map to describe more complex program concepts. Settling
on a single image of a program is sometimes the most difficult step for program stakeholders. Page 4
Logic Model Development Guide You can’t do “good” evaluation if you have a poorly planned program.
Beverly Anderson Parsons (1999) Resources/ Inputs Activities Outputs Outcomes Impact Holiday flight
schedules Family schedules Frequent flyer holiday options Holiday weather Create family schedule Get
holiday flight info Get tickets Arrange ground transport Tickets for all family members Frequent flyer
miles used Money saved Family members enjoy vacation Continued good family relations 1 2 3 4 5 Your
Planned Work Trip Planning Your Intended Results Trip Results ••••• • • • • • • • •
Chapter 1 Why Use a Logic Model? As you can see from the travel plan example, logic models are useful
tools in many ways. Because they are pictorial in nature, they require systematic thinking and planning
to better describe programs. The visual representation of the master plan in a logic model is flexible,
points out areas of strength and/or weakness, and allows stakeholders to run through many possible
scenarios to find the best. In a logic model, you can adjust approaches and change courses as program
plans are developed. Ongoing assessment, review, and corrections can produce better program design
and a system to strategically monitor, manage, and report program outcomes throughout development
and implementation. Effective evaluation and program success rely on the fundamentals of clear
stakeholder assumptions and expectations about how and why a program will solve a particular
problem, generate new possibilities, and make the most of valuable assets. The logic model approach
helps create shared understanding of and focus on program goals and methodology, relating activities to
projected outcomes.
Logic Models Better Position Programs For Success Many evaluation experts agree that use of the logic
model is an effective way to ensure program success. Using a logic model throughout your program
helps organize and systematize program planning, management, and evaluation functions. 1. In Program
Design and Planning, a logic model serves as a planning tool to develop program strategy and enhance
your ability to clearly explain and illustrate program concepts and approach for key stakeholders,
including funders. Logic models can help craft structure and organization for program design and build
in self-evaluation based on shared understanding of what is to take place. During the planning phase,
developing a logic model requires stakeholders to examine best practice research and practitioner
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developing a logic model requires stakeholders to examine best practice research and practitioner
experience in light of the strategies and activities selected to achieve results. 2. In Program
Implementation, a logic model forms the core for a focused management plan that helps you identify
and collect the data needed to monitor and improve programming. Using the logic model during
program implementation and management requires you to focus energies on achieving and
documenting results. Logic models help you to consider and prioritize the program aspects most critical
for tracking and reporting and make adjustments as necessary. 3. For Program Evaluation and Strategic
Reporting, a logic model presents program information and progress toward goals in ways that inform,
advocate for a particular program approach, and teach program stakeholders. Page 5 Logic Model
Development Guide If program planners don’t have any hypotheses guiding them, their potential for
learning from the initiative is low, and the program is probably in trouble (p. 1). Everything You Wanted
to Know About Logic Models but Were Afraid to Ask, Connie Schmitz and Beverly Anderson Parsons
(1999) The bane of evaluation is a poorly designed program. Ricardo Millett, Director, WKKF Evaluation
Unit We all know the importance of reporting results to funders and to community stakeholders alike.
Communication is a key component of a program’s success and sustainability. Logic models can help
strategic marketing efforts in three primary ways: • Describing programs in language clear and specific
enough to be understood and evaluated. • Focusing attention and resources on priority program
operations and key results for the purposes of learning and program improvement. • Developing
targeted communication and marketing strategies. The Table below describes the relationship between
a successful program and the benefits derived from the use of logic models. How Logic Models Better
Position Programs Toward Success. Logic Models Strengthen the Case for Program Investment Clear
ideas about what you plan to do and why – as well as an organized approach to capturing, documenting,
and disseminating program results – enhance the case for investment in your program. Page 6 Logic
Model Development Guide Program Elements Planning and Design Program Implementation and
Management Evaluation, Communication, and Marketing Criteria for Program Success1 Program goals
and objectives, and important side effects are well defined ahead of time. Program goals and objectives
are both plausible and possible. Relevant, credible, and useful performance data can be obtained. The
intended users of the evaluation results have agreed on how they will use the information. Benefits of
Program Logic Models2 Finds “gaps” in the theory or logic of a program and work to resolve them.
Builds a shared understanding of what the program is all about and how the parts work together.
Focuses attention of management on the most important connections between action and results.
Provides a way to involve and engage stakeholders in the design, processes, and use of evaluation. 1
Wholey, J. S., Hatry, H. P., & Newcomer, K. E. (Eds.). (1994). Handbook of Practical Program Evaluation.
San Francisco: Jossey-Bass Publishers. 2 Barley, Z., Phillips, C., & Jenness, M. (1998). Decoding Program
Logic Models. Workshop presented at the Annual Meeting of the American Evaluation Association,
Chicago, IL, November, 1998. There are many ways to conduct evaluations, and professional evaluators
tend to agree that there is no “one best way” to do any evaluation. Instead, good evaluation requires
carefully thinking through the questions that need to be answered, the type of program being
evaluated, and the ways in which the information generated will be used. Good evaluation, in our view,
should provide useful information about program functioning that can contribute to program
improvement. W.K. Kellogg Foundation Evaluation Unit Chapter 1 Developing a Program Logic Model
Requires a Simple Image and a Straightforward Approach A picture IS worth a thousand words. The
point of developing a logic model is to come up with a relatively simple image that reflects how and why
your program will work. Doing this as a group brings the power of consensus and group examination of
values and beliefs about change processes and program results. Logic Models Reflect Group Process and
Shared Understanding Frequently, a professional evaluator is charged with developing a logic model for
program practitioners. But a logic model developed by all stakeholders – program staff, participants, and
evaluators – produces a more useful tool and refines program concepts and plans in the process. We
recommend that a logic model be developed collaboratively in an inclusive, collegial process that
engages as many key stakeholders as possible. This guide provides a step-by-step process to assist
program planners. Like Programs, Logic Models Can Change Over Time As a program grows and
develops, so does its logic model. A program logic model is merely a snapshot of a program at one point
in time; it is not the program with its actual flow of events and outcomes. A logic model is a work in
progress, a working draft that can be refined as the program develops. Simple Logic Model Basics
Creating a logic model: What they look like and what needs to be included Logic models come in as
many sizes and shapes as the programs they represent. A simple model focuses on project-level results
and explains five basic program components. The elements outlined below are typical of the model
promoted by United Way of America to support an outcomes-based approach to program planning and
evaluation. Developing and Reading a Basic Logic Model Read from left to right, logic models describe
program basics over time, beginning with best practice information or knowledge about “what works”
from successful program practitioners and other trusted authorities. Reading a logic model means
following the chain of reasoning or “If...then...” statements which connect the program’s parts. The gray
box in the left column defines the assumptions stated in “If...then...” terms. Page 7 Logic Model
Development Guide LOGIC MODEL IF…THEN Assumptions: • Certain resources are needed to operate
your program. • If you have access to them, then you can use them to accomplish your planned
activities. • If you accomplish your planned activities, then, you will, it is hoped, deliver the amount of
product and/or service that you intended. • If you accomplish your planned activities to the extent
intended, then your participants will benefit in specific ways. • If these benefits to participants are
achieved, then certain changes in organizations, communities, or systems might occur under specified
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achieved, then certain changes in organizations, communities, or systems might occur under specified
conditions. Building a Logic Model by Basic Program Components As you conceptualize your program,
begin by describing your basic assumptions and then add the following program components in the
order that they should occur. 1. Factors are resources and/or barriers, which potentially enable or limit
program effectiveness. Enabling protective factors or resources may include funding, existing
organizations, potential collaborating partners, existing organizational or interpersonal networks, staff
and volunteers, time, facilities, equipment, and supplies. Limiting risk factors or barriers might include
such things as attitudes, lack of resources, policies, laws, regulations, and geography. 2. Activities are the
processes, techniques, tools, events, technology, and actions of the planned program. These may
include products – promotional materials and educational curricula; services – education and training,
counseling, or health screening; and infrastructure – structure, relationships, and capacity used to bring
about the desired results. 3. Outputs are the direct results of program activities. They are usually
described in terms of the size and/or scope of the services and products delivered or produced by the
program. They indicate if a program was delivered to the intended audiences at the intended “dose.” A
program output, for example, might be the number of classes taught, meetings held, or materials
produced and distributed; program participation rates and demography; or hours of each type of service
provided. 4. Outcomes are specific changes in attitudes, behaviors, knowledge, skills, status, or level of
functioning expected to result from program activities and which are most often expressed at an
individual level. 5. Impacts are organizational, community, and/or system level changes expected to
result from program activities, which might include improved conditions, increased capacity, and/or
changes in the policy arena. Thinking about a program in logic model terms prompts the clarity and
specificity required for success, and often demanded by funders and your community. Using a simple
logic model produces (1) an inventory of what you have and what you need to operate your program;
(2) a strong case for how and why your program will produce your desired results; and (3) a method for
program management and assessment. Other Logic Model Examples In practice, most logic models are
more complex and fall into one of three categories: the theory approach model (conceptual), outcome
approach model, or activities approach model (applied) – or a blend of several types. It is not unusual
for a program to use all three types of logic models for different purposes. No one model fits all needs,
so you will Page 8 Logic Model Development Guide Chapter 1 need to decide exactly what you want to
achieve with your logic model – and where you are in the life of your program – before deciding on
which model to use. Types of Logic Models: Emphasis and Strengths Descriptions of Three Approaches
to Logic Models: Which Fits Your Program? 1. Theory Approach Models emphasize the theory of change
that has influenced the design and plan for the program. These logic models provide rich explanation of
the reasons for beginning to explore an idea for a given program. Sometimes they have additional parts
that specify the problem or issue addressed by the program, describe the reasons for selecting certain
types of solution strategies, connect proven strategies to potential activities, and other assumptions the
planners hold that influence effectiveness. These models illustrate how and why you think your program
will work. They are built from the “big picture” kinds of thoughts and ideas that went into
conceptualizing your program. They are coming to be most often used to make the case in grant
proposals. Models describing the beginnings of a program in detail are most useful during program
planning and design. Page 9 Logic Model Development Guide Types of Logic Models: Emphasis and
Strengths A program is a theory and an evaluation is its test. In order to organize the evaluation to
provide a responsible test, the evaluator needs to understand the theoretical premises on which the
program is based (p. 55). Carol Weiss (1998) Intended Results Beginnings Should contribute to the
results you expect based on this theory of change If your assumptions about the factors that influence
your issues hold true... Planned Work Then, the activities you plan to do which build on these
assumptions... Evaluation, Communication, Marketing Implementation Planning & Design Grant
Proposal Reports & Other Media Management Plan theory type outcomes type activities type Program
Logic Model what we have done so far how we will do what we say we will do what we hope to do 2.
Outcomes Approach Models focus on the early aspects of program planning and attempt to connect the
resources and/or activities with the desired results in a workable program. These models often
subdivide outcomes and impact over time to describe short-term (1 to 3 years), long-term (4 to 6 years),
and impact (7 to 10 years) that may result from a given set of activities. Although these models are
developed with a theory of change in mind, this aspect is not usually emphasized explicitly. Models that
outline the approach and expectations behind a program’s intended results are most useful in designing
effective evaluation and reporting strategies. 3. Activities Approach Models pay the most attention to
the specifics of the implementation process. A logic model of this type links the various planned
activities together in a manner that maps the process of program implementation. These models
describe what a program intends to do and as such are most useful for the purposes of program
monitoring and management. This type provides the detailed steps you think you will need to follow to
implement your program. It shows what you will actually do in your community if your proposal is
funded. Models that emphasize a program’s planned work are most often used to inform management
planning activities. Working Through Theory Approach Logic Models Emphasizes Assumptions A theory
approach logic model links theoretical ideas together to explain underlying program assumptions. The
focus here is on the problem or issue and the reasons for proposing the solution suggested in your
program’s approach. Remember, the theory logic model is broad and about “big ideas,” not about
specific program “nuts and bolts.” Noted evaluator and program theorist Carol Weiss (1998) explains
that for program planning, monitoring, and evaluation, it is important to know not only what the
program expects to achieve but also how. We must understand the principles on which a program is
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program expects to achieve but also how. We must understand the principles on which a program is
based, a notion not included in evaluation until recently. Discussions about the whethers, hows, and
whys of program success require credible evidence and attention to the paths by which outcomes and
impacts are produced. The theory logic model is suitable for use by funders and grantees. A case
example of its use is provided below. In this case, the model describes a WKKF cluster initiative’s
(Comprehensive Community Health Models of Michigan) programming strategy or its theory of change.
Notice that this model places emphasis on “Your Beginnings” by including the assumptions identified by
program planners as the principles behind the design of the initiative. Page 10 Logic Model
Development Guide The purpose of using program logic models in WKKF grantmaking is to help internal
and external stakeholders understand how the Foundation’s investment will contribute to achieving the
intended goals. This understanding should help these various stakeholders make informed decisions
about program priorities, funding priorities, assistance to grantees, evaluation of programming impact,
and marketing, communication, and marketing strategies. W.K. Kellogg Foundation Evaluation
Handbook (1998) Chapter 1 Working with Outcome Approach Models Highlights Activities and Program
Implementation Outcome approach logic models display the interrelationships between specific
program activities and their outcomes. On the next page is an example drawn from the Calhoun County
Health Improvement Program, funded under the Comprehensive Community Health Models of Michigan
initiative. This linear, columnar model emphasizes the causal linkages thought to exist among program
components. The arrows show which sets of activities program developers believed would contribute to
what outcomes. These statements serve as logical assertions about the perceived relationship among
program operations and desired results and are the hallmark of the logic model process. Notice that this
model emphasizes “Your Intended Results” in the greatest relative detail and anticipates achievement
outside the time allotted for the initiative. Page 11 Logic Model Development Guide These models help
build a common understanding between managers and evaluators.... Such agreement is a prerequisite
for evaluation work that is likely to be useful to management. [These models] display the key events
(inputs, activities, outcomes) that could be monitored and the assumed causal linkages that could be
tested in evaluations of the program. Joseph S. Wholey, Harry P. Hatry, and K.E. Newcomer (1994)
Assumptions Health is a community issue and communities will form partnerships to resolve health care
problems. Commnities can influence and shape public and market policy at the local, state, and national
levels. External agents, working in partnership with communities, can serve as catalysts for change.
Shifting revenues and incentives to primary care and prevention will improve health status. Information
on health status and systems is required for informed decision making. Your Beginnings Your Planned
Work Your Intended Results Inputs Activities Outputs Outcomes Impact Active Participation in the
Reform Process Inclusive Community DecisionMaking Community-wide Coverage and Access
Comprehensive, Integrated Health Care Delivery System Community Health Assessment Communitybased Health Information Systems Improved Health Status Increased Health Care System Efficiency
More Effective Distribution of Community Health Care Resources Administrative Processes for Health
Data, Policy, and Advocacy External Technical Assistance Consumers Providers Payers Staff Example of a
Theory Logic model (Adapted from WKKF’s Comprehensive Community Health Models of Michigan).
Using the Activities Approach Models to Track Outcomes The activities approach logic model also
connects program resources and activities to desired results but does so in very great detail. Each
outcome is usually dealt with separately by the activities and events that must take place to keep the
program on track. The model emphasizing “Your Planned Work” can be used as a work plan or
management tool for program components and in conjunction with other models. Notice how it points
out what program activities need to be monitored and what kind of measurements might indicate
progress toward results. Below is one model describing the connections between project tasks and
outcome achievement for the community coverage strand from the outcome approach example
provided earlier. Page 12 Logic Model Development Guide Not only will a logic model clarify each
element of your program, it will enable you to respond to the question: “To what do I want to be held
accountable?”. The Evaluation Forum (1999) Activities that encourage consumers, providers, and payers
to seek support, and achieve common goals. Activities that increase consumer awareness and access to
health promotion, disease prevention, and primary care services. Activities that increase linkages among
medical, health, and human service systems. Activities that lead to the development of a community
access and coverage plan. Activities that lead to the development of a community health information
network. Activities that lead to the development of a community health assessment and reporting
program. Inputs Activities Outputs Consumers, providers, and payers to participate in governance
processes. Sufficient staff with expertise and leadership skills to implement the program at the local
level. Sufficient external technical assistance to support staff in program implementation Consumers,
providers, and payers serving on the CCHIP Governing Board seek, support, and achieve common goals.
Increased community access and participation in health promotion, disease prevention, and primary
care services. Linkages are forged among medical, health, and human service systems. Third-party
administered contract for community-wide coverage is in place. Fiber-optic information network is in
place (CHIN). Community health assessment and reporting program is in place. CCHIP Governing Board
is deemed inclusive and accountable by the community stakeholders. Increased numbers of community
members utilize the health promotion, disease prevention, and primary care service provided Improved
access/coverage for the insured, under-, and non-insured in the community. Improved Health Status
Community members utilize the CHIN for information collection, storage, analysis, and exchange.
Information provided by the Health Report Card is used to make community health decisions. Outcomes
Impact Your Planned Work Your Intended Results Chapter 1 Example of an Outcome Approach model
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Impact Your Planned Work Your Intended Results Chapter 1 Example of an Outcome Approach model
(example drawn from the Calhoun County Health Improvement Program, funded under the
Comprehensive Community Health Models of Michigan initiative). Adapted from the Calhoun County
Health Improvement Program, one site of WKKF’s Comprehensive Community Health Models of
Michigan initiative There Is No Best Logic Model Try several on for size. Choose the model that fits your
program best and provides the information you need in the format that is most helpful. Like anything
else, it takes practice to use logic models as effective program tools. We learn through trial and error to
find what works best for what program. Don’t hesitate to experiment with program logic model design
to determine what works best for your program. And don’t be concerned if your model doesn’t look like
one of the case examples. The following show how the logic model forms gather information that can be
used throughout your program’s life – from defining the theory on which your program rests to
evaluating program impact. Page 13 Logic Model Development Guide Insurance market issues are
identified and documented. Insurance market issues are prioritized based on potential for successful
reform. The Purchasing Alliance will identify insurance market issues and strategies to reform those
identified issues will be developed and implemented. High priority issues are identified and examined.
Strategies to reform the high priority issues identified have been developed. Change agents with
sufficient capacity and resources to successfully execute insurance market reform are identified.
Equitable access to community-wide coverage. Change agents contracted to implement insurance
market reform (minimum of 2). % decrease of people uninsured (201). % decrease of new Medicaid
eligible consumers achieving coverage before in the hospital (203). % in Medicaid participating
providers, using $1000 threshold level (204). Deliverable–6 Your Planned Work Your Intended Results
Milestone Activities Outputs Outcomes Activities to increase beneficiary enrollment and provider
participation in Medicaid and other third party sponsored insurance and reimbursment plans (2P1) How
to use a Logic Model Through the Life of Your Program: Page 14 Logic Model Development Guide
CLARIFYING PROGRAM THEORY: 1. PROBLEM OR ISSUE STATEMENT: Describe the problem(s) your
program is attempting to solve or the issue(s) your program will address. 2. COMMUNITY
NEEDS/ASSETS: Specify the needs and/or assets of your community that led your organization to design
a program that addresses the problem. 3. DESIRED RESULTS (OUTPUTS, OUTCOMES AND IMPACTS):
Identify desired results, or vision of the future, by describing what you expect to achieve near- and longterm. 4. INFLUENTIAL FACTORS: List the factors you believe will influence change in your community. 5.
STRATEGIES: List general successful strategies or “best practices” that have helped communities like
yours achieve the kinds of results your program promises. 6. ASSUMPTIONS: State the assumptions
behind how and why the change strategies will work in your community. 1. Program Planning 2.
Program Implementation 3. Program Evaluation DEMONSTRATING YOUR PROGRAM’S PROGRESS: 1.
OUTPUTS: For each program activity, identify what outputs (service delivery/implementation targets)
you aim to produce. 2. OUTCOMES: Identify the short-term and long-term outcomes you expect to
achieve for each activity. 3. IMPACT: Describe the impact you anticipate in your community in 7 to 10
years with each activity as a result of your program. 4. ACTIVITIES: Describe each of the activities you
plan to conduct in your program. 5. RESOURCES: Describe the resources or influential factors available
to support your program activities. PROGRAM EVALUATION QUESTIONS AND INDICATORS: 1. FOCUS
AREA: From your program theory logic model, list the components of the most important aspects of
your program. 2. AUDIENCE: Identify the key audiences for each focus area. Who has an interest in your
program? 3. QUESTIONS: For each focus area and audience, list the questions they may have about your
program. 4. INFORMATION USE: For each audience and question you have identified, identify the ways
you will use the evaluation information. 5. INDICATORS: Describe what information could be collected
that would indicate the status of your program and its participants for each question. 6. TECHNICAL
ASSISTANCE: Indicate the extent to which your organization has the evaluation and data management
expertise to collect and analyze the data that relates to this indicator.
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Module 9: Program Planning: Focus on Behavior Change
Tuesday, April 4, 2017
11:51 AM
OVERVIEW
The purpose of this module is to provide an overview of behavior change models and health communications
strategies used to develop and support population-based health promotion programs.
Objectives
At the conclusion of this module, the learner will be able to:
• Discuss health promotion from an ecological perspective
• Describe key components of behavior change theories
• Select appropriate behavior change models
• Illustrate how different types of communication effect health behavior
• Incorporate behavior change models and health communication strategies into program planning and
implementation
Required Readings
• National Cancer Institute, U.S. Department of Health and Human Services (DHHS). (2005). Theory at a
Glance, Part 2 (pp. 9-33). Available
at http://sbccimplementationkits.org/demandrmnch/ikitresources/theory-at-a-glance-a-guide-forhealth-promotion-practice-second-edition/
• Kreuter, M., Lezin, N.,Kreuter, M., Green, L. Community health promotion Ideas that work Chapter 5:
Theory applied, Sudbury, MA: Jones and Bartlett. Available through HS/HSL Course Reserves in 780
blackboard
• Centers for Disease Control and Prevention. (2016). Gateway to Health Communications and Social
Marketing Practice.
• U.S. Department of Health and Human Services (DHHS). The Guide to Community Preventive
Services. Available at http://www.thecommunityguide.org/index.html
Recommended Readings
• Centers for Disease Control and Prevention. (2002). CDCynergy Web: Your Guide to Effective Health
Communication. Available at http://www.orau.gov/cdcynergy/web/
• Centers for Disease Control and Prevention. (2016). Health Literacy. Available
at http://www.cdc.gov/healthliteracy/
Directions
Read the module content and activities. Then complete the assignment for the module.
National Cancer Institute, U.S. Department of Health and Human Services (DHHS). (2005). Theory at a
Glance, Part 2 (pp. 9-33), full text
From <The Ecological Perspective: A Multilevel, Interactive Approach Contemporary health promotion involves more than simply educating
individuals about healthy practices. It includes efforts to change organizational behavior, as well as the physical and social environment of
communities. It is also about developing and advocating for policies that support health, such as economic incentives. Health promotion
programs that seek to address health problems across this spectrum employ a range of strategies, and operate on multiple levels. The ecological
perspective emphasizes the interaction between, and interdependence of, factors within and across all levels of a health problem. It highlights
people’s interactions with their physical and sociocultural environments. Two key concepts of the ecological perspective help to identify
intervention points for promoting health: first, behavior both affects, and is affected by, multiple levels of influence; second, individual behavior
both shapes, and is shaped by, the social environment (reciprocal causation). To explain the first key concept of the ecological perspective,
multiple levels of influence, McLeroy and colleagues (1988)4 identified five levels of influence for healthrelated behaviors and conditions.
Defined in Table 1., these levels include: (1) intrapersonal or individual factors; (2) interpersonal factors; (3) institutional or organizational
factors; (4) community factors; and (5) public policy factors. 10 THEORY AT A GLANCE Figure 2. A Multilevel Approach to Epidemiology Social and
Economic Policies Institutions Neighborhoods and Communities Living Conditions Social Relationships Individual Risk Factors Pathophysiological
Pathways Individual/Population Health Genetic/Constitutional Factors Environment Lifecourse Source: Smedley BD, Syme SL (eds.), Institute of
Medicine. Promoting Health: Strategies from Social and Behavioral Research. Washington, D.C.:, National Academies Press, 2000. Table 1. An
Ecological Perspective: Levels of Influence Concept Intrapersonal Level Interpersonal Level Community Level Institutional Factors Community
Factors Public Policy Definition Individual characteristics that influence behavior, such as knowledge, attitudes, beliefs, and personality traits
Interpersonal processes and primary groups, including family, friends, and peers that provide social identity, support, and role definition Rules,
regulations, policies, and informal structures, which may constrain or promote recommended behaviors Social networks and norms, or
standards, which exist as formal or informal among individuals, groups, and organizations Local, state, and federal policies and laws that regulate
or support healthy actions and practices for disease prevention, early detection, control, and management In practice, addressing the community
level requires taking into consideration institutional and public policy factors, as well as social networks and norms. Figure 2. illustrates how
different levels of influence combine to affect population health. Each level of influence can affect health behavior. For example, suppose a
woman delays getting a recommended mammogram (screening for breast cancer). At the individual level, her inaction may be due to fears of
finding out she has cancer. At the interpersonal level, her doctor may neglect to tell her that she should get the test, or she may have friends
who say they do not believe it is important to get a mammogram. At the organizational level, it may be hard to schedule an appointment,
because there is only a part-time radiologist at the clinic. At the policy level, she may lack insurance coverage, and thus be unable to afford the
fee. Thus, the outcome, the woman’s failure to get a mammogram, may result from multiple factors. The second key concept of an ecological
perspective, reciprocal causation, suggests that people both influence, and are influenced by, those around them. For example, a man with high
cholesterol may find it hard to follow the diet his doctor has prescribed because his company cafeteria doesn’t offer healthy food choices. To
comply with his doctor’s instructions, he can try to change the environment by asking the cafeteria manager to add healthy items to the menu,
or he can dine elsewhere. If he and enough of his fellow employees decide to find someplace else to eat, the cafeteria may change its menu to
maintain lunch business. Thus, the cafeteria environment may compel this man to change his dining habits, but his new habits may ultimately
bring about change in the cafeteria as well. 11 PART 2 THEORIES AND APPLICATIONS 12 THEORY AT A GLANCE An ecological perspective shows
the advantages of multilevel interventions that combine behavioral and environmental components. For instance, effective tobacco control
programs often use multiple strategies to discourage smoking.5 Employee smoking cessation clinics have a stronger impact if the workplace has
a no-smoking policy and the city has a clean indoor air ordinance. Adolescents are less likely to begin smoking if their peers disapprove of the
habit and laws prohibiting tobacco sales to minors are strictly enforced. Health promotion programs are more effective when planners consider
multiple levels of influence on health problems. Theoretical Explanations of Three Levels of Influence The next three sections examine theories
and their applications at the individual (intrapersonal), interpersonal, and community levels of the ecological perspective. At the individual and
interpersonal levels, contemporary theories of health behavior can be broadly categorized as “Cognitive-Behavioral.” Three key concepts cut
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interpersonal levels, contemporary theories of health behavior can be broadly categorized as “Cognitive-Behavioral.” Three key concepts cut
across these theories: 1. Behavior is mediated by cognitions; that is, what people know and think affects how they act. 2. Knowledge is necessary
for, but not sufficient to produce, most behavior changes. 3. Perceptions, motivations, skills, and the social environment are key influences on
behavior. Community-level models offer frameworks for implementing multi-dimensional approaches to promote healthy behaviors. They
supplement educational approaches with efforts to change the social and physical environment to support positive behavior change. Individual
or Intrapersonal Level The individual level is the most basic one in health promotion practice, so planners must be able to explain and influence
the behavior of individuals. Many health practitioners spend most of their work time in one-on-one activities such as counseling or patient
education, and individuals are often the primary target audience for health education materials. Because individual behavior is the fundamental
unit of group behavior, individual-level behavior change theories often comprise broader-level models of group, organizational, community, and
national behavior. Individuals participate in groups, manage organizations, elect and appoint leaders, and legislate policy. Thus, achieving policy
and institutional change requires influencing individuals. In addition to exploring behavior, individuallevel theories focus on intrapersonal factors
(those existing or occurring within the individual self or mind). Intrapersonal factors include knowledge, attitudes, beliefs, motivation, selfconcept, developmental history, past experience, and skills. Individual-level theories are presented below. • The Health Belief Model (HBM)
addresses the individual’s perceptions of the threat posed by a health problem (susceptibility, severity), the benefits of avoiding the threat, and
factors influencing the decision to act (barriers, cues to action, and self-efficacy). • The Stages of Change (Transtheoretical) Model describes
individuals’ motivation and readiness to change a behavior. • The Theory of Planned Behavior (TPB) examines the relations between an
individual’s beliefs, attitudes, intentions, behavior, and perceived control over that behavior. • The Precaution Adoption Process Model (PAPM)
names seven stages in an individual’s journey from awareness to action. It begins with lack of awareness and advances through subsequent
stages of becoming aware, deciding whether or not to act, acting, and maintaining the behavior. Health Belief Model (HBM) The Health Belief
Model (HBM) was one of the first theories of health behavior, and remains one of the most widely recognized in the field. It was developed in the
1950s by a group of U.S. Public Health Service social psychologists who wanted to explain why so few people were participating in programs to
prevent and detect disease. For example, the Public Health Service was sending mobile X-ray units out to neighborhoods to offer free chest Xrays (screening for tuberculosis). Despite the fact that this service was offered without charge in a variety of convenient locations, the program
was of limited success. The question was, “Why?” To find an answer, social psychologists examined what was encouraging or discouraging
people from participating in the programs. They theorized that people’s beliefs about whether or not they were susceptible to disease, and their
perceptions of the benefits of trying to avoid it, influenced their readiness to act. In ensuing years, researchers expanded upon this theory,
eventually concluding that six main constructs influence people’s decisions about whether to take action to prevent, screen for, and control
illness. They argued that people are ready to act if they: • Believe they are susceptible to the condition (perceived susceptibility) • Believe the
condition has serious consequences (perceived severity) • Believe taking action would reduce their susceptibility to the condition or its severity
(perceived benefits) • Believe costs of taking action (perceived barriers) are outweighed by the benefits • Are exposed to factors that prompt
action (e.g., a television ad or a reminder from one’s physician to get a mammogram) (cue to action) • Are confident in their ability to
successfully perform an action (self-efficacy) Since health motivation is its central focus, the HBM is a good fit for addressing problem behaviors
that evoke health concerns (e.g., high-risk sexual behavior and the possibility of contracting HIV). Together, the six constructs of the HBM provide
a useful framework for designing both short-term and long-term behavior change strategies. (See Table 2.) When applying the HBM to planning
health programs, practitioners should ground their efforts in an understanding of how susceptible the target population feels to the health
problem, whether they believe it is serious, and whether they believe action can reduce the threat at an acceptable cost. Attempting to effect
changes in these factors is rarely as simple as it may appear. 13 PART 2 THEORIES AND APPLICATIONS Concept Perceived susceptibility Perceived
severity Perceived benefits Perceived barriers Cues to action Self-efficacy Definition Beliefs about the chances of getting a condition Beliefs about
the seriousness of a condition and its consequences Beliefs about the effectiveness of taking action to reduce risk or seriousness Beliefs about
the material and psychological costs of taking action Factors that activate ”readiness to change” Confidence in one’s ability to take action
Potential Change Strategies • Define what populations(s) are at risk and their levels of risk • Tailor risk information based on an individual’s
characteristics or behaviors • Help the individual develop an accurate perception of his or her own risk • Specify the consequences of a condition
and recommended action • Explain how, where, and when to take action and what the potential positive results will be • Offer reassurance,
incentives, and assistance; correct misinformation • Provide ”how to” information, promote awareness, and employ reminder systems • Provide
training and guidance in performing action • Use progressive goal setting • Give verbal reinforcement • Demonstrate desired behaviors Table 2.
Health Belief Model 14 THEORY AT A GLANCE High blood pressure screening campaigns often identify people who are at high risk for heart
disease and stroke, but who say they have not experienced any symptoms. Because they don’t feel sick, they may not follow instructions to take
prescribed medicine or lose weight. The HBM can be useful for developing strategies to deal with noncompliance in such situations. According to
the HBM, asymptomatic people may not follow a prescribed treatment regimen unless they accept that, though they have no symptoms, they do
in fact have hypertension (perceived susceptibility). They must understand that hypertension can lead to heart attacks and strokes (perceived
severity). Taking prescribed medication or following a recommended weight loss program will reduce the risks (perceived benefits) without
negative side effects or excessive difficulty (perceived barriers). Print materials, reminder letters, or pill calendars might encourage people to
consistently follow their doctors’ recommendations (cues to action). For those who have, in the past, had a hard time losing weight or
maintaining weight loss, a behavioral contract might help establish achievable, short-term goals to build confidence (self-efficacy). Stages of
Change (Transtheoretical) Model Developed by Prochaska and DiClemente,6 the Stages of Change Model evolved out of studies comparing the
experiences of smokers who quit on their own with those of smokers receiving professional treatment. The model’s basic premise is that
behavior change is a process, not an event. As a person attempts to change a behavior, he or she moves through five stages: precontemplation,
contemplation, preparation, action, and maintenance (see Table 3.). Definitions of the stages vary slightly, depending on the behavior at issue.
People at different points along this continuum have different informational needs, and benefit from interventions designed for their stage.
Whether individuals use self-management methods or take part in professional programs, they go through the same stages of change.
Nonetheless, the manner in which they pass through these stages may vary, depending on the type of behavior change. For example, a person
who is trying to give up smoking may experience the stages differently than someone who is seeking to improve their dietary habits by eating
more fruits and vegetables. The Stages of Change Model has been applied to a variety of individual behaviors, as well as to organizational
change. The Model is circular, not linear. In other words, people do not systematically progress from one stage to the next, ultimately
“graduating” from the behavior change process. Instead, they may enter the change process at any stage, relapse to an earlier stage, and begin
the process once more. They may cycle through this process repeatedly, and the process can truncate at any point. 15 PART 2 THEORIES AND
APPLICATIONS Stage Precontemplation Contemplation Preparation Action Maintenance Definition Has no intention of taking action within the
next six months Intends to take action in the next six months Intends to take action within the next thirty days and has taken some behavioral
steps in this direction Has changed behavior for less than six months Has changed behavior for more than six months Potential Change Strategies
Increase awareness of need for change; personalize information about risks and benefits Motivate; encourage making specific plans Assist with
developing and implementing concrete action plans; help set gradual goals Assist with feedback, problem solving, social support, and
reinforcement Assist with coping, reminders, finding alternatives, avoiding slips/relapses (as applicable) Table 3. Stages of Change Model 16
THEORY AT A GLANCE Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200
people). The health educator decides to offer group smoking cessation clinics to employees at various times and locations. Several months pass,
however, and only 50 of the smokers sign up for the clinics. At this point, the health educator faces a dilemma: how can the 150 smokers who are
not participating in the clinics be reached? The Stages of Change Model offers perspective on ways to approach this problem. First, the model
can be employed to help understand and explain why they are not attending the clinics. Second, it can be used to develop a comprehensive
smoking program to help more current and former smokers change their smoking behavior, and maintain that change. By asking a few simple
questions, the health educator can assess what stages of contemplation potential program participants are in. For example: • Are you interested
in trying to quit smoking? (Pre-contemplation) • Are you thinking about quitting smoking soon? (Contemplation) • Are you ready to plan how
you will quit smoking? (Preparation) • Are you in the process of trying to quit smoking? (Action) • Are you trying to stay smoke-free?
(Maintenance) The employees’ responses will help to pinpoint where the participants are on the continuum of change, and to tailor messages,
strategies, and programs appropriate to their needs. For example, individuals who enjoy smoking are not interested in trying to quit, and
therefore will not attend a smoking cessation clinic; for them, a more appropriate intervention might include educational interventions designed
to move them out of the “precontemplation” stage and into “contemplation” (e.g., using carbon monoxide testing to demonstrate the effect of
smoking on health). On the other hand, individuals who are ready to plan how to quit smoking (the “preparation” stage) can be encouraged to
do so, and moved to the next stage, “action.” Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory
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do so, and moved to the next stage, “action.” Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory
of Reasoned Action (TRA) explore the relationship between behavior and beliefs, attitudes, and intentions. Both the TPB and the TRA assume
behavioral intention is the most important determinant of behavior. According to these models, behavioral intention is influenced by a person’s
attitude toward performing a behavior, and by beliefs about whether individuals who are important to the person approve or disapprove of the
behavior (subjective norm). The TPB and TRA assume all other factors (e.g., culture, the environment) operate through the models’ constructs,
and do not independently explain the likelihood that a person will behave a certain way. The TPB differs from the TRA in that it includes one
additional construct, perceived behavioral control; this construct has to do with people’s beliefs that they can control a particular behavior. Azjen
and Driver7 added this construct to account for situations in which people’s behavior, or behavioral intention, is influenced by factors beyond
their control. They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it. (See Table
4.) It has application beyond these limited situations, however. People’s perceptions about controllability may have an important influence on
behavior. Concept Behavioral intention Attitude Subjective norm Perceived behavioral control Definition Perceived likelihood of performing
behavior Personal evaluation of the behavior Beliefs about whether key people approve or disapprove of the behavior; motivation to behave in a
way that gains their approval Belief that one has, and can exercise, control over performing the behavior Measurement Approach Are you likely
or unlikely to (perform the behavior)? Do you see (the behavior) as good, neutral, or bad? Do you agree or disagree that most people approve
of/disapprove of (the behavior)? Do you believe (performing the behavior) is up to you, or not up to you? Table 4. Theory of Planned Behavior
Surveillance data show that young, acculturated Hispanic women are more likely to get Pap tests than those who are older and less
acculturated.8 A health department decides to implement a cervical cancer screening program targeting older Hispanic women. In planning the
campaign, practitioners want to conduct a survey to learn what beliefs, attitudes, and intentions in this population are associated with seeking a
Pap test. They design the survey to gauge: when the women received their last Pap test (behavior); how likely they are to seek a Pap test
(intention); attitudes about getting a Pap test (attitude); whether or not “most people who are important to me” would want them to get a Pap
test (subjective norm); and whether or not getting a Pap test is something that is “under my control” (perceived behavioral control). The
department will compare survey results with data about who has or has not received a Pap test to identify beliefs, attitudes, and intentions that
predict seeking one. 17 PART 2 THEORIES AND APPLICATIONS Figure 3. Theory of Reasoned Action and Theory of Planned Behavior Behavioral
beliefs Evaluation of behavioral outcomes Attitude toward behavior Normative beliefs Motivation to comply Subjective norm Control beliefs
Perceived power Perceived behavioral control Behavioral intention Behavior Note: Upper blue section shows the Theory of Reasoned Action; the
entire figure shows the Theory of Planned Behavior. 18 THEORY AT A GLANCE Figure 3. shows the TPB’s explanation for how behavioral intention
determines behavior, and how attitude toward behavior, subjective norm, and perceived behavioral control influence behavioral intention.
According to the model, attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the
behavior. Beliefs about social standards and motivation to comply with those norms affect subjective norms. The presence or lack of things that
will make it easier or harder to perform the behavior affect perceived behavioral control. Thus, a causal chain of beliefs, attitudes, and intentions
drives behavior. Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the
journey from lack of awareness to adoption and/or maintenance of a behavior. It is a relatively new model that has been applied to an increasing
number of health behaviors, including: osteoporosis prevention, colorectal cancer screening, mammography, hepatitis B vaccination, and home
testing for radon gas. In the first stage of the PAPM, an individual may be completely unaware of a hazard (e.g., radon exposure, the link
between unprotected sex and HIV). The person may subsequently become aware of the issue but remain unengaged by it (Stage 2). Next, the
person faces a decision about acting (Stage 3); may decide not to act (Stage 4), Figure 4. Stages of the Precaution Adoption Process Model Stage
1: Unaware of Issue Stage 2: Unengaged by Issue Stage 3: Deciding About Acting Stage 5: Decided to Act Stage 6: Acting Stage 4: Decided Not to
Act Stage 7: Maintenance 19 PART 2 or may decide to act (Stage 5). The stages of action (Stage 6) and maintenance (Stage 7) follow. (See Figure
4.) According to the PAPM, people pass through each stage of precaution adoption without skipping any of them. It is possible for people to
move backwards from some later stages to earlier ones, but once they have completed the first two stages of the model they do not return to
them. For example, a person does not move from unawareness to awareness and then back to unawareness. The PAPM bears similarities to the
Stages of Change model, but differs in important ways. Stages of Change offers insights for addressing hard-to-change behaviors such as smoking
or overeating; it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available. The PAPM
recognizes that people who are unaware of an issue, or are unengaged by it, face different barriers from those who have decided not to act. The
PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making.
Interpersonal Level At the interpersonal level, theories of health behavior assume individuals exist within, and are influenced by, a social
environment. The opinions, thoughts, behavior, advice, and support of the people surrounding an individual influence his or her feelings and
behavior, and the individual has a reciprocal effect on those people. The social environment includes family members, coworkers, friends, health
professionals, and others. Because it affects behavior, the social environment also impacts health. Many theories focus at the interpersonal level,
but this monograph highlights Social Cognitive Theory (SCT). SCT is one of the most frequently used and robust health behavior theories. It
explores the reciprocal interactions of people and their environments, and the psychosocial determinants of health behavior. Social Cognitive
Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic, ongoing process in which personal factors, environmental factors, and human
behavior exert influence upon each other. THEORIES AND APPLICATIONS 20 THEORY AT A GLANCE According to SCT, three main factors affect
the likelihood that a person will change a health behavior: (1) self-efficacy, (2) goals, and (3) outcome expectancies. If individuals have a sense of
personal agency or self efficacy, they can change behaviors even when faced with obstacles. If they do not feel that they can exercise control
over their health behavior, they are not motivated to act, or to persist through challenges.9 As a person adopts new behaviors, this causes
changes in both the environment and in the person. Behavior is not simply a product of the environment and the person, and environment is not
simply a product of the person and behavior. SCT evolved from research on Social Learning Theory (SLT), which asserts that people learn not only
from their own experiences, but by observing the actions of others and the benefits of those actions. Bandura updated SLT, adding the construct
of self-efficacy and renaming it SCT. (Though SCT is the dominant version in current practice, it is still sometimes called SLT.) SCT integrates
concepts and processes from cognitive, behaviorist, and emotional models of behavior change, so it includes many constructs. (See Table 5.) It
has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10 to pain control.11 Concept
Reciprocal determinism Behavioral capability Expectations Self-efficacy Observational learning (modeling) Reinforcements Definition The
dynamic interaction of the person, behavior, and the environment in which the behavior is performed Knowledge and skill to perform a given
behavior Anticipated outcomes of a behavior Confidence in one’s ability to take action and overcome barriers Behavioral acquisition that occurs
by watching the actions and outcomes of others’ behavior Responses to a person’s behavior that increase or decrease the likelihood of
reoccurrence Potential Change Strategies Consider multiple ways to promote behavior change, including making adjustments to the environment
or influencing personal attitudes Promote mastery learning through skills training Model positive outcomes of healthful behavior Approach
behavior change in small steps to ensure success; be specific about the desired change Offer credible role models who perform the targeted
behavior Promote self-initiated rewards and incentives Table 5. Social Cognitive Theory Figure 5. An Integrative Model Behavioral beliefs and
their evaluative aspects Normative beliefs and motivation to comply Efficacy beliefs Attitude Norm Self-efficacy Skills Intention Behavior
Environmental constraints Other individual difference variables Personality traits Attitudes toward targets Demographic variables External
variable Reciprocal determinism describes interactions between behavior, personal factors, and environment, where each influences the others.
Behavioral capability states that, to perform a behavior, a person must know what to do and how to do it. Expectations are the results an
individual anticipates from taking action. Bandura considers self-efficacy the most important personal factor in behavior change, and it is a nearly
ubiquitous construct in health behavior theories. Strategies for increasing self-efficacy include: setting incremental goals (e.g., exercising for 10
minutes each day); behavioral contracting (a formal contract, with specified goals and rewards); and monitoring and reinforcement (feedback
from self-monitoring or record keeping). Observational learning, or modeling, refers to the process whereby people learn through the
experiences of credible others, rather than through their own experience. Reinforcements are responses to behavior that affect whether or not
one will repeat it. Positive reinforcements (rewards) increase a person’s likelihood of repeating the behavior. Negative reinforcements may make
repeated behavior more likely by motivating the person to eliminate a negative stimulus (e.g., when drivers put the key in the car’s ignition, the
beeping alarm reminds them to fasten their seatbelt). Reinforcements can be internal or external. Internal rewards are things people do to
reward themselves. External rewards (e.g., token incentives) encourage continued participation in multiple-session programs, but generally are
not effective for sustaining long-term change because they do not bolster a person’s own desire or commitment to change. Figure 5. illustrates
how selfefficacy, environmental, and individual factors impact behavior. 21 PART 2 THEORIES AND APPLICATIONS A university in a rural area
develops a church-based intervention to help congregation members change their habits to meet cancer risk reduction guidelines (behavior).
Many members of the church have low incomes, are overweight, rarely exercise, eat foods that are high in sugar and fat, and are uninsured
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Many members of the church have low incomes, are overweight, rarely exercise, eat foods that are high in sugar and fat, and are uninsured
(personal factors). Because of their rural location, they often must drive long distances to attend church, visit health clinics, or buy groceries
(environment). The program offers classes that teach healthy cooking and exercise skills (behavioral capability). Participants learn how eating a
healthy diet and exercising will benefit them (expectations). Health advisors create contracts with participants, setting incremental goals (selfefficacy). Respected congregation members serve as role models (observational learning). Participants receive T-shirts, recipe books, and other
incentives, and are taught to reward themselves by making time to relax (reinforcement). As church members learn about healthy lifestyles, they
bring healthier foods to church, reinforcing their healthy habits (reciprocal determinism). 22 THEORY AT A GLANCE Community Level Initiatives
serving communities and populations, not just individuals, are at the heart of public health approaches to preventing and controlling disease.
Community-level models explore how social systems function and change and how to mobilize community members and organizations. They
offer strategies that work in a variety of settings, such as health care institutions, schools, worksites, community groups, and government
agencies. Embodying an ecological perspective, community-level models address individual, group, institutional, and community issues.
Communities are often understood in geographical terms, but they can be defined by other criteria too. For instance, there are communities of
shared interests (e.g., the artists’ community) or collective identity (e.g., the African American community). When planning community-level
interventions, it is critical to learn about the community’s unique characteristics. This is particularly true when addressing health issues in
ethnically or culturally diverse communities. Comprehensive health promotion programs often use advocacy techniques to help support
individual behavior change with organizational and regulatory change. In recent years, innovative tools and methods for evaluation and
measurement have been developed to capture the successes of community-level health promotion efforts.12 13 Tobacco control/smoking
prevention is one area where programs have been extensively evaluated. Local tobacco control initiatives typically pursue four concurrent goals:
(1) raising the priority of smoking as a health concern, (2) helping community members to change smoking behavior, (3) strengthening legal and
economic deterrents to smoking, and (4) reinforcing social norms that discourage smoking. This multi-level approach has been proven very
effective. The conceptual frameworks in this section offer strategies for intervening at the community level: • Community Organization and
Other Participatory Models emphasize community-driven approaches to assessing and solving health and social problems. • Diffusion of
Innovations Theory addresses how new ideas, products, and social practices spread within an organization, community, or society, or from one
society to another. • Communication Theory describes how different types of communication affect health behavior. Community Organization
and Other Participatory Models Community organizing is a process through which community groups are helped to identify common problems,
mobilize resources, and develop and implement strategies to reach collective goals. Strict definitions of community organizing assume that the
community itself identifies the problems to address (not an outside change agent). Public health professionals often adapt the methods of
community organizing to launch programs that reflect the priorities of community members, but may not be initiated by them. Community
organizing projects that start with the community’s priorities, rather than an externally imposed agenda, are more likely to succeed. Community
organizing is consistent with an ecological perspective in that it recognizes multiple levels of a health problem. It can be integrated with SCTbased strategies that take into account the dynamic between personal factors, environmental factors, and human behavior. Theories of social
networks and social support (exploring the influence of social relationships on health decision making and behavior) can be used to adapt
community organizing strategies to health education goals. Social systems theory (exploring how organizations in a community interact with
each other and the outside world) is also useful for this purpose. Community organizing is not a single mode of practice; it can involve different
approaches to effecting change. Jack Rothman14 produced the best-known classification of these change models, describing community
organizing according to three general types: locality development, social planning, and social action. These models sometimes overlap and can
be combined. • Locality development (or community development) is process oriented. With the aim of developing group identity and cohesion,
it focuses on building consensus and capacity. • Social planning is task oriented. It stresses problem solving and usually relies heavily on expert
practitioners. • Social action is both process and task oriented. Its goals are to increase the community’s capacity to solve problems and to
achieve concrete changes that redress social injustices. The different approaches broadly classified as community organizing share in common
several concepts that are key to achieving and measuring change. (See Table 6.) Empowerment describes a social action process through which
individuals, organizations, or communities gain confidence and skills to improve their quality of life.15 Community capacity refers to 23 PART 2
THEORIES AND APPLICATIONS THEORY AT A GLANCE Term Empowerment Community capacity Participation Relevance Issue selection Critical
consciousness Definition A social action process through which people gain mastery over their lives and their communities Characteristics of a
community that affect its ability to identify, mobilize around, and address problems Engagement of community members as equal partners;
reflects the principle, “Never do for others what they can do for themselves” Community organizing that ”starts where the people are”
Identifying immediate, specific, and realizable targets for change that unify and build community strength Awareness of social, political, and
economic forces that contribute to social problems Potential Change Strategies Community members assume greater power, or expand their
power from within, to create desired changes Community members participate actively in community life, gaining leadership skills, social
networks, and access to power Community members develop leadership skills, knowledge, and resources through their involvement Community
members create their own agenda based on felt needs, shared power, and awareness of resources Community members participate in
identifying issues; targets are chosen as part of a larger strategy Community members discuss the root causes of problems and plan actions to
address them Table 6. Community Organization characteristics of a community that allow it to identify social problems and address them (e.g.,
trusting relationships between neighbors, civic engagement). Participation in the organizing process helps community members to gain
leadership and problemsolving skills. Relevance involves activating participants to address issues that are important to them. Issue selection
entails pulling apart a web of interrelated problems into distinct, immediate, solvable pieces. Critical consciousness emphasizes helping
community members to identify the root causes of social problems. The social action model differs from other forms of community intervention
in that it is grassroots based, conflict oriented, and geared to mobilizing disadvantaged people to act on their own behalf.16 Goals vary, but
typically include policy and other significant changes that participants have identified as important. Largely based on the organizing work of Saul
Alinsky and the Industrial Areas Foundation,17 this approach employs direct-action strategies as the primary means of fostering change. It
focuses on building power and encouraging community members to develop their capacities as active citizens.18 In a social action approach to
community organizing, self-interest is seen as the motivation for action: community members become involved when they see that it will benefit
them to take action, and targeted institutions are willing to make changes when they believe it is in their self-interest to do so. Community
organizing seeks to expand participants’ sense of self-interest to an ever-wider sphere, from the individual or family level to their block,
neighborhood, city, state, and so on.19 Participants grow through this process, learning to take an active role in shaping the future of their
communities. Media Advocacy is an essential tactic in community organizing. It involves using the mass media strategically to advance public
policies.20 Because the media bring attention to specific issues, they set the agenda for the public and policy makers. The media often present
health information in medical terms, focusing on technological breakthroughs and personal health habits. Media advocacy assumes the root of
most health problems is not that people lack information, but that they lack the power to change social and economic conditions. It seeks to
balance news coverage by framing issues to emphasize social, economic, and political—rather than personal and behavioral—influences on
health.21 25 PART 2 THEORIES AND APPLICATIONS Responding to high rates of cancer among African Americans, a health department wishes to
increase consumption of fresh fruits and vegetables in a low-income, urban neighborhood. The department surveys community members to find
out why they do not eat more fruits and vegetables. They learn there are few supermarkets within easy walking distance, and residents shop at
local stores that do not offer fresh, affordable produce. Many do not own cars; they must take the bus, spend money on taxis, or carry shopping
bags for blocks to shop at the supermarket. The health department contacts a community-based organization that has been working to improve
neighborhood conditions, and shares the findings with them (participation). The organization’s leaders invite department staff to attend a
community meeting, where residents discuss why there are fewer supermarkets in low-income neighborhoods (critical consciousness). Residents
say they would buy healthier, less expensive foods at the supermarket if they could get a ride home (relevance). The community organization
decides to organize a campaign to convince the local supermarket to start a shuttle service (issue selection). The health department trains
residents to assess the potential cost and ridership of the shuttle service (community capacity). Residents plan an event and invite the media.
They line up in front of the supermarket with shopping carts and signs, and explain both the problem and the potential solution to reporters
(media advocacy). Stories appear in the local newspapers. The supermarket’s management meets with community residents and tells them the
market loses thousands of dollars each year due to stolen shopping carts. Residents explain that the store will have fewer shopping cart losses if
they start a shuttle (self-interest). The supermarket agrees to give free rides to inner-city shoppers. Through their success, residents gain skills
and confidence, and are inspired to think about other ways to strengthen their community (empowerment). Figure 6. Sociocultural Environment
Logic Framework Guide to Community Preventive Services: Sociocultural Environment Logic Framework DETERMINANTS IMMEDIATE OUTCOMES
HEALTH OUTCOME EQUITY and SOCIAL JUSTICE 1* Neighborhood Living Conditions Community Development and Employment Opportunities 2 3
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HEALTH OUTCOME EQUITY and SOCIAL JUSTICE 1* Neighborhood Living Conditions Community Development and Employment Opportunities 2 3
Civic Engagement and Participation in Decision-Making 4 Prevaling Community Norms, Customs, and Processes Opportunities for Education and
Developing Capacity Health Promotion, Prevention, and Care Opportunities 5 6 *Links 1-6 indicate strategic points for intervention SOCIETAL
RESOURCES Standard of living Culture and history Social institutions Built environments Political structures Economic systems Technology
PHYSICAL ENVIROMNMENT Natural Resources SOCIETAL RESOURCES concerns the presence of essential resources while EQUITY and SOCIAL
JUSTICE concerns the distribution of those resources within the population HEALTHIER COMMUNITIES HEALTHY POPULATION A pathway that will
not be examined Source: Institute of Medicine. Speaking of Health: Assessing Health Communications Strategies for Diverse Populations.
Washington, D.C.: National Academies Press, 2002. In participatory action research, the people who are being studied take an active role in some
or all phases of the research. Participatory research builds an alliance between professional researchers and lay participants, and enables a
dialogue between them.22 When planning and implementing health programs, the program’s beneficiaries help to direct the type of inquiry,
collect and analyze data, imagine possible solutions, and evaluate the costs and benefits of each choice. They engage in a learning process, both
checking and complementing expert knowledge. One example of participatory action research is the NCI’s COMMIT program, which explored
whether implementing an intervention through community organizations would result in a higher “quit rate” among heavy smokers than in the
comparison communities.23 24 26 THEORY AT A GLANCE The CDC Task Force on the Guide to Community and Preventive Services created an
organizing logic framework to illustrate how community-level factors influence health status. (See Figure 6.) They noted that disparities in access
to health care; behaviors in response to illness; exposure to environmental and occupational hazards; health promotion and disease prevention
behaviors; and experience of stress, societal support, and social cohesion all contribute to disparities in health status. Therefore, communitylevel interventions that address neighborhood conditions, employment opportunities, behavioral norms, opportunities for education and
training, and access to health promotion, prevention, and care are key to addressing health disparities.25 The model shows elements and
associations at play in translating theory into research and action. Diffusion of Innovations In public health and health promotion, practitioners
who want to make efficient use of resources must attend to the reach, adoption, implementation, and maintenance of programs. It is not
enough to develop innovative programs; to reduce the burden of cancer, these programs must be disseminated widely. Cancer control measures
will not realize their full potential for improving population health until effective programs are broadly diffused and disseminated. Multiple
critiques, including one by the National Cancer Policy Board, suggest that failing to implement proven methods of cancer prevention and early
detection results in tens of thousands of premature deaths each year.26 Diffusion expands the number of people who are exposed to and
reached by successful interventions, strengthening their public health impact. Diffusion of Innovations Theory addresses how ideas, products,
and social practices that are perceived as “new” spread throughout a society or from one society to another. According to the late E.M. Rogers,
diffusion of innovations is “the process by which an innovation is communicated through certain channels over time among the members of a
social system.”27 Diffusion Theory has been used to study the adoption of a wide range of health behaviors and programs, including condom
use, smoking cessation, and use of new tests and technologies by health practitioners. Table 7. defines concepts that are central to this theory.
Diffusion of innovations that prevent disease and promote health requires a multilevel change process that usually takes place in 27 PART 2
THEORIES AND APPLICATIONS Table 7. Concepts in Diffusion of Innovations Concept Innovation Communication channels Social system Time
Definition An idea, object, or practice that is thought to be new by an individual, organization, or community The means of transmitting the new
idea from one person to another A group of individuals who together adopt the innovation How long it takes to adopt the innovation 28 THEORY
AT A GLANCE diverse settings, through different strategies. At the individual level, adopting a health behavior innovation usually involves lifestyle
change. At the organizational level, it may entail starting programs, changing regulations, or altering personnel roles. At a community level,
diffusion can include using the media, advancing policies, or starting initiatives. According to Rogers, a number of factors determine how quickly,
and to what extent, an innovation will be adopted and diffused. By considering the benefits of an innovation (see Table 8.), practitioners can
position it effectively, thereby maximizing its appeal. Specifically: • The relative advantage of an innovation shows its superiority over whatever it
replaces. • Compatibility is an appropriate fit with the intended audience. • Complexity has to do with how easy it is to implement the
innovation. • Trialability pertains to whether it can be tried on an experimental basis. • Observability reflects whether the innovation will
produce tangible results. Effective diffusion requires practitioners to use both informal and formal communications channels and a spectrum of
strategies for different settings. Disseminating an innovation in a variety of ways increases the likelihood that it will be adopted and
institutionalized. Communication usually should include both mass media and interpersonal interactions. Through the two-step flow of
communication, information from the media moves in two stages. First, opinion leaders, who pay close attention to the media, receive the
information. Second, they convey their own interpretations, as well as the media content, to others. This process highlights the value of social
networks for influencing adoption decisions. Rogers described the process of adoption as a classic “bell curve,” with five categories of adopters:
innovators, early adopters, early majority adopters, late majority adopters, and laggards. When an innovation is introduced, the majority of
people will either be early majority adopters or late majority adopters; fewer will be early adopters or laggards; and very few will be innovators
(the first people to use the innovation). By identifying the Table 8. Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion
Attribute Relative advantage Compatibility Complexity Trialability Observability Key Question Is the innovation better than what it will replace?
Does the innovation fit with the intended audience? Is the innovation easy to use? Can the innovation be tried before making a decision to
adopt? Are the results of the innovation observable and easily measurable? A university designs a program to help elementary school children
cultivate healthy lifestyle habits and avoid chronic disease. The program has many components: it addresses the foods that children eat by
modifying the fat and sugar content of school lunches, it teaches important health information through a classroom-based health education
curriculum, and it encourages physical activity through a physical education component. It is highly successful; follow-up studies show that
children who went through the program in elementary school continue to have healthier habits in their adolescence than those who did not go
through the program. The fact that the program is successful is not enough to ensure it will change elementary school practices. To achieve a
broader impact, the program must diffuse to other sites. Program planners may seek to demonstrate the relative advantage of the program by
emphasizing its positive outcomes. They may try to show its compatibility by demonstrating that state policy-makers (e.g., the state Board of
Education) have approved its materials. The program’s complexity can be limited by creating user-friendly materials for teachers and cafeteria
workers. By making the materials available on a Web site, they can enhance its trialability. Professional demonstrations of the program
components can create an element of observability. characteristics of people in each adopter category, practitioners can more effectively plan
and implement strategies that are customized to their needs. Communication Theory Communication theory explores “who says what, in which
channels, to whom, and with what effects.” It investigates how messages are created, transmitted, received, and assimilated. When applied to
public health problems, the central question theories of communication seek to answer is, “How do communication processes contribute to, or
discourage, behavior change?” Focused on improving the health of communities rather than examining the underlying processes of
communication, public health communications is the scientific development, strategic dissemination, and evaluation of relevant, accurate,
accessible, and understandable health information, communicated to and from intended audiences to advance the public’s health.28 Public
health communications should represent an ecological perspective and foster multilevel strategies, such as tailored messages at the individual
level, targeted messages at the group level, social marking at the community level, media advocacy at the policy level, and mass media
campaigns at the population level.29 Public health communications can increase knowledge and awareness of a health issue; influence
perceptions, beliefs, and attitudes that factor into social norms; prompt action; demonstrate or illustrate healthy skills; increase support for
services; debunk misconceptions; and strengthen organizational relations.30 On the other hand, without supports in the social and physical
environment, health communications alone may not be enough to sustain individual-level behavior changes, may not be effective for relaying
complex health messages, and cannot compensate for lack of access to health care or healthy environments.31 29 THEORIES PART 2 AND
APPLICATIONS 30 THEORY AT A GLANCE Since other communication strategies are discussed elsewhere in this monograph, this section examines
the role of mass media in public health interventions. The media are interconnected, large-scale organizations that gather, process, and
disseminate news, information, entertainment, and advertising worldwide. Whether they are small operations, such as a neighborhood
newspaper, or large corporations employing tens of thousands of people, the media influence almost every aspect of human life: economic,
political, social, and behavioral. Media Effects The outcomes of media dissemination of ideas, images, themes, and stories are termed media
effects. Media effects research investigates not only how the media influence the knowledge, opinions, attitudes, and behaviors of audience
members, but also how audience members affect the media. Because audience members are active seekers and users of health information, the
content transmitted through the media reflects their needs, interests, and preferences. Two questions are central to understanding the effects of
media on audience members: 1) What factors affect the likelihood that a person will be exposed to a given message? 2) How do media effects
vary with the amount of exposure to that message?32 Funding is a primary factor that determines whether or not audience members will be
exposed to a message through the mass media, since money is needed to buy media time and space. Many public health programs do not have
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exposed to a message through the mass media, since money is needed to buy media time and space. Many public health programs do not have
large budgets, so they often must rely on strategies for free distribution. Options may include public service announcements, embedding health
messages in entertainment programs (e.g., soap operas), or promoting news coverage of public health topics in print and electronic media.
Community institutions can adopt and disseminate messages, and social networks can also generate excitement about some messages,
depending on their content.33 How often do people need to hear a message before it influences their beliefs or behaviors? This depends on
several factors. Characteristics of target audiences (e.g., their readiness for change, the ways they process information), the complexity of the
health issue, the presence of competing messages, and the nature of the health message influence the relationship between exposure to a
health message and an outcome effect. Repeated exposure to a message, especially when it is delivered through multiple channels, may
intensify its impact on audience members.34 Planners often assume that a certain percentage of the target audience will be exposed to a
message and that another fraction of those who receive the message will be engaged by it. Yet there are several possible paths through which a
health communications message can influence someone’s beliefs and/or behaviors. These include immediate learning (people learn directly from
the message), delayed learning (the impact of the message is not processed until some time after it has been conveyed), generalized learning (in
addition to the message itself, people are persuaded about concepts related to the message), social diffusion (messages stimulate discussion
among social groups, thereby affecting beliefs), and institutional diffusion (messages instigate a response from public institutions that reinforces
the message’s impact on the target audience.)35 Agenda Setting The mass media can illuminate and focus attention on issues, helping to
generate public awareness and momentum for change. A major focus of communications research has been on how the mass media influence
public opinion, especially about politics and policymaking. Agenda setting involves setting the media agenda (what is covered), the public agenda
(what people think about), and the policy agenda (regulatory or legislative actions on issues).36 (See Table 9.) Research on agenda setting has
shown that the amount of media coverage an issue receives correlates strongly with the public’s opinion of how important that issue is. An
axiom underlying this area of study is that mass media may not tell us what to think, but they are surprisingly effective in telling us what to think
about. A critical construct of agenda setting, however, reinterprets this idea. Framing is a process in which someone tells the audience what
aspect of the story is important. In other words, they tell the audience not only what to think about, but how to think about it. The way facts are
packaged to tell a story creates the frame. By framing stories to emphasize social and environmental factors that affect health, public health
advocates can use the media to pressure decision makers to develop and support healthy policies. New Communication Technologies New
communication technologies have opened an extraordinary range of avenues for influencing health behavior. “E-health” (one element of new
communication technologies) is the use of emerging information and communication technology, especially the Internet, to improve or enable
31 PART 2 THEORIES AND APPLICATIONS Concept Media agenda setting Public agenda setting Policy agenda setting Problem definition Framing
Definition Institutional factors and processes influencing how the media define, select, and emphasize issues The link between issues covered in
the media and the public’s priorities The link between issues covered in the media and the legislative priorities of policy makers Factors and
process leading to the identification of an issue as a “problem” by social institutions Selecting and emphasizing certain aspects of a story and
excluding others Potential Change Strategies Understand media professionals’ needs and routines for gathering and reporting news Use media
advocacy or partnerships to raise public awareness of key health issues Advocate for media coverage to educate and pressure policy makers
about changes to the physical and social environment needed to promote health Community leaders, advocacy groups, and organizations define
an issue for the media and offer solutions Advocacy groups “package” an important health issue for the media and the public Table 9. Agenda
Setting, Concepts, Definitions, and Applications 32 THEORY AT A GLANCE health and health care. The term refers to an emerging field in the
intersection of medical informatics, public health, and business.37 It bridges clinical and non-clinical sectors, and includes both individual and
population health-oriented tools.38 E-health communication strategies include, but are not limited to: health information on the Internet, online
support groups, online collaborative communities, information tailored by computer technologies, educational computer games,
computercontrolled in-home telephone counseling, and patient-provider e-mail contact.39 Major benefits of e-health strategies are increased
reach (the ability to communicate to broad, geographically dispersed audiences), asynchronous communication (interaction not bounded by
having to communicate at the same time) the ability to integrate multiple communication modes and formats (e.g., audio, video, text, graphics),
the ability to track, preserve, and analyze communication (computer records of interaction, analysis of interaction trends), user control of the
communication system (the ability to customize programs to user specifications), and interactivity (e.g., increased capacity for feedback).40
Educational and behavioral interventions employing new communication technologies are forging new ground and therefore benefit from the
perspective provided by theories of health behavior. Like communications in other media, e-health interventions can address issues at the
individual, group, or community/societal level; different theories may be appropriate, depending on the project’s goals. For example,
computertailored print materials encouraging individuals to eat more fruits and vegetables could be designed using the Stages of Change Model.
Online support groups may apply theories of social support and social networks. Community organizing approaches have been used to
coordinate Internet-based campaigns through www.Meetup.com (a technology platform that helps people self-organize local gatherings).
Innovative e-health projects are expanding the range of tools that planners can use to develop cancer control and other interventions. For
instance, NCI’s Cancer Control Planet http://cancercontrolplanet. cancer.gov/ links public health professionals to comprehensive cancer control
resources. NCI also has published data from its Health Information National Trends Survey (HINTS) on the Web at
http://cancercontrol.cancer.gov/ hints/. The HINTS program helps survey researchers, program planners, and social scientists understand how
adults 18 years and older are using different communication channels, including the Internet. For example, according to recent HINTS data, when
asked where they would go first if they had a strong need to get information about cancer, 34 percent of respondents said they would go to the
Internet. The HINTS data illustrate consumers’ increasing reliance on the Internet as an easily accessible source of health information. The
Internet has been characterized as a “hybrid technology” because it has the potential to reach millions of people with information that can be
tailored to individual needs and preferences.41 E-health interventions frequently offer information, education, and support directly to
consumers. For example, the Association of Online Cancer Resources (ACOR), a collection of online communities designed to provide timely and
accurate information in a supportive environment, is one case in point. ACOR delivers 1.8 million cancer messages each week
(http://www.acor.org/). Not all e-health interventions are Web-based. Computer applications have also allowed new uses of traditional health
communications media, such as print and telephone. Tailored print communications (TPCs) and telephonedelivered interventions (TDIs) are two
examples that have the potential for reaching linguistically and culturally diverse audiences. TPCs are printed materials created especially for an
individual, based on relevant information about that person. Over 40 studies of TPCs have been conducted on a wide range of health topics,
including diet, exercise, smoking cessation, mammography, and prostate cancer; most have found positive outcomes evidence. TDIs include a
range of human-delivered counseling and reminder interventions delivered using the telephone and computer-generated voice response
systems. Studies indicate that TDIs are effective across different populations and health topics, but do not have a broad-based reach. They have
not been widely used by diverse populations.42 Interactive games offer another vehicle for intervention. Lieberman et al. designed a series of
Nintendo video games to improve children’s and adolescents’ prevention and self care behaviors for asthma, diabetes, smoking prevention, and
other health topics (see Figure 7.).43 The games were based on well-established theories of learning and behavior change, such as Social
Cognitive Theory. They reduced players’ urgent care and emergency medical visits by as much as 77 percent.44 Though research has
demonstrated the effectiveness of some new communications technologies, further inquiry is needed into the mechanisms’ underlying
success.45 Opportunities are increasing for people to gain free access to the Internet via libraries and kiosks.46 Unequal access remains
problematic, however. Significant gaps in Internet usage between Caucasians, African Americans, and Hispanics persist,47 and people with lower
levels of educational attainment are also less likely to have Internet access. Because the Internet is a text-based medium, literacy issues that
make it difficult for people to read print materials are also barriers to accessing Web-based information. There is danger that new computer
technologies could worsen existing inequities in health status for diverse populations. It is therefore important to involve community members in
planning e-health interventions and to offer them ongoing training and support for using these emerging communications tools.48 33 PART 2
THEORIES AND APPLICATIONS Figure 7. An Asthma Self-Management Video Game for Children (Bronkie the Bronchiasaurus)
https://cf.son.umaryland.edu/NRSG780/module9/index.htm>
Highlights:
To explain the first key concept of the ecological perspective, multiple levels of influence, McLeroy and colleagues
(1988)4 identified five levels of influence for healthrelated behaviors and conditions. Defined in Table 1., these levels
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(1988)4 identified five levels of influence for healthrelated behaviors and conditions. Defined in Table 1., these levels
include: (1) intrapersonal or individual factors; (2) interpersonal factors; (3) institutional or organizational factors; (4)
community factors; and (5) public policy factors.
An Ecological Perspective: Levels of Influence
Intrapersonal Level: Individual characteristics that influence behavior, such as knowledge, attitudes, beliefs, and
personality traits
Interpersonal Level: Interpersonal processes and primary groups, including family, friends, and peers that provide
social identity, support, and role definition
Community Level
Institutional Factors: Rules, regulations, policies, and informal structures, which may constrain or promote
recommended behaviors
Community Factors : Social networks and norms, or standards, which exist as formal or informal among
individuals, groups, and organizations
Public Policy: Local, state, and federal policies and laws that regulate or support healthy actions and practices for
disease prevention, early detection, control, and management
Each level of influence can affect health behavior.
Reciprocal causation suggests that people both influence, and are influenced by, those around them
Health promotion programs are more effective when planners consider multiple levels of influence on health
problems.
At the individual and interpersonal levels, contemporary theories of health behavior can be broadly categorized as
“Cognitive-Behavioral.” Three key concepts cut across these theories:
1. Behavior is mediated by cognitions; that is, what people know and think affects how they act.
2. Knowledge is necessary for, but not sufficient to produce, most behavior changes.
3. Perceptions, motivations, skills, and the social environment are key influences on behavior.
Individual or Intrapersonal Level:
individual-level behavior change theories often comprise broader-level models of group, organizational,
community, and national behavior. Individuals participate in groups, manage organizations, elect and appoint
leaders, and legislate policy. Thus, achieving policy and institutional change requires influencing individuals.
Individual-level theories presented below:
The Health Belief Model (HBM) addresses the individual’s perceptions of the threat posed by a health problem
(susceptibility, severity), the benefits of avoiding the threat, and factors influencing the decision to act (barriers, cues
to action, and self-efficacy).
Argues that people are ready to act if they:
1. Believe they are susceptible to the condition (perceived susceptibility) (Potential Change Strategies •
Define what populations(s) are at risk and their levels of risk • Tailor risk information based on an
individual’s characteristics or behaviors • Help the individual develop an accurate perception of his or her
own risk)
2. Believe the condition has serious consequences (perceived severity) (• Specify the consequences of a
condition and recommended action )
3. Believe taking action would reduce their susceptibility to the condition or its severity (perceived
benefits) • Explain how, where, and when to take action and what the potential positive results will be
4. Believe costs of taking action (perceived barriers) are outweighed by the benefits • Offer reassurance,
incentives, and assistance; correct misinformation
5. Are exposed to factors that prompt action (e.g., a television ad or a reminder from one’s physician to
get a mammogram) (cue to action) • Provide ”how to” information, promote awareness, and employ
reminder systems
6. Are confident in their ability to successfully perform an action (self-efficacy) • Provide training and
guidance in performing action • Use progressive goal setting • Give verbal reinforcement • Demonstrate
desired behaviors
Since health motivation is its central focus, the HBM is a good fit for addressing problem behaviors that evoke
health concerns (e.g., high-risk sexual behavior and the possibility of contracting HIV).
The Stages of Change (Transtheoretical) Model describes individuals’ motivation and readiness to change a behavior.
The model’s basic premise is that behavior change is a process, not an event. As a person attempts to change a
behavior, he or she moves through five stages: precontemplation, contemplation, preparation, action, and
maintenance. People at different points along this continuum have different informational needs, and benefit
from interventions designed for their stage.
The Stages of Change Model has been applied to a variety of individual behaviors, as well as to organizational
change. The Model is circular, not linear. In other words, people do not systematically progress from one stage
to the next, ultimately “graduating” from the behavior change process. Instead, they may enter the change
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to the next, ultimately “graduating” from the behavior change process. Instead, they may enter the change
process at any stage, relapse to an earlier stage, and begin the process once more. They may cycle through this
process repeatedly, and the process can truncate at any point.
Precontemplation: Has no intention of taking action within the next six months- Increase awareness of need for
change; personalize information about risks and benefits
Contemplation: Intends to take action in the next six months- Motivate; encourage making specific plans
Preparation: Intends to take action within the next thirty days and has taken some behavioral steps in this
direction - Assist with developing and implementing concrete action plans; help set gradual goals
Action: Has changed behavior for less than six months -Assist with feedback, problem solving, social support,
and reinforcement
Maintenance: Has changed behavior for more than six months - Assist with coping, reminders, finding
alternatives, avoiding slips/relapses (as applicable)
The Theory of Planned Behavior (TPB) examines the relations between an individual’s beliefs, attitudes, intentions,
behavior, and perceived control over that behavior.
The Theory of Planned Behavior (TPB) and the associated Theory of Reasoned Action (TRA) explore the
relationship between behavior and beliefs, attitudes, and intentions. Both the TPB and the TRA assume
behavioral intention is the most important determinant of behavior. According to these models, behavioral
intention is influenced by a person’s attitude toward performing a behavior, and by beliefs about whether
individuals who are important to the person approve or disapprove of the behavior (subjective norm).
Theory of Planned Behavior - concept, definition and measurement approach:
Behavioral intention: Perceived likelihood of performing behavior - Are you likely or unlikely to (perform
the behavior)?
Attitude: Personal evaluation of the behavior- Do you see (the behavior) as good, neutral, or bad?
Subjective norm: Beliefs about whether key people approve or disapprove of the behavior; motivation to
behave in a way that gains their approval - Do you agree or disagree that most people approve
of/disapprove of (the behavior)?
Perceived behavioral control: Belief that one has, and can exercise, control over performing the behaviorDo you believe (performing the behavior) is up to you, or not up to you?
The Precaution Adoption Process Model (PAPM) names seven stages in an individual’s journey from awareness to
action. It begins with lack of awareness and advances through subsequent stages of becoming aware, deciding
whether or not to act, acting, and maintaining the behavior.
It is a relatively new model that has been applied to an increasing number of health behaviors, including:
osteoporosis prevention, colorectal cancer screening, mammography, hepatitis B vaccination, and home testing
for radon gas. In the first stage of the PAPM, an individual may be completely unaware of a hazard (e.g., radon
exposure, the link between unprotected sex and HIV). The person may subsequently become aware of the issue
but remain unengaged by it (Stage 2). Next, the person faces a decision about acting (Stage 3); may decide not to
act (Stage 4), or may decide to act (Stage 5). The stages of action (Stage 6) and maintenance (Stage 7) follow.
The PAPM bears similarities to the Stages of Change model, but differs in important ways. Stages of Change
offers insights for addressing hard-to-change behaviors such as smoking or overeating; it is less helpful when
dealing with hazards that have recently been recognized or precautions that are newly available. The PAPM
recognizes that people who are unaware of an issue, or are unengaged by it, face different barriers from those
who have decided not to act. The PAPM prompts practitioners to develop intervention strategies that take into
account the stages that precede active decision-making.
Interpersonal Level
At the interpersonal level, theories of health behavior assume individuals exist within, and are influenced by, a
social environment. The opinions, thoughts, behavior, advice, and support of the people surrounding an
individual influence his or her feelings and behavior, and the individual has a reciprocal effect on those people.
The social environment includes family members, coworkers, friends, health professionals, and others. Because
it affects behavior, the social environment also impacts health. Many theories focus at the interpersonal level,
but this monograph highlights Social Cognitive Theory (SCT). SCT is one of the most frequently used and robust
health behavior theories. It explores the reciprocal interactions of people and their environments, and the
psychosocial determinants of health behavior.
Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic, ongoing process in which
personal factors, environmental factors, and human behavior exert influence upon each other.
According to SCT, three main factors affect the likelihood that a person will change a health behavior: (1) selfefficacy, (2) goals, and (3) outcome expectancies. If individuals have a sense of personal agency or self efficacy,
they can change behaviors even when faced with obstacles. If they do not feel that they can exercise control
over their health behavior, they are not motivated to act, or to persist through challenges.9 As a person adopts
new behaviors, this causes changes in both the environment and in the person. Behavior is not simply a product
of the environment and the person, and environment is not simply a product of the person and behavior.
SCT evolved from research on Social Learning Theory (SLT), which asserts that people learn not only from their
own experiences, but by observing the actions of others and the benefits of those actions. Bandura updated SLT,
adding the construct of self-efficacy and renaming it SCT. (Though SCT is the dominant version in current
practice, it is still sometimes called SLT.) SCT integrates concepts and processes from cognitive, behaviorist, and
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practice, it is still sometimes called SLT.) SCT integrates concepts and processes from cognitive, behaviorist, and
emotional models of behavior change, so it includes many constructs. (See Table 5.) It has been used
successfully as the underlying theory for behavior change in areas ranging from dietary change10 to pain
control.
Social Cognitive Theory- concept, definition and protentional change strategy:
Reciprocal determinism: The dynamic interaction of the person, behavior, and the environment in which the
behavior is performed- Consider multiple ways to promote behavior change, including making adjustments to
the environment or influencing personal attitudes
Behavioral capability: Knowledge and skill to perform a given behavior - Promote mastery learning through skills
training
Expectations: Anticipated outcomes of a behavior- Model positive outcomes of healthful behavior
Self-efficacy: Confidence in one’s ability to take action and overcome barriers- Approach behavior change in
small steps to ensure success; be specific about the desired change
Observational learning (modeling): Behavioral acquisition that occurs by watching the actions and outcomes of
others’ behavior - Offer credible role models who perform the targeted behavior
Reinforcements: Responses to a person’s behavior that increase or decrease the likelihood of reoccurrence Promote self-initiated rewards and incentives
Bandura considers self-efficacy the most important personal factor in behavior change, and it is a nearly
ubiquitous construct in health behavior theories. Strategies for increasing self-efficacy include: setting
incremental goals (e.g., exercising for 10 minutes each day); behavioral contracting (a formal contract, with
specified goals and rewards); and monitoring and reinforcement (feedback from self-monitoring or record
keeping).
Community Level
Initiatives serving communities and populations, not just individuals, are at the heart of public health
approaches to preventing and controlling disease. Community-level models explore how social systems function
and change and how to mobilize community members and organizations. Communities are often understood in
geographical terms, but they can be defined by other criteria too. For instance, there are communities of shared
interests (e.g., the artists’ community) or collective identity (e.g., the African American community). When
planning community-level interventions, it is critical to learn about the community’s unique characteristics. This
is particularly true when addressing health issues in ethnically or culturally diverse communities.
Comprehensive health promotion programs often use advocacy techniques to help support individual behavior
change with organizational and regulatory change. In recent years, innovative tools and methods for evaluation
and measurement have been developed to capture the successes of community-level health promotion
efforts.12 13 Tobacco control/smoking prevention is one area where programs have been extensively evaluated.
Local tobacco control initiatives typically pursue four concurrent goals: (1) raising the priority of smoking as a
health concern, (2) helping community members to change smoking behavior, (3) strengthening legal and
economic deterrents to smoking, and (4) reinforcing social norms that discourage smoking. This multi-level
approach has been proven very effective.
•Community Organization and Other Participatory Models emphasize community-driven approaches to
assessing and solving health and social problems.
Community organizing is a process through which community groups are helped to identify common
problems, mobilize resources, and develop and implement strategies to reach collective goals. Strict
definitions of community organizing assume that the community itself identifies the problems to address
(not an outside change agent). Public health professionals often adapt the methods of community
organizing to launch programs that reflect the priorities of community members, but may not be initiated
by them. Community organizing projects that start with the community’s priorities, rather than an
externally imposed agenda, are more likely to succeed
Community organizing is consistent with an ecological perspective in that it recognizes multiple levels of a
health problem. It can be integrated with SCT-based strategies that take into account the dynamic
between personal factors, environmental factors, and human behavior. Theories of social networks and
social support (exploring the influence of social relationships on health decision making and behavior) can
be used to adapt community organizing strategies to health education goals. Social systems theory
(exploring how organizations in a community interact with each other and the outside world) is also useful
for this purpose. Community organizing is not a single mode of practice; it can involve different
approaches to effecting change. Jack Rothman14 produced the best-known classification of these change
models, describing community organizing according to three general types: locality development, social
planning, and social action. These models sometimes overlap and can be combined.
Locality development (or community development) is process oriented. With the aim of developing
group identity and cohesion, it focuses on building consensus and capacity
Social planning is task oriented. It stresses problem solving and usually relies heavily on expert
practitioners.
Social action is both process and task oriented. Its goals are to increase the community’s capacity to
solve problems and to achieve concrete changes that redress social injustices
Community Organization - Term, definition and potential change strategy:
Empowerment: A social action process through which people gain mastery over their lives and their
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Empowerment: A social action process through which people gain mastery over their lives and their
communities ---Community members assume greater power, or expand their power from within, to
create desired changes
Community Capacity: Characteristics of a community that affect its ability to identify, mobilize
around, and address problems, characteristics of a community that allow it to identify social
problems and address them (e.g., trusting relationships between neighbors, civic engagement).--Community members participate actively in community life, gaining leadership skills, social
networks, and access to power
Participation: Engagement of community members as equal partners; reflects the principle, “Never
do for others what they can do for themselves”, in the organizing process helps community
members to gain leadership and problem solving skills --- Community members develop leadership
skills, knowledge, and resources through their involvement
Relevance: Community organizing that ”starts where the people are” activating participants to
address issues that are important to them. ---Community members create their own agenda based
on felt needs, shared power, and awareness of resources
Issue Selection: Identifying immediate, specific, and realizable targets for change that unify and
build community strength, entails pulling apart a web of interrelated problems into distinct,
immediate, solvable pieces --- Community members participate in identifying issues; targets are
chosen as part of a larger strategy
Critical Consciousness: Awareness of social, political, and economic forces that contribute to social
problems, emphasizes helping community members to identify the root causes of social
problems. --- Community members discuss the root causes of problems and plan actions to address
them
The social action model differs from other forms of community intervention in that it is grassroots based,
conflict oriented, and geared to mobilizing disadvantaged people to act on their own behalf.16 Goals vary,
but typically include policy and other significant changes that participants have identified as important.
Largely based on the organizing work of Saul Alinsky and the Industrial Areas Foundation,17 this approach
employs directaction strategies as the primary means of fostering change. It focuses on building power
and encouraging community members to develop their capacities as active citizens.18 In a social action
approach to community organizing, self-interest is seen as the motivation for action: community members
become involved when they see that it will benefit them to take action, and targeted institutions are
willing to make changes when they believe it is in their self-interest to do so. Community organizing seeks
to expand participants’ sense of self-interest to an ever-wider sphere, from the individual or family level to
their block, neighborhood, city, state, and so on. Participants grow through this process, learning to take
an active role in shaping the future of their communities.
Media Advocacy is an essential tactic in community organizing. It involves using the mass media
strategically to advance public policies. Because the media bring attention to specific issues, they set the
agenda for the public and policy makers. The media often present health information in medical terms,
focusing on technological breakthroughs and personal health habits. Media advocacy assumes the root of
most health problems is not that people lack information, but that they lack the power to change social
and economic conditions. It seeks to balance news coverage by framing issues to emphasize social,
economic, and political—rather than personal and behavioral—influences on health
In participatory action research, the people who are being studied take an active role in some or all phases
of the research. Participatory research builds an alliance between professional researchers and lay
participants, and enables a dialogue between them.22 When planning and implementing health programs,
the program’s beneficiaries help to direct the type of inquiry, collect and analyze data, imagine possible
solutions, and evaluate the costs and benefits of each choice. They engage in a learning process, both
checking and complementing expert knowledge. One example of participatory action research is the NCI’s
COMMIT program, which explored whether implementing an intervention through community
organizations would result in a higher “quit rate” among heavy smokers than in the comparison
communities
Guide to Community Preventive Services: Sociocultural Environment Logic Framework : The CDC Task
Force on the Guide to Community and Preventive Services created an organizing logic framework to
illustrate how community-level factors influence health status. They noted that disparities in access to
health care; behaviors in response to illness; exposure to environmental and occupational hazards; health
promotion and disease prevention behaviors; and experience of stress, societal support, and social
cohesion all contribute to disparities in health status. Therefore, community-level interventions that
address neighborhood conditions, employment opportunities, behavioral norms, opportunities for
education and training, and access to health promotion, prevention, and care are key to addressing health
disparities.25 The model shows elements and associations at play in translating theory into research and
action.
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• Diffusion of Innovations Theory addresses how new ideas, products, and social practices spread within an
organization, community, or society, or from one society to another.
In public health and health promotion, practitioners who want to make efficient use of resources must
attend to the reach, adoption, implementation, and maintenance of programs. It is not enough to develop
innovative programs; to reduce the burden of cancer, these programs must be disseminated widely.
Cancer control measures will not realize their full potential for improving population health until effective
programs are broadly diffused and disseminated. Multiple critiques, including one by the National Cancer
Policy Board, suggest that failing to implement proven methods of cancer prevention and early detection
results in tens of thousands of premature deaths each year.26 Diffusion expands the number of people
who are exposed to and reached by successful interventions, strengthening their public health impact.
Diffusion of Innovations Theory addresses how ideas, products, and social practices that are perceived as
“new” spread throughout a society or from one society to another. According to the late E.M. Rogers,
diffusion of innovations is “the process by which an innovation is communicated through certain channels
over time among the members of a social system.” Diffusion Theory has been used to study the adoption
of a wide range of health behaviors and programs, including condom use, smoking cessation, and use of
new tests and technologies by health practitioners
Diffusion of innovations that prevent disease and promote health requires a multilevel change process
that usually takes place in diverse settings, through different strategies. At the individual level, adopting a
health behavior innovation usually involves lifestyle change. At the organizational level, it may entail
starting programs, changing regulations, or altering personnel roles. At a community level, diffusion can
include using the media, advancing policies, or starting initiatives. According to Rogers, a number of
factors determine how quickly, and to what extent, an innovation will be adopted and diffused. By
considering the benefits of an innovation, practitioners can position it effectively, thereby maximizing its
appeal.
Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion, (attribute, definition and key
question):
Relative advantage: shows its superiority over whatever it replaces. -Is the innovation better than
what it will replace?
Compatibility: is an appropriate fit with the intended audience. --- Does the innovation fit with the
intended audience?
Complexity: has to do with how easy it is to implement the innovation. -- Is the innovation easy to
use?
Trialability: pertains to whether it can be tried on an experimental basis --- Can the innovation be
tried before making a decision to adopt?
Observability: reflects whether the innovation will produce tangible results. --- Are the results of the
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Observability: reflects whether the innovation will produce tangible results. --- Are the results of the
innovation observable and easily measurable?
Effective diffusion requires practitioners to use both informal and formal communications channels and a
spectrum of strategies for different settings. Disseminating an innovation in a variety of ways increases the
likelihood that it will be adopted and institutionalized. Communication usually should include both mass
media and interpersonal interactions. Through the two-step flow of communication, information from the
media moves in two stages. First, opinion leaders, who pay close attention to the media, receive the
information. Second, they convey their own interpretations, as well as the media content, to others. This
process highlights the value of social networks for influencing adoption decisions. Rogers described the
process of adoption as a classic “bell curve,” with five categories of adopters: innovators, early adopters,
early majority adopters, late majority adopters, and laggards. When an innovation is introduced, the
majority of people will either be early majority adopters or late majority adopters; fewer will be early
adopters or laggards; and very few will be innovators (the first people to use the innovation). By
identifying the characteristics of people in each adopter category, practitioners can more effectively plan
and implement strategies that are customized to their needs.
• Communication Theory describes how different types of communication affect health behavior.
Communication theory explores “who says what, in which channels, to whom, and with what effects.” It
investigates how messages are created, transmitted, received, and assimilated. When applied to public
health problems, the central question theories of communication seek to answer is, “How do
communication processes contribute to, or discourage, behavior change?” Focused on improving the
health of communities rather than examining the underlying processes of communication, public health
communications is the scientific development, strategic dissemination, and evaluation of relevant,
accurate, accessible, and understandable health information, communicated to and from intended
audiences to advance the public’s health. Public health communications should represent an ecological
perspective and foster multilevel strategies, such as tailored messages at the individual level, targeted
messages at the group level, social marking at the community level, media advocacy at the policy level,
and mass media campaigns at the population level. Public health communications can increase knowledge
and awareness of a health issue; influence perceptions, beliefs, and attitudes that factor into social norms;
prompt action; demonstrate or illustrate healthy skills; increase support for services; debunk
misconceptions; and strengthen organizational relations.30 On the other hand, without supports in the
social and physical environment, health communications alone may not be enough to sustain individuallevel behavior changes, may not be effective for relaying complex health messages, and cannot
compensate for lack of access to health care or healthy environments.
Since other communication strategies are discussed elsewhere in this monograph, this section examines
the role of mass media in public health interventions. The media are interconnected, large-scale
organizations that gather, process, and disseminate news, information, entertainment, and advertising
worldwide. Whether they are small operations, such as a neighborhood newspaper, or large corporations
employing tens of thousands of people, the media influence almost every aspect of human life: economic,
political, social, and behavioral.
Media Effects:
The outcomes of media dissemination of ideas, images, themes, and stories are termed media effects.
Media effects research investigates not only how the media influence the knowledge, opinions, attitudes,
and behaviors of audience members, but also how audience members affect the media. Because audience
members are active seekers and users of health information, the content transmitted through the media
reflects their needs, interests, and preferences. Two questions are central to understanding the effects of
media on audience members: 1) What factors affect the likelihood that a person will be exposed to a given
message? 2) How do media effects vary with the amount of exposure to that message? Funding is a
primary factor that determines whether or not audience members will be exposed to a message through
the mass media, since money is needed to buy media time and space. Many public health programs do not
have large budgets, so they often must rely on strategies for free distribution. Options may include public
service announcements, embedding health messages in entertainment programs (e.g., soap operas), or
promoting news coverage of public health topics in print and electronic media. Community institutions can
adopt and disseminate messages, and social networks can also generate excitement about some
messages, depending on their content.33 How often do people need to hear a message before it
influences their beliefs or behaviors? This depends on several factors. Characteristics of target audiences
(e.g., their readiness for change, the ways they process information), the complexity of the health issue,
the presence of competing messages, and the nature of the health message influence the relationship
between exposure to a health message and an outcome effect. Repeated exposure to a message,
especially when it is delivered through multiple channels, may intensify its impact on audience members.
Planners often assume that a certain percentage of the target audience will be exposed to a message and
that another fraction of those who receive the message will be engaged by it. Yet there are several
possible paths through which a health communications message can influence someone’s beliefs and/or
behaviors. These include immediate learning (people learn directly from the message), delayed learning
(the impact of the message is not processed until some time after it has been conveyed), generalized
learning (in addition to the message itself, people are persuaded about concepts related to the message),
social diffusion (messages stimulate discussion among social groups, thereby affecting beliefs), and
institutional diffusion (messages instigate a response from public institutions that reinforces the message’s
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institutional diffusion (messages instigate a response from public institutions that reinforces the message’s
impact on the target audience.)
Agenda Setting:
The mass media can illuminate and focus attention on issues, helping to generate public awareness and
momentum for change. A major focus of communications research has been on how the mass media
influence public opinion, especially about politics and policymaking. Agenda setting involves setting the
media agenda (what is covered), the public agenda (what people think about), and the policy agenda
(regulatory or legislative actions on issues). Research on agenda setting has shown that the amount of
media coverage an issue receives correlates strongly with the public’s opinion of how important that issue
is. An axiom underlying this area of study is that mass media may not tell us what to think, but they are
surprisingly effective in telling us what to think about. A critical construct of agenda setting, however,
reinterprets this idea. Framing is a process in which someone tells the audience what aspect of the story is
important. In other words, they tell the audience not only what to think about, but how to think about it.
The way facts are packaged to tell a story creates the frame. By framing stories to emphasize social and
environmental factors that affect health, public health advocates can use the media to pressure decision
makers to develop and support healthy policies.
Agenda Setting, Concepts, Definitions, and Applications - Concept, Definition and Potential Change
Strategies:
Media Agenda Setting: Institutional factors and processes influencing how the media define,
select, and emphasize issues-- Understand media professionals’ needs and routines for
gathering and reporting news
Public agenda setting: The link between issues covered in the media and the public’s
priorities--- Use media advocacy or partnerships to raise public awareness of key health issues
Policy Agenda Setting: The link between issues covered in the media and the legislative
priorities of policy makers.--- Advocate for media coverage to educate and pressure policy
makers about changes to the physical and social environment needed to promote health
Problem definition: Factors and process leading to the identification of an issue as a
“problem” by social institutions---Community leaders, advocacy groups, and organizations
define an issue for the media and offer solutions
Framing: Selecting and emphasizing certain aspects of a story and excluding others --Advocacy groups “package” an important health issue for the media and the public
New Communication Technologies:
New communication technologies have opened an extraordinary range of avenues for influencing health
behavior. “E-health” (one element of new communication technologies) is the use of emerging
information and communication technology, especially the Internet, to improve or enable health and
health care. The term refers to an emerging field in the intersection of medical informatics, public health,
and business. It bridges clinical and non-clinical sectors, and includes both individual and population
health-oriented tools. E-health communication strategies include, but are not limited to: health
information on the Internet, online support groups, online collaborative communities, information tailored
by computer technologies, educational computer games, computer controlled in-home telephone
counseling, and patient-provider e-mail contact
Major benefits of e-health strategies are increased reach (the ability to communicate to broad,
geographically dispersed audiences), asynchronous communication (interaction not bounded by having to
communicate at the same time) the ability to integrate multiple communication modes and formats (e.g.,
audio, video, text, graphics), the ability to track, preserve, and analyze communication (computer records
of interaction, analysis of interaction trends), user control of the communication system (the ability to
customize programs to user specifications), and interactivity (e.g., increased capacity for feedback).40
Educational and behavioral interventions employing new communication technologies are forging new
ground and therefore benefit from the perspective provided by theories of health behavior. Like
communications in other media, e-health interventions can address issues at the individual, group, or
community/societal level; different theories may be appropriate, depending on the project’s goals. For
example, computer tailored print materials encouraging individuals to eat more fruits and vegetables
could be designed using the Stages of Change Model. Online support groups may apply theories of social
support and social networks.
Community organizing approaches have been used to coordinate Internet-based campaigns through
www.Meetup.com (a technology platform that helps people self-organize local gatherings). Innovative ehealth projects are expanding the range of tools that planners can use to develop cancer control and other
interventions. For instance, NCI’s Cancer Control Planet http://cancercontrolplanet. cancer.gov/ links
public health professionals to comprehensive cancer control resources. NCI also has published data from
its Health Information National Trends Survey (HINTS) on the Web at http://cancercontrol.cancer.gov/
hints/. The HINTS program helps survey researchers, program planners, and social scientists understand
how adults 18 years and older are using different communication channels, including the Internet. For
example, according to recent HINTS data, when asked where they would go first if they had a strong need
to get information about cancer, 34 percent of respondents said they would go to the Internet.
The HINTS data illustrate consumers’ increasing reliance on the Internet as an easily accessible source of
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The HINTS data illustrate consumers’ increasing reliance on the Internet as an easily accessible source of
health information. The Internet has been characterized as a “hybrid technology” because it has the
potential to reach millions of people with information that can be tailored to individual needs and
preferences.41 E-health interventions frequently offer information, education, and support directly to
consumers. For example, the Association of Online Cancer Resources (ACOR), a collection of online
communities designed to provide timely and accurate information in a supportive environment, is one
case in point. ACOR delivers 1.8 million cancer messages each week (http://www.acor.org/).
Not all e-health interventions are Web-based. Computer applications have also allowed new uses of
traditional health communications media, such as print and telephone. Tailored print communications
(TPCs) and telephone delivered interventions (TDIs) are two examples that have the potential for reaching
linguistically and culturally diverse audiences. TPCs are printed materials created especially for an
individual, based on relevant information about that person. Over 40 studies of TPCs have been conducted
on a wide range of health topics, including diet, exercise, smoking cessation, mammography, and prostate
cancer; most have found positive outcomes evidence. TDIs include a range of human-delivered counseling
and reminder interventions delivered using the telephone and computer-generated voice response
systems. Studies indicate that TDIs are effective across different populations and health topics, but do not
have a broad-based reach. They have not been widely used by diverse populations. Interactive games offer
another vehicle for intervention. Lieberman et al. designed a series of Nintendo video games to improve
children’s and adolescents’ prevention and self care behaviors for asthma, diabetes, smoking prevention,
and other health topics (see Figure 7.).43 The games were based on well-established theories of learning
and behavior change, such as Social Cognitive Theory. They reduced players’ urgent care and emergency
medical visits by as much as 77 percent.44 Though research has demonstrated the effectiveness of some
new communications technologies, further inquiry is needed into the mechanisms’ underlying success.45
Opportunities are increasing for people to gain free access to the Internet via libraries and kiosks.46
Unequal access remains problematic, however. Significant gaps in Internet usage between Caucasians,
African Americans, and Hispanics persist,47 and people with lower levels of educational attainment are
also less likely to have Internet access. Because the Internet is a text-based medium, literacy issues that
make it difficult for people to read print materials are also barriers to accessing Web-based information.
There is danger that new computer technologies could worsen existing inequities in health status for
diverse populations. It is therefore important to involve community members in planning e-health
interventions and to offer them ongoing training and support for using these emerging communications
tools.
• U.S. Department of Health and Human Services (DHHS). The Guide to Community Preventive
Services. Available at http://www.thecommunityguide.org/index.html
WHAT IS THE COMMUNITY GUIDE? The Guide to Community Preventive Services (Community Guide) is a
collection of all the evidence-based findings and recommendations of the Community Preventive Services Task
Force (Task Force). It is a credible resource to help you make decisions by providing information on:
• Community preventive services, programs, and policies that have been shown to work
• How these programs, services, and policies may fit the needs of your community
• Estimated costs and potential return on investment
WHAT IS THE COMMUNITY PREVENTIVE SERVICES TASK FORCE? The Task Force is an independent, nonfederal,
unpaid group of public health and prevention experts whose members are appointed by the Director of the
Centers for Disease Control and Prevention (CDC). The Task Force was established in 1996 by the U.S.
Department of Health and Human Services. Congress has mandated that the Task Force provide information for
a wide range of decision makers. CDC is mandated to provide administrative, research, and technical support for
the Task Force
WHAT WILL YOU FIND IN THE COMMUNITY GUIDE? The Task Force issues evidence-based findings and
recommendations on many public health topics such as: • Adolescent health • Alcohol • Asthma • Birth defects
• Cancer • Cardiovascular disease • Diabetes • Emergency Preparedness • Health communication • Health
equity • HIV/AIDS, STIs, and pregnancy • Mental health • Motor vehicle • Nutrition • Obesity • Oral health •
Physical activity • Social environment • Tobacco • Vaccines • Violence • Worksite health promotion
WHO IS THE COMMUNITY GUIDE FOR? A wide range of decision makers use the Community Guide: • State and
local health departments • Boards of health • Non-governmental organizations • Policymakers and legislators •
Health plans and systems • Research and program funders • Public health practitioners • Clinicians • Educators
and school administrators • Employers and companies • Researchers and evaluators • Community health
centers • City and county planners • Social service agencies and organizations
HOW CAN YOU USE THE COMMUNITY GUIDE? Use the Community Guide to: Foster dialogue—Stimulate
conversation among individuals and groups about public health challenges and effective solutions Develop
policies—Identify evidence-based policies communities can pursue Mobilize communities—Engage individuals
and groups to address public health issues Inform research priorities—Develop research agendas, priorities for
funding, and funding announcements Educate—Teach others about the systematic review process and
evidence-based public health Evaluate—Find out whether programs, services, and policies are helping you meet
your public health goals Support funding proposals and decisions— Establish priorities for seeking financial
support of research, evaluation, programmatic or policy initiatives to make best use of limited resources
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WHAT MAKES THE COMMUNITY GUIDE CREDIBLE? Expert Oversight—The Task Force oversees development of
the Community Guide. The members of the Task Force are renowned for their expertise in public health
research, practice, and policy. Systematic review teams are led or supported by scientists at CDC, and include
government, academic, policy, and practice based partners. Collaboration—Task Force collaborators are active
in all aspects of developing, disseminating, and helping prepare the Community Guide to assure that it meets
real-world needs. Partners come from a range of government, academic, policy, and practice-based settings and
include: • Liaisons to the Task Force—individuals from non-profit organizations and federal agencies with official
Task Force liaison status who serve without compensation to represent the views, concerns, and needs of their
members and constituents • Scientists and program managers from CDC • Researchers, practitioners, and
policymakers from other federal agencies and throughout the United States Scientific Methods—The Task Force
findings and recommendations are based on evidence from systematic reviews of community preventive
services, programs, and policies found in the scientific literature. These systematic reviews evaluate the
evidence by: • Analyzing all available evidence on what works to promote health and prevent disease, injury,
and disability • Assessing the economic benefits of the interventions found to be effective • Identifying where
more evidence is needed
BEHAVIOR CHANGE: AN ECOLOGICAL PERSPECTIVE
Effective public health and health promotion programs help maintain and improve health and the wellbeing and self-sufficiency of individuals, families, organizations and communities. They generally
require behavior change at multiple levels. Programs that are most likely to succeed are based on
understanding targeted behaviors and their environmental context. Health behavior theory is a key
component in the program planning, implementation and evaluation process.
What is a theory?
A set of interrelated concepts, definitions and proposals that present a systematic view of events or situations by
specifying relationships among variables to explain or predict events or situations.
Behavior change theories investigate answers to the why, what and how health problems should be
addressed.
Health Promotion has an ecological perspective that involves more than educating individuals and the
community about health practices. It includes efforts to change organizational behavior and physical
and social environments of communities. It is also about developing and advocating for policies that
support health.
From <https://cf.son.umaryland.edu/NRSG780/module9/subtopic1.htm>
INDIVIDUAL AND INTERPERSONAL LEVEL BEHAVIOR CHANGE
On the individual and interpersonal level behavior change theories are categorized as “CognitiveBehavioral” and focus on three key concepts:
• Knowledge affects action
• Knowledge is necessary but not sufficient to produce behavior change
• Perceptions, motivations, skills and the social environment are critical factors that influences
behavior
This topic will highlight three behavior change models:
1. Health Belief Model (HBM)
2. Stages of Change (Transtheoretical) Model
3. Social Cognitive Theory
There are many others that may assist you in program planning; and several additional models are
discussed in the Theory at a Glance assigned reading.
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discussed in the Theory at a Glance assigned reading.
Health Belief Model
The Health Belief Model focuses on an individual’s perceptions of the threat of a health problem and
the behavior change necessary to prevent or manage the problem. It was developed by Godfrey
Hochbaum, Stephen Kegels, and Irwin Rosenstock in the 1950s and is regarded as the beginning of
systematic theory-based research in health behavior. It remains one of the most recognized models in
the field.
It includes six factors that influence decisions and an individual’s readiness to act:
• Perceived susceptibility
• Perceived severity
• Perceived benefits
• Perceived barriers
• Cues to action
• Self-efficacy
Because the Health Belief Model focuses on the of the threat of susceptibility, it is important to
recognize that it is not appropriate for developing programs for all age groups. This is particularly the
case when designing programs for adolescents, who often perceive themselves as invulnerable. It is
very effective with many other populations when trying to reduce the threat of disease.
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very effective with many other populations when trying to reduce the threat of disease.
The following image is an example of a health promotion program focusing on the "threat of
susceptibility”.
Stages of Change (Transtheoretical) Model
The Stages of Change (Transtheoretical) Model is based on the premise that behavior change is a
process, not an event. As individuals attempt to change behavior, they move through five stages:
1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
Individuals can cycle back and forward in the process. The Stages of Change (Transtheoretical) Model
It was developed by John Prochaska and Carlo DiClemente in 1983, and used to explain experiences
of smokers trying to quit.
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This model has been used successfully in a variety of settings, and continues to be used to understand
and examine health behaviors such as smoking, substance abuse, exercise and dietary behaviors. Dr.
DiClemente is on the faculty of UMBC and leads its HABITS Laboratory.
Social Cognitive Theory (SCT)
Social Cognitive Theory focuses on the dynamic interrelationships of personal factors, environmental
factors and human behavior. It was developed by Albert Bandura in 1986, and identifies three main
factors that influence health behavior:
• Self-efficacy--Individual’s beliefs about their capabilities to produce designated levels of
performance that exercise influence over events that affect their lives
• Goals
• Outcome expectancies
Social Cognitive Theory’s critical element is self-efficacy. Factors effecting self-efficacy include:
• Affective Processes: Processes regulating emotional states and elicitation of emotional reactions
• Cognitive Processes: Thinking processes involved in the acquisition, organization and use of
information
• Motivation: Activation to action--level of motivation is reflected in choice of courses of action, and
in the intensity and persistence of effort
• Self-Regulation: Exercise of influence over one's own motivation, thought processes, emotional
states and patterns of behavior
Bandura supported the view that individual actions are the result of an interaction among personal,
behavioral and environmental influences. Individuals consider the results of their own behavior,
personal factors, and alter their environment to change subsequent behavior. Bandura changed the
label of his theory from social learning to social “cognitive theory” to emphasize the role that cognition
plays in “people’s capability to construct reality, self-regulate, encode information, and perform
behaviors” (para 2).
Source: Pajares, F. (2002).Overview of social cognitive theory and of self-efficacy. Retrieved
fromhttp://www.uky.edu/~eushe2/Pajares/eff.html
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Social Cognitive Theory has been used successfully in changing behavior in a number of domains
including dietary behavior, HIV/AIDs, breastfeeding and pain control. One of the most well recognized
areas is the Stanford Chronic Disease Self-Management Program developed by Kate Lorig, DrPH,
RN.
For more information on the application of behavior models in community health promotion programs
read Kreuter, M., Lezin, N.,Kreuter, M., Green, L. Community health promotion Ideas that work Chapter
5: Theory applied, Sudbury, MA: Jones and Bartlett. Available through HS/HSL Course Reserves in
780 blackboard.
COMMUNITY-LEVEL BEHAVIOR CHANGE
Community-level models provide frameworks for multi-dimensional approaches to health promotion.
They augment educational efforts by incorporating strategies to change the social and physical
environment to encourage behavior change. Community-level models are the key to public health
approaches to preventing and controlling disease. They utilize an ecological approach to explore how
social systems function and change and how community members and organizations can mobilize to
support positive behavior change. Community-level models provide evidence-based strategies for a
variety of settings including health care organizations, schools, worksites, community groups and
government agencies.
Frameworks for Intervening on the Community-Level
1. Community Organization/Participatory Models
These models help community groups to identify common problems, mobilize resources and
develop and implement strategies to reach collective goals. The models generally involve
community development, social planning and social action to increase the community’s capacity
to solve problems. They utilize a variety of techniques to achieve change noted in the table below.
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Advocacy is an important tool in community organization and effective program
planning. Healthpolicies, within organizations and on the local, state and national level, that
support programs have the capacity to greatly increase the impact of programs.
2. Diffusion of Innovation
The Diffusion of Innovation model explains how a new idea or product gains momentum and
spreads through a given population. Diffusion increases the population reached by communitybased interventions and strengthens the public health impact of initiatives.
Characteristics of innovations that influence the extent to which a recommendation will be
adopted:
○ Relative advantage:
the degree to which the innovation is perceived as better than the idea it supersedes. Relative
advantage refers to the extent to which the innovation is more productive, efficient, costs less, or
improves in some other manner upon existing practices.
It might seem like relative advantage alone should be enough to persuade persons to adopt an
innovation. Certainly relative advantage is a key indicator of adoption. But sometimes relative
advantage is a matter of debate (e.g., legalized abortion), not immediately evident (e.g., sustainable
agricultural practices), complex to understand (e.g., food irradiation), circumvented by
economic/business/political circumstances (e.g., the popularity of the VHS over the Beta format for
home use video tapes), considered as morally abhorrent (e.g., chemical warfare), or moderated by
difficulties involved in the transition from the old to the new (e.g., switching from traditional
television to HDTV).
Don't better ideas eventually win out? Not always (ask users of Macintosh computers). And
sometimes good ideas like genetically modified food (accept, for the sake of argument, the value
judgment here) undergo delays and considerable costs to developers due to initial public resistance
that might have been avoided if change agents had focused upon factors other than just relative
advantage (e.g., biotechnology companies have had to spend much money on repairing public
relations by not anticipating public resistance in Europe to genetically modified foods).
○ Compatibility:
the degree to which the innovation is perceived as being consistent with existing values, past
experiences, and needs of potential adopters.
Compatibility is the trump card for all innovations, even those with high relative advantage. An
innovation must be considered socially acceptable to be implemented. And some innovations
require much time and discussion before they become socially acceptable.
• If the idea seems morally irreconcilable, then the innovation will not be
adopted (e.g., euthanasia for the terminally ill is having a hard time
catching on with the American public; human cloning might never be
accepted).
• If the innovation is very or sometimes even just a little bit different than
current practices, then the innovation will not be adopted (e.g., news
reports state that the U.S. Treasury might have to give up on Sacagawea
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reports state that the U.S. Treasury might have to give up on Sacagawea
dollars because people do not like to use them).
○ Complexity:
the degree to which the innovation is perceived as difficult to understand and use.
An innovation need not be particularly complex from the viewpoint of its developers. Feminists, for
example, often complain that the public simply doesn't "get it." It is the perception of the end user
that means the most for achieving public adoption of a new technology.
• Food irradiation is difficult to understand, which is part of the reason it has
been slow to be adopted by Americans.
• Personal computers were difficult to learn about when they first were
introduced, which slowed their adoption despite their clear relative
advantages.
• No-till farming was complex to understand and also difficult at first to
implement because one had to make required adjustments to existing
machinery oneself before manufacturers saw sufficient demand to mass
produce no-till equipment.
○ Trialability:
the degree to which the innovation may be experimented with on a limited basis.
Innovations are easier to adopt if they can be tried out in part, on a temporary basis, or easily
dispensed with after trial.
• Nuclear waste storage facilities have to be located and built correctly the
first time.
• There is no going back from affirmative action, civil rights legislation,
legalized marriage for gay/lesbian couples, and so forth.
○ Observability:
the degree to which the results of the innovation are visible to others.
The chances of adoption are greater if folks can easily observe relative advantages of the new
technology. In fact, after some adopt, observability can improve the diffusion effect, a critical
component of technology transfer we will learn about later in Part I.
• The advantages of genetically modified foods are not easily observable, at
least not at present, for consumers. Therefore, challenges to gm foods
carry greater weight than if gm foods had highly visible benefits.
• A no-tilled farm field had negative observability at first because "good"
farmers did not leave plant residue on their fields; they instead left the
ground clean of plant residue with deep furrows.
From <http://www.soc.iastate.edu/sapp/soc415Diffusion1.html>
The process of adoption is similar to a bell-shaped curve with five categories of adopters:
○ Innovators:
(first 5 percent of adopters) tend to be venturesome, cosmopolite, networked with other
innovators, have available financial resources, understand complex technical knowledge, and be
able to cope with uncertainty. Change agents should recognize that, for high-involvement
innovations, innovators do not significantly affect adoption decisions. Innovators, by definition, are
too socially marginal to gain the respect needed to be an opinion leader. Thus, while adoption by
innovators might encourage the change agent , it cannot be expected that innovators will generate
much diffusion effect.
○ Early adopters:
(next 10 percent of adopters) are respected and more local than innovators. It is from this category
that the change agent should expect to locate opinion leaders. These persons are venturesome, but
sufficiently skeptical to recognize good innovations from poor ones. Because opinion leaders have
more influence on the diffusion effect than persons in any other adopter category, it is persons in
this category that the change agent attempts to persuade to adopt.
○ Early majority adopters:
(next 35 percent) tend to interact frequently with peers, seldom hold positions of opinion leadership
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(next 35 percent) tend to interact frequently with peers, seldom hold positions of opinion leadership
but have strong interconnectedness within the system's interpersonal networks, and tend to have a
long period of deliberation before making an adoption decision.
○ Late majority adopters:
(next 35 percent) tend to adopt from economic/social necessity due to the diffusion effect. They
usually are skeptical and cautious and have few extra resources to risk on high-involvement
innovations.
○ Laggards:
(final 15 percent) are the most localite, suspicious of change agents and innovations, and have few
resources to risk. It might sound as if the laggards are a doltish lot. In fact, persons within this
category might be highly innovative in their symbolic adoption but slow to implement because they
have few financial resources to offset transition costs or little access to innovation-evaluation
information. By coincidence or design, laggards are the "smartest" ones when seemingly beneficial
innovations become unexpectedly costly or ineffective.
The inability of some to adopt when they would like to do so underscores the fact that new
technology adoption can further existing inequalities. That is, if the new technology creates
economic advantages, but requires resources to offset transaction costs, then income inequalities
can widen as a result of new technology adoption. The innovativeness-needs paradox refers
to the social problem wherein the individuals who most need the benefits of an innovation generally
are the last to adopt it.
From <http://www.soc.iastate.edu/sapp/soc415Diffusion1.html>
Identifying the characteristics of populations in each adopter category is critical to effective
program planning to meet the specific needs of a community. Many of the adoption strategies
used in business have been utilized to promote public health programs. Check out the local Brick
Bodies website to see how they successfully address the characteristics of innovations and think
how you can use some of these strategies in program planning.
Source: http://image.slidesharecdn.com/rogersdiffusionofinnovationsmodel-120205231217NSG 780Final Page 46
Source: http://image.slidesharecdn.com/rogersdiffusionofinnovationsmodel-120205231217phpapp01/95/rogers-diffusion-of-innovations-model-4-728.jpg?cb=1328483651
For more information on the Diffusion of Innovation Model please review the following
website: http://www.indiana.edu/~t581qual/Assignments/Diffusion_of_Innovations.pdf
3. Communication Theories
Communication Theories describes how different types of messages affect health behavior. They
considers how messages are developed, relayed, received and acted upon. Public health
communications involve the scientific development, strategic dissemination and evaluation of
relevant, accurate, accessible and understandable health information, communicated to and from
intended audiences to advance the public’s health.
Public health communications utilize multiple approaches:
○ Tailored messages at the individual level
○ Targeted messages at the group level
○ Social marketing at the community level
○ Media advocacy at the policy level
○ Mass media campaigns at the population level
Health communications alone have generally not been shown to sustain behavior change. (Think of the
many times that health professionals provide brochures or tip sheets or just comment on needed
behavior change, such as weight loss, and do not find their patients complying.) Health communications
need to be coupled with other strategies that change the social and physical environment. Recall the
discussion of the North Karalia/Finland experience.
The Centers for Disease Control and Prevention is a leader in health communications and health
literacy. It offers a wide variety of tools available at varying level to support public health programs.
Its audience insight series offers tools to enhance health communication with target populations
including specific ethnic groups, providers, teenagers and baby boomers. Its Gateway to Health
Communications and Social Marketing Practice provides tools and templates to develop health
communication and social marketing campaigns and programs.
Guide to Community Preventive Services
The Community Preventive Services Task Force was established in 1996 by the U.S. Department of
Health and Human Services to identify population health interventions that are scientifically proven to
save lives, increase lifespans, and improve quality of life. The task force produces recommendations
and identifies evidence gaps to help inform the decision making of federal, state, and local health
departments, other government agencies, communities, healthcare providers, employers, schools and
research organizations.
Similar to its companion document, the Guide to Clinical Preventive Services, the Guide to
Community Preventive Services is regularly updated to assist program planners study and replicate
evidence-based programs and policies to improve health and prevent disease.
Systematic reviews are used to answer these questions:
• Which program and policy interventions have been proven effective?
• Are there effective interventions that are right for my community?
• What might effective interventions cost; what is the likely return on investment?
Explore the website and use this important reference as you begin to develop your programs.
From <https://cf.son.umaryland.edu/NRSG780/module9/subtopic3.htm>
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Module 10: Leading Causes of Morbidity and Mortality
Thursday, April 13, 2017
12:24 PM
Module 10: Leading Causes of Morbidity and Mortality
OVERVIEW
This module begins the final section of the course focusing on population-based health
promotion and community practice. The purpose of this module is to further examine two of the
leading causes of mortality and morbidity—cancer and mental health disorders. It emphasizes
disease prevalence and prevention strategies and population-based initiatives on the national
and state level designed to reduce the burden of cancer and mental health disorders.
Objectives
At the conclusion of this module, the learner will be able to:
• Explain the prevalence of cancer in relation to the leading causes of mortality and
morbidity
• Explain the prevalence of mental health disorders in relation to the leading causes of
morbidity
• Identify prevention strategies for cancer
• Identify prevention strategies for mental health disorders
• Discuss national planning models for cancer and mental health disorders
• Discuss national planning models for mental health disorders
• Review the state goals for addressing population-based cancer control
• Review the state goals for addressing population-based mental health disorders
Required Readings
• American Cancer Society. (2016). Facts and Figures 2016, pp. 1-3, 43-49, 53-55.
Available at http://www.cancer.org/acs/groups/content/
@research/documents/document/acspc-047079.pdf
• Centers for Disease Control and Prevention. (May 2, 2014). Potentially Preventable
Deaths from the Five Leading Causes of Death —United States, 2008–2010, Morbidity
and Mortality Week Report, 63(17). Available
at http://www.cdc.gov/mmwr/pdf/wk/mm6317.pdf
• National Alliance on Mental Illness. (2016). Mental Health By The Numbers. Available
at http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers
• Substance Abuse and Mental Services Administration. (n.d.) Risk and Protective Factors.
Available at https://www.samhsa.gov/capt/practicing-effectiveprevention/prevention-behavioral-health/risk-protective-factors
• Substance Abuse and Mental Health Services Administration. (2016). Mental and
Substance Use Disorders. Available at http://www.samhsa.gov/disorders
Recommended
• Centers for Disease Control and Prevention. (2011). Public Health Action Plan to Integrate
Mental Health Promotion and Mental Illness Prevention with Chronic Disease Prevention
2011-2015. Available at http://www.mhrb.org/dbfiles/docs/Brochure/11_220990
_Sturgis_MHMIActionPlan_FINAL-Web_tag508.pdf
• National Cancer Institute. (2016). Cancer trends progress report: 2015 update. Available
at http://www.progressreport.cancer.gov/
• World Health Organization. (2013). Mental Health Action Plan 2013-2020 pp 1-10.
Directions
Read the module content and activities. Then complete the assignment for the module
American Cancer Society. (2016). Facts and Figures 2016, pp. 1-3, 43-49, 53-55.
What Is Cancer?
Cancer is a group of diseases characterized by the uncontrolled growth and spread of abnormal cells. If
the spread is not controlled, it can result in death. Cancer is caused by external factors, such as tobacco,
infectious organisms, and an unhealthy diet, and internal factors, such as inherited genetic mutations,
hormones, and immune conditions. These factors may act together or in sequence to cause cancer. Ten
or more years often pass between exposure to external factors and detectable cancer. Treatments
include surgery, radiation, chemotherapy, hormone therapy, immune therapy, and targeted therapy
(drugs that interfere specifically with cancer cell growth).
Can Cancer Be Prevented?
A substantial proportion of cancers could be prevented. All cancers caused by tobacco use and heavy
alcohol consumption could be prevented completely. In 2016, about 188,800 of the estimated 595,690
NSG 780Final Page 48
alcohol consumption could be prevented completely. In 2016, about 188,800 of the estimated 595,690
cancer deaths in the US will be caused by cigarette smoking, according to a recent study by American
Cancer Society epidemiologists. In addition, the World Cancer Research Fund estimates that about 20%
of all cancers diagnosed in the US are related to body fatness, physical inactivity, excess alcohol
consumption, and/or poor nutrition, and thus could also be prevented. Certain cancers are related to
infectious agents, such as human papillomavirus (HPV), hepatitis B virus (HBV), hepatitis C virus (HCV),
human immunodeficiency virus (HIV), and Helicobacter pylori (H. pylori). Many of these cancers could be
avoided by preventing these infections through behavioral changes or vaccination, or by treating the
infection. Many of the more than 5 million skin cancer cases that are diagnosed annually could be
prevented by protecting skin from excessive sun exposure and not using indoor tanning devices.
Screening can prevent colorectal and cervical cancers by allowing for the detection and removal of
precancerous lesions. Screening also offers the opportunity to detect some cancers early, when
treatment is less extensive and more likely to be successful. Screening is known to help reduce mortality
for cancers of the breast, colon, rectum, cervix, and lung (among long-term and/or heavy smokers). In
addition, a heightened awareness of changes in certain parts of the body, such as the breast, skin,
mouth, eyes, or genitalia, may also result in the early detection of cancer. For complete cancer screening
guidelines, see page 66
How Many People Alive Today Have Ever Had Cancer?
Nearly 14.5 million Americans with a history of cancer were alive on January 1, 2014. Some of these
individuals were diagnosed recently and undergoing treatment, while most were diagnosed many years
ago with no current evidence of cancer.
How Many New Cases and Deaths Are Expected to Occur This Year?
About 1,685,210 new cancer cases are expected to be diagnosed in 2016 (Table 1, page 4). This estimate
does not include carcinoma in situ (noninvasive cancer) of any site except urinary bladder, nor does it
include basal cell or squamous cell skin cancers because these are not required to be reported to cancer
registries. Table 2 (page 5) provides estimated new cancer cases in 2016 by state.
About 595,690 Americans are expected to die of cancer in 2016, which translates to about 1,630 people
per day (Table 1, page 4). Cancer is the second most common cause of death in the US, exceeded only
by heart disease, and accounts for nearly 1 of every 4 deaths. Table 3 (page 6) provides estimated
cancer deaths by state in 2016.
How Much Progress Has Been Made in the Fight against Cancer?
Trends in cancer death rates are the best measure of progress against cancer. The total cancer death
rate rose for most of the 20th century because of the tobacco epidemic, peaking in 1991 at 215 cancer
deaths per 100,000 persons. However, from 1991 to 2012, the rate dropped 23% because of reductions
in smoking, as well as improvements in early detection and treatment. This decline translates into the
avoidance of more than 1.7 million cancer deaths. Death rates are declining for all four of the most
common cancer types – lung, colorectal, breast, and prostate (Figure 1, page 2 and Figure 2, page 3).
Do Cancer Incidence and Death Rates Vary By State?
Tables 4 (page 7) and 5 (page 8) provide average annual incidence and death rates during 2008 to 2012
for selected cancer types by state. For some cancers (e.g., lung), there is substantial variation by state,
whereas for others (e.g., breast), there is less variation. For more information about geographic
disparities in cancer occurrence, see page 53.
Who Is at Risk of Developing Cancer?
Cancer usually develops in older people; 86% of all cancers in the United States are diagnosed in people
50 years of age or older.
Certain behaviors also increase risk, such as smoking, eating an unhealthy diet, or not being physically
active. Cancer researchers use the word “risk” in different ways, most commonly expressing risk as
lifetime risk or relative risk. Lifetime risk refers to the probability that an individual will develop or die
from cancer over the course of a lifetime. In the US, the lifetime risk of developing cancer is 42% (1 in 2)
in men and 38% (1 in 3) in women (Table 6, page 14). These probabilities are estimated based on the
overall experience of the general population and may overestimate or underestimate individual risk
because of differences in exposures (e.g., smoking), family history, and/or genetic susceptibility.
Relative risk is a measure of the strength of the relationship between a risk factor and cancer. It
compares the risk of developing cancer in people with a certain exposure or trait to the risk in people
who do not have this characteristic. For example, men and women who smoke are about 25 times more
likely to develop lung cancer than nonsmokers, so their relative risk of lung cancer is 25. Most relative
NSG 780Final Page 49
likely to develop lung cancer than nonsmokers, so their relative risk of lung cancer is 25. Most relative
risks are not this large. For example, women who have a mother, sister, or daughter with a history of
breast cancer are about twice as likely to develop breast cancer as women who do not have this family
history; in other words, their relative risk is about 2. For most types of cancer, risk is higher with a family
history of the disease. It is now thought that many familial cancers arise from the interplay between
common gene variations and lifestyle/environmental risk factors. Only a small proportion of cancers are
strongly hereditary, that is, caused by an inherited genetic alteration that confers a very high risk.
What Percentage of People Survive Cancer?
The 5-year relative survival rate for all cancers diagnosed during 2005-2011 was 69%, up from 49%
during 1975-1977 (Table 7, page 18). Improvement in survival reflects both the earlier diagnosis of
certain cancers and improvements in treatment. Survival statistics vary greatly by cancer type and stage
at diagnosis (Table 8, page 21).
Relative survival is the percentage of people who are alive a designated time period (usually 5 years)
after a cancer diagnosis divided by the percentage expected to be alive in the absence of cancer based
on normal life expectancy. It does not distinguish between patients who have no evidence of cancer and
those who have relapsed or are still in treatment. The 5-year relative survival rate does not represent
the proportion of people who are cured because cancer deaths occur beyond 5 years after diagnosis. For
information about how survival rates were calculated for this report, see “Sources of Statistics” on page
64.
Although relative survival rates provide some indication about the average survival experience of cancer
patients in a given population, they should be interpreted with caution. First, 5-year survival rates do
not reflect the most recent advances in detection and treatment because they are based on patients
who were diagnosed as far back as 10 years. Second, they are not equally applicable to all patients
because of factors that affect individual survival, such as treatment, other illnesses, and biological or
behavioral differences. Third, improvements in survival rates over time do not always indicate progress
against cancer. For example, increases in average survival time can occur if screening results in the
detection of some indolent cancers that would have gone undetected in the absence of screening
(overdiagnosis). Screening also artificially increases survival rates when early diagnosis does not extend
lifespan.
Trends in Age-adjusted Cancer Death Rates by site, Males US, 1930-2012
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How Is Cancer Staged?
Staging describes the extent or spread of cancer at the time of diagnosis. Proper staging is essential for
optimizing therapy and assessing prognosis. A cancer’s stage is based on the size or extent of the
primary tumor and whether it has spread to nearby lymph nodes or other areas of the body. A number
of different staging systems are used to classify cancer. A system of summary staging is used for
descriptive and statistical analysis of tumor registry data and is particularly useful for looking at trends
over time. According to this system, if cancer cells are present only in the layer of cells where they
developed and have not spread, the stage is in situ. If cancer cells have penetrated beyond the original
layer of tissue, the cancer has become invasive and is categorized as local, regional, or distant based on
the extent of spread. (For a more detailed description of these categories, see the footnotes in Table 8
on page 21.)
Clinicians use a different staging system, called TNM, for most cancers. The TNM system assesses cancer
growth and spread in 3 ways: extent of the primary tumor (T), absence or presence of regional lymph
node involvement (N), and absence or presence of distant metastases (M). Once the T, N, and M
categories are determined, a stage of 0, I, II, III, or IV is assigned, with stage 0 being in situ, stage I being
early, and stage IV being the most advanced disease. Some cancers (e.g., lymphoma) have alternative
staging systems. As the biology of cancer has become better understood, additional tumor-specific
features have been incorporated into treatment plans and/or stage for some cancers.
Trends in Age-adjusted Cancer Death Rates by site, Females US 1930-2012
Tobacco Use
Smoking remains the world’s most preventable cause of death. Since the first US Surgeon General’s
report on smoking and health in 1964, there have been more than 20 million premature deaths
attributable to smoking in the US. Each year, cigarette smoking results in an estimated 480,000
premature deaths, 42,000 of which are due to secondhand smoke exposure.1, 2 The number of people
who die prematurely or suffer illness from tobacco use impose substantial health-related economic
costs on society. In 2012, smoking accounted for $176 billion in health care-related expenditures in the
US.
NSG 780Final Page 51
US.
Cigarette Smoking
Cigarette smoking increases the risk of cancers of the oral cavity and pharynx, larynx, lung, esophagus,
pancreas, uterine cervix, kidney, bladder, stomach, colorectum, and liver, as well as acute myeloid
leukemia.1 In addition, the International Agency for Research on Cancer recently concluded that there is
some evidence that tobacco smoking causes female breast cancer, and the Surgeon General concluded
that smoking increases the risk of advanced-stage prostate cancer.1,3 Excluding secondhand smoke,
smoking is estimated to cause 32% of all cancer deaths in the US,4 including 83% of lung cancer deaths
among men and 76% of lung cancer deaths among women (Figure 4).
•The prevalence of current cigarette smoking (defined as smoking at least 100 cigarettes and currently
smoking) among adults 18 years of age and older has declined by more than half, from 42% in 1965 to
17% in 2014; however, reductions vary across population subgroups.
•Based on the 2014 National Health Interview Survey (NHIS), approximately 40 million adults (18 years
and older) were current smokers,7 about 4.5 million fewer than in 2004.8
•The proportion of daily smokers reporting light or intermittent smoking (fewer than 10 cigarettes per
day) increased between 2004 (17%) and 2014 (27%), whereas heavy smoking (30 or more cigarettes per
day) declined from 13% to 7%.7, 8
•Although uptake of smoking began earlier in men than in women, the gender gap, particularly among
non-Hispanic whites, has narrowed. As of 2014, there was a 2 percentage point difference in smoking
prevalence between white men (19%) and women (17%), a 9 percentage point difference between nonHispanic black men (23%) and women (14%), a 7 percentage point difference between Hispanic men
(15%) and women (8%), and a 9 percentage point difference between Asian men (14%) and women
(5%).7
•Smoking is most common, and has declined more slowly, among those with the least education. In
2014, smoking prevalence was 23% among adults 25 years and older with less than a high school
diploma and 5% among those with graduate degrees. Smoking was most prevalent among adults with a
GED (General Educational Development), or high school equivalency credential (43%).7
•Among US states in 2013, the prevalence of adult smoking ranged from 10% in Utah to 27% in West
Virginia and Kentucky.
• Although current cigarette smoking among US high school students (at least once in the past 30 days)
increased from 28% in 1991 to 36% in 1997, it declined to 9% in 2014.10, 11
• In contrast to the decline in cigarette smoking among teens, current use of hookahs in this age group
has increased
dramatically, from 4% in 2011 to 9% in 2014, and is now as common as smoking.11
Cigar Smoking
Cigar smoking causes many of the same diseases as cigarette smoking and smokeless tobacco. Regular
cigar smoking is associated with an increased risk of cancers of the lung, oral cavity, larynx, esophagus,
and probably pancreas.12 Cigar smokers have 4 to 10 times the risk of dying from lung, laryngeal, oral,
or esophageal cancer compared to never smokers.13, 14 Historically, lower tax rates on cigars have
caused some smokers to switch from cigarettes to less costly cigars.
• While total cigarette consumption declined by one-third from 2000 to 2011, large cigar consumption
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• While total cigarette consumption declined by one-third from 2000 to 2011, large cigar consumption
more than tripled, from 3.9 billion (cigarette equivalents) to 12.9 billion.15
• According to the 2012-2013 National Adult Tobacco Survey (NATS), 2% of adults (3% of men and <1%
of women) reported smoking cigars every day or some days.16
• Cigar use was highest among non-Hispanic blacks (4%) and those with household incomes <$20,000.16
• In 2014, 8% of US high school students had smoked cigars, cigarillos, or little cigars at least once in the
past 30 days
down from 18% in 1999.10, 11
• In contrast to non-Hispanic whites and Hispanics, cigars are the most common form of tobacco use
among black high
school students (9%, versus 5% to 6% for e-cigarettes, hookahs, and cigarettes).11
Secondhand Smoke
There is no safe level of exposure to secondhand smoke (SHS), or environmental tobacco smoke, which
contains more than 7,000 chemicals, at least 69 of which cause cancer.17 Exposure to SHS increases the
risk of lung diseases, including lung cancer, coronary artery disease, and heart attacks.18-20 SHS can
also cause coughing, wheezing, chest tightness, and reduced lung function in adult nonsmokers. 21
Laws that prohibit smoking in public places and create smoke-free environments are the most effective
approach to prevent exposure to and harm from SHS. In addition, there is strong
evidence that smoke-free policies decrease the prevalence of both adult and youth smoking.20, 22
Momentum to regulate public smoking began to increase in 1990, and smoke-free laws have become
increasingly common and comprehensive over time.
• Each year, about 7,330 nonsmoking adults die of lung cancer as a result of breathing SHS.1
• Nationwide, SHS exposure among nonsmokers declined from 84% in 1988-199423 to 25% in
2011-2012,24 likely reflecting widespread implementation of smoke-free laws and reduction in smoking
prevalence. However, this progress differs by subgroup, and poor individuals remain substantially more
likely to be exposed than those who are more affluent.
• In the US, as of July 1, 2015, 763 municipalities and 24 states, the District of Columbia, Puerto Rico,
and the US Virgin Islands have laws in place requiring all non-hospitality workplaces, restaurants, and
bars to be 100% smoke-free.25
• Currently, 49% of the US population is covered by a 100% smoke-free policy in workplaces,
restaurants, and bars.25
E-cigarettes
Electronic nicotine delivery systems (ENDS) are battery-operated devices that allow the user to inhale a
vapor produced from cartridges or tanks filled with a liquid typically containing nicotine, propylene
glycol and/or vegetable glycerin, other chemicals, and sometimes flavoring. The term e-cigarettes will be
used hereafter to refer to any ENDS, including those not designed to mimic cigarettes. Some studies
have shown lower levels of toxic chemicals in aerosol from e-cigarette products than in smoke from
combustible cigarettes, and e-cigarettes are promoted as a less harmful alternative to traditional
cigarettes and a way to bypass smoke-free laws. However, the long-term health risks of using these
products, or being exposed to them secondhand, are unknown and likely vary depending on the specific
e-cigarette product and how it is used. While the health risks of e-cigarettes are not fully known, there is
growing concern that e-cigarette use will normalize cigarette smoking and lead to the use of other forms
of tobacco products with known health risks. Indeed, a recent study indicates that adolescent ecigarette users are much more likely to initiate cigarette, cigar, or hookah smoking than nonusers.26
Also, these products may discourage utilization of evidence-based cessation
therapies among those who want to quit. E-cigarettes have been gaining in popularity, particularly
among high school
students.
• According to the 2012-2013 NATS, 2% of adults were current (every day or some days) e-cigarette
users.16
• The prevalence of ever use of e-cigarettes among adults doubled between 2010 and 2011, from 3% to
6%.27
• E-cigarette use (at least once in the past 30 days) has increased most rapidly among high school
students, surpassing cigarette smoking in 2014 to become the most common form of tobacco use;
prevalence increased from 2% in 2011 to 13% in 2014.11
• In high school students, e-cigarette use is more than twice as high among non-Hispanic whites (15%)
and Hispanics (15%) as among blacks (6%).
Smokeless Tobacco Products
Smokeless tobacco products include moist snuff, chewing tobacco, snus (a “spitless,” moist powder
tobacco pouch), dissolvable nicotine products, and a variety of other tobacco-containing products that
are not smoked. These products cause oral, esophageal, and pancreatic cancers; precancerous lesions of
the mouth gum recession; bone loss around the teeth; and tooth staining.28, 29 They can also lead to
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the mouth gum recession; bone loss around the teeth; and tooth staining.28, 29 They can also lead to
nicotine addiction. Compared to quitting completely, switching to smokeless tobacco products as a
substitute for smoking has been shown to increase the risk of tobacco-related death.30 Furthermore,
smokers who use smokeless products as a supplemental source of nicotine to postpone or
avoid quitting will increase rather than decrease their risk of lung cancer. Recently, the smokeless
market in high-income countries, including the US, has been consolidated from smaller tobacco
companies into the control of tobacco multinational corporations.
In the US, the sales of smokeless tobacco products are growing at a more rapid pace than cigarettes.32
As part of their
marketing strategy, the industry is actively promoting these products both for use in settings where
smoking is prohibited and as a way to quit smoking. However, there is no evidence to date that these
products are as effective as proven cessation therapies for quitting. When smokeless tobacco was
aggressively marketed in the US in the 1970s and 1980s, use of these products increased among
adolescent males, but not among older smokers trying to quit. The use of any smokeless tobacco
product is not considered a safe substitute for quitting.33, 34
• The sales of moist snuff increased by 66% between 2005 and 2011.35
• According to the 2014 NHIS, 2% of adults 18 years of age and older (4% of men and <1% of women)
currently (every day or some days) used smokeless tobacco products.7
• According to the 2012-2013 NATS, whites and American Indians/Alaska Natives were more likely to
use smokeless tobacco than non-Hispanic black, Hispanics/Latinos, or Asians.15
• Current adult smokeless tobacco use (including snus use) varied from <2% in California; Washington,
DC; and Massachusetts to 9% in West Virginia in 2013.9
• According to the 2014 National Youth Tobacco Survey, 10% of high school boys and 1% of girls used
smokeless tobacco in the past 30 days.11
Smoking Cessation
Smokers who quit, regardless of age, increase their longevity, with those who quit before middle age
generally experiencing a lifespan similar to never smokers.36 Smoking cessation reduces the risk of lung
and other cancers caused by smoking. In addition, cancer survivors who quit smoking have better health
outcomes than those who do not.
• According to the 2014 NHIS, 57% (52.2 million) of the 92.3 million Americans who ever smoked at least
100 cigarettes
are now former smokers.7
• In 2014, 49% of current smokers attempted to quit for at least one day in the past year.7
• Smokers with an undergraduate or graduate degree are more likely to succeed in quitting than less
educated smokers.37
• Although effective cessation treatments can double or triple a smoker’s chances of long-term
abstinence, only 32% of people who try to quit used counseling or medication. Use of smoking cessation
aids is particularly low among smokers withlower educational attainment.38
• In 2013, 56% of high school students who were current cigarette smokers tried to quit during the 12
months preceding
the survey.39
Reducing Tobacco Use and Exposure
There are federal, state, and local initiatives aimed at reducing tobacco exposure. While states have
been at the forefront of tobacco control efforts, the importance of the federal government’s role was
emphasized in a 2007 Institute of Medicine Report.40 Federal initiatives in tobacco control hold promise
for reducing tobacco use, and include regulation of tobacco products, national legislation ensuring
coverage of some clinical cessation services, and tax increases. The Family Smoking Prevention and
Tobacco Control Act of 2009 granted the US Food and Drug Administration (FDA) the authority to
regulate the manufacturing, selling, and marketing of tobacco products. Key provisions that have
already gone into effect include the prohibition of misleading descriptors such as light, low, and mild on
tobacco product labels and the prohibition of fruit and candy cigarette flavorings. Provisions in the 2010
Affordable Care Act ensure at least minimum coverage of evidence-based cessation treatments,
including pharmacotherapy and cessation counseling, to previously uninsured tobacco users, pregnant
Medicaid
recipients, and eligible Medicare recipients. Furthermore, costsharing for evidence-based cessation
treatments was eliminated for new or renewed private health plans and Medicare recipients. In 2000,
the US Surgeon General outlined the goals and components of comprehensive statewide tobacco
control programs.41 These programs seek to prevent the initiation of tobacco use among youth,
promote quitting at all ages, eliminate nonsmokers’ exposure to SHS, and identify and eliminate the
disparities related to tobacco use and its effects among different population groups. The Centers for
Disease Control and Prevention (CDC) recommends funding levels for comprehensive tobacco use
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Disease Control and Prevention (CDC) recommends funding levels for comprehensive tobacco use
prevention and cessation programs for all 50 states and the District of Columbia. In fiscal year 2015, 7
states allocated 50% or more of CDC-recommended funding levels for tobacco control programs. 24
States that have previously invested in comprehensive tobacco control programs, such as California,
Massachusetts, and Florida, have reduced smoking rates and saved millions of dollars in tobacco-related
health care costs.41 For more information about tobacco control, visit cancer.org/statistics to view the
most recent edition of Cancer Prevention & Early Detection Facts & Figures.
Conclusion
Substantial progress has been made in reducing the disease burden from tobacco over the 52 years
since the first report of the Surgeon General’s Advisory Committee on Smoking and Health in 1964.
Smoking prevalence has been reduced by more than half, and millions of premature deaths have been
averted. Nevertheless, more needs to be done to further reduce the health and economic burden of
tobacco. Numerous studies confirm that a comprehensive approach to tobacco control, including higher
taxes, 100% smoke-free environments, coverage for tobacco dependence treatment, full
implementation of the FDA Family Smoking Prevention and Tobacco Control Act, and vigorous tobacco
counter-advertising, can be successful in reducing deaths, disease, and economic disruption from
tobacco use.
Nutrition & Physical Activity
The World Cancer Research Fund estimates that about 20% of cancers that occur in the US are due to
the combined effects of excess alcohol consumption, poor nutrition, physical inactivity, and excess
weight, and thus could be prevented.1 For the 83% of people who don’t smoke, maintaining a healthy
body weight, being physically active on a regular basis, and eating a healthy diet are the most important
ways to reduce cancer risk. Studies estimate that adults who follow these healthy lifestyle
recommendations, including not smoking, are 36% less likely to be diagnosed with cancer and 40% less
likely to die from the disease. The American Cancer Society’s nutrition and physical activity guidelines
emphasize the importance of weight control, physical activity, healthy dietary patterns, and limited, if
any, alcohol consumption in reducing cancer risk and helping people stay well. Unfortunately, the
majority of Americans are not meeting these recommendations.3 The Society’s guidelines also include
recommendations for community action because of the large influence that physical and social
environments have on individual food and activity behaviors.
The following recommendations reflect the best nutrition and physical activity evidence available to
help Americans reduce their risk of cancer and promote overall health. See Cancer Prevention & Early
Detection Facts & Figures at cancer.org/statistics for more detailed information on how nutrition,
physical activity, and body weight affect cancer risk.
Recommendations for Individual Choices
1. Achieve and maintain a healthy weight throughout life.
• Be as lean as possible throughout life without being underweight.
• Avoid excess weight gain at all ages. For those who are currently overweight or obese, losing even a
small amount of weight has health benefits and is a good place to start.
• Engage in regular physical activity and limit consumption of high-calorie foods and beverages as key
strategies for maintaining a healthy weight.
Overweight and obesity are clearly associated with increased risk for developing many cancers, including
adenocarcinoma of the esophagus and cancers of the breast (in postmenopausal women), colorectum,
endometrium, kidney, liver, and pancreas. Overweight and obesity may also be associated with an
increased risk of aggressive prostate cancer, non-Hodgkin lymphoma, multiple myeloma, and cancers of
the cervix, ovary, and gallbladder. Abdominal fatness in particular is convincingly associated with
colorectal cancer, and probably related to higher risk of pancreatic and endometrial cancers. In addition,
accumulating evidence suggests that obesity increases the risk for cancer recurrence and decreases
survival rates for several cancers. 4, 5 Some studies have shown that intentional weight loss is
associated with decreased cancer risk among women, but the evidence is less clear for men. The
prevalence of obesity among US adults 20-74 years of age more than doubled between 1976-1980 (15%)
and 1999-2000 (31%), but since 2005 has remained around 35%. However, among certain subgroups,
such as Hispanic (45%) and non-Hispanic black (57%) women, obesity prevalence is much higher.
Similar to adults, obesity among children and adolescents has risen rapidly in the past several decades
across race, ethnicity, and gender. In 2011-2012, 17% of American children 2 to 19 years of age were
obese, including 20% of blacks, 22% of Hispanics, 14% of non-Hispanic whites, and 7% of Asians.8
However, a recent study suggests that obesity rates among children and adolescents have plateaued
over the past decade, with declines reported among children 2 to 5 years of age, perhaps an indication
that the obesity epidemic is stalling.8 Because overweight in youth tends to continue throughout life,
efforts to establish healthy body weight patterns should begin in childhood. The high prevalence of
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efforts to establish healthy body weight patterns should begin in childhood. The high prevalence of
obesity in children and adolescents may impact the future cancer burden. More than likely, the obesity
epidemic is already impacting cancer rates. For example, rising endometrial cancer incidence rates likely
reflect, to some extent,
the increasing prevalence of obesity.9 Additionally, some researchers have speculated that the
longstanding, historic
increases in life expectancy in the US may level off or even decline within the first half of this century as
a result of the
obesity epidemic.
2. Adopt a physically active lifestyle.
• Adults should engage in at least 150 minutes of moderate intensity or 75 minutes of vigorous-intensity
activity each week, or an equivalent combination, preferably spread throughout the week.
• Children and adolescents should engage in at least 1 hour of moderate- or vigorous-intensity activity
each day, with
vigorous-intensity activity at least three days each week.
• Limit sedentary behavior such as sitting, lying down, and watching television and other forms of
screen-based
entertainment.
• Doing any intentional physical activity above usual activities can have many health benefits.
Living a physically active lifestyle helps reduce the risk of a variety of cancer types, as well as heart
disease, diabetes, and many other diseases. Scientific evidence indicates that physical activity may
reduce the risk of cancers of the breast, colon, and endometrium, as well as advanced prostate
cancer.10 Physical activity also indirectly reduces the risk of developing obesity related cancers because
of its role in helping to maintain a healthy weight. Being active is thought to reduce cancer risk largely by
improving energy metabolism and reducing circulating concentrations of estrogen, insulin, and insulinlike growth factors. Physical activity also improves the quality of life of cancer patients and has been
associated with reduced cancer recurrence and overall mortality in cancer survivor groups, including
breast, colorectal, prostate, and ovarian cancer.
Despite the wide variety of health benefits from being active, in 2014 30% of adults reported no leisuretime activity, and only 50% met recommended levels of aerobic activity. Similarly, only 25% of children
12 to 15 years of age and 27% of high school students met recommendations. However, recent data
released by the CDC indicate that trends may be slightly improving. The proportion of adults meeting
recommended aerobic and muscle-strengthening guidelines increased from 14% in 1998 to 22% in 2014.
3. Consume a healthy diet, with an emphasis on plant foods.
• Choose foods and beverages in amounts that help achieve and maintain a healthy weight.
• Limit consumption of red and processed meat.
• Eat at least 2½ cups of vegetables and fruits each day.
• Choose whole grains instead of refined-grain products.
There is strong scientific evidence that healthy dietary patterns, in combination with regular physical
activity, are needed to maintain a healthy body weight and to reduce cancer risk. Studies have shown
that individuals who eat more processed and red meat, potatoes, refined grains, and sugar-sweetened
beverages and foods are at a higher risk of developing or dying from a variety of cancers. Alternatively,
adhering to a diet that contains a variety of fruits and vegetables, whole grains, and fish or poultry and
fewer red and processed meats is associated with lower risk. Recent studies found that dietary and
lifestyle behaviors consistent with the American Cancer Society nutrition and physical activity guidelines
are associated with lower mortality rates for all causes of death combined, and for cancer and
cardiovascular diseases specifically.11, 12 Despite the known benefits of a healthy diet, Americans are
not following recommendations; according to the US Department of Agriculture, the majority of
Americans would need to substantially lower their intake of added sugars, added fats, refined grains,
and sodium, and increase their consumption
of fruits, vegetables, whole grains, and low-fat dairy products in order to meet the 2010 Dietary
Guidelines for Americans.
The scientific study of nutrition and cancer is highly complex, and many important questions remain
unanswered. It is not presently clear how single nutrients, combinations of nutrients, over-nutrition, and
energy imbalance, or the amount and distribution of body fat and nutritional exposures at particular
stages of life, affect a person’s risk of specific cancers. Until more is known about the specific
components of diet that influence cancer risk, the best advice is to consume a mostly plant-based diet
that limits red and processed meats and emphasizes a variety of vegetables, fruits, and whole grains. A
special emphasis should be placed on controlling total caloric intake to help achieve and maintain a
healthy weight.
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4. If you drink alcoholic beverages, limit consumption.
People who drink alcohol should limit their intake to no more than two drinks per day for men and one
drink per day for
women. Alcohol consumption is a risk factor for cancers of the mouth, pharynx, larynx, esophagus, liver,
colorectum, female breast, and possibly pancreas.3, 10, 13, 14 For each of these cancers, risk increases
substantially with the intake of more than two drinks per day. Even a few drinks per week may be
associated with a slightly increased risk of breast cancer in women.15 Alcohol consumption combined
with tobacco use increases the risk of cancers of the mouth, larynx, and esophagus far more than either
drinking or smoking alone.10
The American Cancer Society Recommendations for Community Action
Many Americans encounter substantial barriers to consuming a healthy diet and engaging in regular
physical activity. Among those barriers that have collectively contributed to increased obesity are:
limited access to affordable, healthy foods; increased portion sizes, especially of restaurant meals;
marketing and advertising of foods and beverages high in calories, fat, and added sugar, particularly to
kids; schools and worksites that are not conducive to good health; community design that hinders
physical activity and promotes sedentary behavior; and economic and time constraints.
The Society’s nutrition and physical activity guidelines include Recommendations for Community Action
because of the tremendous influence that the surrounding environment has on individual food and
activity choices. Acknowledging that reversing obesity trends will require extensive policy and
environmental changes, the Society calls for public, private, and community organizations to create
social and physical environments that support the adoption and maintenance of healthy eating and
physical activity behaviors to help people stay well. Achieving these recommendations requires multiple
strategies and bold action, ranging from the implementation of community and workplace health
promotion programs to policies that affect community planning, transportation, school-based physical
activity, and food services. The tobacco control experience has shown that policy and environmental
changes at the national, state, and local levels are critical to achieving changes in individual behavior.
Measures such as smoke-free laws and increases in cigarette excise taxes have been highly effective in
deterring tobacco use. To avert an epidemic of obesity-related disease, similar
purposeful changes in public policy and in the community environment are required to help individuals
make smart food
and physical activity choices and maintain a healthy body weight.
The Global Fight against Cancer
The ultimate mission of the American Cancer Society is to eliminate cancer as a major health problem.
Because cancer knows no boundaries, this mission extends around the world. Cancer is an enormous
global health burden, touching every region and socioeconomic group. Today, cancer accounts for about
1 in every 7 deaths worldwide – more than HIV/AIDS, tuberculosis, and malaria combined. In 2012,
there were an estimated 14.1 million cases of cancer diagnosed around the world and 8.2 million cancer
deaths. More than 60% of cancer deaths occur in low- and middle-income countries, many of which lack
the medical resources and health systems to support the disease burden. Moreover, the global cancer
burden is growing at an alarming pace; in 2030 alone, about 21.7 million new cancer cases and 13.0
million cancer deaths are expected to occur, simply due to the growth and aging of the population. The
future burden may be
further increased by the adoption of behaviors and lifestyles associated with economic development
and urbanization (e.g., smoking, poor diet, physical inactivity, and reproductive patterns) in low- and
middle-income countries. Tobacco use is a major cause of the increasing global burden of cancer as the
number of smokers worldwide continues to grow.
Worldwide Tobacco Use
Tobacco-related diseases are the most preventable cause of death worldwide, responsible for the
deaths of approximately half of all long-term tobacco users.
• Each year, tobacco use is responsible for almost 6 million deaths, 80% of which are in low- and middleincome countries; by 2030, this number is expected to increase to 8 million.
• Between 2002 and 2030, tobacco-attributable deaths are expected to decrease by 9% in high-income
countries, while
increasing by 100% (from 3.4 million to 6.8 million) in low and middle-income countries.
The first global public health treaty under the auspices of the World Health Organization, the
Framework Convention on
Tobacco Control (FCTC), was unanimously adopted by the World Health Assembly on May 21, 2003, and
NSG 780Final Page 57
Tobacco Control (FCTC), was unanimously adopted by the World Health Assembly on May 21, 2003, and
subsequently entered into force as a legally binding accord for all ratifying states on February 27, 2005.
The purpose of the treaty is to fight the devastating health and economic effects of tobacco on a global
scale by requiring parties to adopt a comprehensive range of tobacco control measures. It features
specific provisions to control both the global supply of and demand for tobacco, including the regulation
of tobacco product contents, packaging, labeling, advertising, promotion, sponsorship, taxation, illicit
trade, youth access, exposure to secondhand tobacco smoke, and environmental and agricultural
impacts. Parties to the treaty are expected to strengthen national legislation, enact effective domestic
tobacco control policies, and cooperate internationally to reduce global tobacco consumption. A
number of major tobacco-producing nations, including Argentina, Indonesia, Malawi, and the United
States, have not ratified the treaty.
• As of November 2015, 180 out of 196 eligible parties have ratified or acceded to the treaty,
representing approximately 89% of the world’s population.
• About one-third of the world’s population was covered by at least one comprehensive tobacco control
measure in 2014, up from about 15% in 2008.
• The WHO estimates that 18% of the world’s population lives in smoke-free environments.
• Although tobacco excise tax increases are among the most cost-effective tobacco control strategies,
only 10% of the world population is covered by comprehensive tobacco tax policy.
The Role of the American Cancer Society
With more than a century of experience in cancer control, the American Cancer Society is uniquely
positioned to help in leading the global fight against cancer and tobacco by assisting and empowering
the world’s cancer societies and anti-tobacco advocates. The Society’s Global Cancer Control and
Intramural Research departments are raising awareness about the growing global cancer burden and
promoting evidence-based cancer and tobacco control programs.
The Society works to reduce the global burden of cancer by preventing cancer, saving lives, diminishing
suffering, catalyzing local responses, and shaping the global policy agenda. Our efforts focus on low- and
middle-income countries.
Make cancer control a political and public health priority. Noncommunicable diseases (NCDs) such as
cancer, heart disease, and diabetes account for about 65% of the world’s deaths. Although 67% of these
deaths occur in low- and middle-income countries, less than 3% of private and public health funding is
allocated to prevent and control NCDs in these areas. In September 2011, world leaders gathered at a
special United Nations High-level Meeting and adopted a Political Declaration that elevates cancer and
other NCDs on the global health and development agenda and includes key commitments to address
these diseases. In 2012, the decision-making body of the World Health Organization (WHO) approved a
resolution calling for a 25% reduction in premature deaths from NCDs by 2025 (also known as 25 by 25).
This ambitious goal set the stage for the adoption of a comprehensive framework aimed at monitoring
NCD risk factors (e.g., smoking prevalence) and indicators of increased access to breast and cervical
cancer screening, palliative care, and vaccination coverage. At a United Nations summit in September
2015, government leaders formally adopted the Sustainable Development Goals, including a stand-alone
target on NCDs and a number of NCD-related targets. This is the first time that NCDs have been included
in these goals as a priority for all countries. To maintain the momentum for making cancer and other
NCDs a global priority, the Society collaborates with key partners, including the NCD Alliance, the Union
for International Cancer Control, the WHO’s International Agency for Research on Cancer, the NCD
Roundtable, and the Taskforce on Women and Non-Communicable Diseases. Last year (2015) was also a
critical time for making women’s cancers a global health and development priority. Cervical and breast
cancers are the most commonly diagnosed cancers among women in most areas of the world. Focusing
on fighting these cancers is a priority for the American Cancer Society, not only because they affect so
many women, but also because cost-effective and proven prevention, screening, and treatment options
exist. To strengthen the case for greater investments in cervical cancer prevention and control, the
Society commissioned Harvard University’s T.H. Chan School of Public Health to estimate the cost of
achieving comprehensive global cervical cancer prevention over the next decade in low- and middleincome
countries. The study found that scaling up comprehensive prevention steadily from 2015 through 2024
would cost $18.3 billion ($8.6 billion for vaccination and $9.7 billion for screening) and that 480 million
women would be screened and 290 million girls would be vaccinated. Develop cancer control capacity
globally. Many governments in low- and middle-income countries are ill-prepared to adequately address
the increasing burden of cancer. In many cases, civil society actors (nongovernmental organizations,
institutions, and individuals) are also not yet fully engaged in cancer control efforts.
The Society’s Global Capacity Development program is intended to strengthen the civil society response
to cancer in focus countries around the world, taking advantage of more than 100 years of institutional
experience and expertise in cancer control. This program provides intensive and culturally appropriate
NSG 780Final Page 58
experience and expertise in cancer control. This program provides intensive and culturally appropriate
technical assistance to targeted organizations in low- and middle-income countries. The program’s areas
of intervention include the basic elements of organizational capacity development, such as governance,
financial management, fundraising, program design and management, and monitoring and evaluation.
Make effective pain treatment available to all in need. Untreated moderate to severe pain, which is
experienced by about 80% of people with advanced cancer, is a consistent feature of cancer care in
resource-limited settings. Improved
access to essential pain medicines is arguably the easiest and least expensive need to meet, would do
the most to relieve suffering, and may also extend survival, according to recent data. The Society has
projects in Nigeria, Ethiopia, Kenya, Uganda, and Swaziland to improve access to essential pain
medicines. In Nigeria, the Society collaborated with the government to make morphine available for the
first time in several years and set up a local production system in 27 teaching hospitals that lowered the
price for patients by 80% to 90%. The Society continues to support the national morphine production
facility in Uganda, which has been operating since 2010, and is supporting Kenya to replicate the model
in the national hospital in Nairobi. The Society is also training health workers in more than 25 teaching
and referral hospitals across the 5 countries through the Pain-Free Hospital Initiative, a 1-year hospitalwide quality improvement initiative designed to change clinical practice by integrating effective, highquality pain treatment into hospital-based services.
Increase awareness about the global cancer burden. The Society continues to work with global
collaborators to increase
awareness about the growing global cancer and tobacco burdens and their impact on low- and middleincome countries. In addition to print publications, the Society website, cancer.org, provides cancer
information to millions of individuals throughout the world. In 2014, 40% of visits to the website came
from outside the US. Information is currently available in English, Spanish, Chinese, Bengali, Hindi,
Korean, Urdu, and Vietnamese.
MMWR Center for Disease Control and Prevention
Potentially Preventable Deaths from the Five Leading Causes of Death — United States, 2008–2010
Mental Health By the Numbers
Millions of Americans are affected by mental health conditions every year. Here are
some facts about the prevalence and impact of mental illness.
- See more at: http://www.nami.org/Learn-More/Mental-Health-By-theNumbers#sthash.GQXlOkeG.dpuf
From <http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers>
Prevalence of Mental Illness
• Approximately 1 in 5 adults in the U.S.—43.8 million, or 18.5%—experiences mental
illness in a given year.1
• Approximately 1 in 25 adults in the U.S.—9.8 million, or 4.0%—experiences a serious
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mental illness in a given year that substantially interferes with or limits one or more major
life activities.2
Approximately 1 in 5 youth aged 13–18 (21.4%) experiences a severe mental disorder
at some point during their life. For children aged 8–15, the estimate is 13%.3
1.1% of adults in the U.S. live with schizophrenia. 4
2.6% of adults in the U.S. live with bipolar disorder. 5
6.9% of adults in the U.S.—16 million—had at least one major depressive episode in
the past year.6
18.1% of adults in the U.S. experienced an anxiety disorder such as posttraumatic
stress disorder, obsessive-compulsive disorder and specific phobias. 7
Among the 20.2 million adults in the U.S. who experienced a substance use
disorder, 50.5%—10.2 million adults—had a co-occurring mental illness.8
Social Stats
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Social Stats
• An estimated 26% of homeless adults staying in shelters live with serious mental
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illness and an estimated 46% live with severe mental illness and/or substance use
disorders.9
Approximately 20% of state prisoners and 21% of local jail prisoners have “a
recent history” of a mental health condition.10
70% of youth in juvenile justice systems have at least one mental health condition
and at least 20% live with a serious mental illness. 11
Only 41% of adults in the U.S. with a mental health condition received mental
health services in the past year. Among adults with a serious mental illness, 62.9%
received mental health services in the past year. 8
Just over half (50.6%) of children aged 8-15 received mental health services in the
previous year.12
African Americans and Hispanic Americans used mental health services at about
one-half the rate of Caucasian Americans in the past year and Asian Americans at
about one-third the rate.13
Half of all chronic mental illness begins by age 14; three-quarters by age 24.
Despite effective treatment, there are long delays—sometimes decades—between
the first appearance of symptoms and when people get help. 14
Consequences of Lack of Treatment
• Serious mental illness costs America $193.2 billion in lost earnings per year. 15
• Mood disorders, including major depression, dysthymic disorder and bipolar
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disorder, are the third most common cause of hospitalization in the U.S. for both
youth and adults aged 18–44.16
Individuals living with serious mental illness face an increased risk of having
chronic medical conditions.17 Adults in the U.S. living with serious mental illness
die on average 25 years earlier than others, largely due to treatable medical
conditions.18
Over one-third (37%) of students with a mental health condition age 14–21 and
older who are served by special education drop out—the highest dropout rate of any
disability group.19
Suicide is the 10th leading cause of death in the U.S., 20 the 3rd leading cause of
death for people aged 10–2421 and the 2nd leading cause of death for people aged
15–24.22
More than 90% of children who die by suicide have a mental health condition. 23
Each day an estimated 18-22 veterans die by suicide. 24
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- See more at: http://www.nami.org/Learn-More/Mental-Health-By-theNumbers#sthash.GQXlOkeG.dpuf
Mental Health Facts Children and Teens
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Mental Health in America
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Mental Health Facts Multicultural
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Risk and Protective Factors
Assessing the risk and protective factors that contribute to substance use disorders helps practitioners select
appropriate interventions.
Many factors influence a person’s chance of developing a mental and/or substance use disorder. Effective
prevention focuses on reducing those risk factors, and strengthening protective factors, that are most closely
related to the problem being addressed. Applying the Strategic Prevention Framework (SPF) helps prevention
professionals identify factors having the greatest impact on their target population.
Risk factors are characteristics at the biological, psychological, family, community, or cultural level that
precede and are associated with a higher likelihood of negative outcomes.
Protective factors are characteristics associated with a lower likelihood of negative outcomes or that reduce
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related to the problem being addressed. Applying the Strategic Prevention Framework (SPF) helps prevention
professionals identify factors having the greatest impact on their target population.
Risk factors are characteristics at the biological, psychological, family, community, or cultural level that
precede and are associated with a higher likelihood of negative outcomes.
Protective factors are characteristics associated with a lower likelihood of negative outcomes or that reduce
a risk factor’s impact. Protective factors may be seen as positive countering events.
Some risk and protective factors are fixed: they don’t change over time. Other risk and protective factors are
considered variable and can change over time. Variable risk factors include income level, peer group, adverse
childhood experiences (ACEs), and employment status.
Individual-level risk factors may include a person’s genetic predisposition to addiction or exposure to alcohol
prenatally.
Individual-level protective factors might include positive self-image, self-control, or social competence.
Download the Shared Risk and Protective Factors diagram (JPG | 47 KB).
Key Features of Risk and Protective Factors
Prevention professionals should consider these key features of risk and protective factors when designing
and evaluating prevention interventions. Then, prioritize the risk and protective factors that most impact
your community.
Risk and Protective Factors Exist in Multiple Contexts
All people have biological and psychological characteristics that make them vulnerable to, or resilient in the
face of, potential behavioral health issues. Because people have relationships within their communities and
larger society, each person’s biological and psychological characteristics exist in multiple contexts. A variety
of risk and protective factors operate within each of these contexts. These factors also influence one another.
Targeting only one context when addressing a person’s risk or protective factors is unlikely to be successful,
because people don’t exist in isolation. For example:
• In relationships, risk factors include parents who use drugs and alcohol or who suffer from mental
illness, child abuse and maltreatment, and inadequate supervision. In this context, parental
involvement is an example of a protective factor.
• In communities, risk factors include neighborhood poverty and violence. Here, protective factors could
include the availability of faith-based resources and after-school activities.
• In society, risk factors can include norms and laws favorable to substance use, as well as racism and a
lack of economic opportunity. Protective factors in this context would include hate crime laws or
policies limiting the availability of alcohol.
Risk and Protective Factors Are Correlated and Cumulative
Risk factors tend to be positively correlated with one another and negatively correlated to protective factors.
In other words, people with some risk factors have a greater chance of experiencing even more risk factors,
and they are less likely to have protective factors.
Risk and protective factors also tend to have a cumulative effect on the development—or reduced
development—of behavioral health issues. Young people with multiple risk factors have a greater likelihood
of developing a condition that impacts their physical or mental health; young people with multiple protective
factors are at a reduced risk.
These correlations underscore the importance of:
• Early intervention
• Interventions that target multiple, not single, factors
Individual Factors Can Be Associated With Multiple Outcomes
Though preventive interventions are often designed to produce a single outcome, both risk and protective
factors can be associated with multiple outcomes. For example, negative life events are associated with
substance use as well as anxiety, depression, and other behavioral health issues. Prevention efforts targeting
a set of risk or protective factors have the potential to produce positive effects in multiple areas.
Risk and Protective Factors Are Influential Over Time
Risk and protective factors can have influence throughout a person’s entire lifespan. For example, risk factors
such as poverty and family dysfunction can contribute to the development of mental and/or substance use
disorders later in life. Risk and protective factors within one particular context—such as the family—may also
influence or be influenced by factors in another context. Effective parenting has been shown to mediate the
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Risk and protective factors can have influence throughout a person’s entire lifespan. For example, risk factors
such as poverty and family dysfunction can contribute to the development of mental and/or substance use
disorders later in life. Risk and protective factors within one particular context—such as the family—may also
influence or be influenced by factors in another context. Effective parenting has been shown to mediate the
effects of multiple risk factors, including poverty, divorce, parental bereavement, and parental mental illness.
The more we understand how risk and protective factors interact, the better prepared we will be to develop
appropriate interventions.
Universal, Selective, and Indicated Prevention Interventions
Not all people or populations are at the same risk of developing behavioral health problems. Prevention
interventions are most effective when they are matched to their target population’s level of risk. Prevention
interventions fall into three broad categories:
• Universal preventive interventions take the broadest approach and are designed to reach entire
groups or populations. Universal prevention interventions might target schools, whole communities, or
workplaces.
• Selective interventions target biological, psychological, or social risk factors that are more prominent
among high-risk groups than among the wider population. Examples include prevention education for
immigrant families with young children or peer support groups for adults with a family history
of substance use disorders.
• Indicated preventive interventions target individuals who show signs of being at risk for a substance
use disorder. These types of interventions include referral to support services for young adults who
violate drug policies or screening and consultation for families of older adults admitted to hospitals
with potential alcohol-related injuries.
From <https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/risk-protective-factors>
Mental and Substance Use Disorders
Learn about the most common mental and substance use disorders and how SAMHSA works to reduce their
impact on America’s communities.
Overview
Mental and substance use disorders affect people from all walks of life and all age groups. These illnesses are
common, recurrent, and often serious, but they are treatable and many people do recover. Learning about
some of the most common mental and substance use disorders can help people recognize their signs and to
seek help.
According to SAMHSA’s 2014 National Survey on Drug Use and Health (NSDUH) (PDF | 3.4 MB) an estimated
43.6 million (18.1%) Americans ages 18 and up experienced some form of mental illness. In the past year,
20.2 million adults (8.4%) had a substance use disorder. Of these, 7.9 million people had both a mental
disorder and substance use disorder, also known as co-occurring mental and substance use disorders.
Various mental and substance use disorders have prevalence rates that differ by gender, age, race, and
ethnicity. To read more about this, visit the Specific Populations and Health Disparities topics, and to find
SAMHSA data that can be sorted on various factors, visit the NSDUH page.
SAMHSA’s mission is to reduce the impact of mental and substance use disorders on America’s communities.
SAMHSA works to prevent and treat mental and substance use disorders and provide supports for people
seeking or already in recovery.
Mental Disorders
Mental disorders involve changes in thinking, mood, and/or behavior. These disorders can affect how we
relate to others and make choices. Mental disorders take many different forms, with some rooted in deep
levels of anxiety, extreme changes in mood, or reduced ability to focus or behave appropriately. Others
involve unwanted, intrusive thoughts and some may result in auditory and visual hallucinations or false
beliefs about basic aspects of reality. Reaching a level that can be formally diagnosed often depends on a
reduction in a person’s ability to function as a result of the disorder.
Anxiety disorders are the most common type of mental disorders, followed by depressive disorders. Different
mental disorders are more likely to begin and occur at different stages in life and are thus more prevalent in
certain age groups. Lifetime anxiety disorders generally have the earliest age of first onset, most commonly
around age 6. Other disorders emerge in childhood, approximately 11% of children 4 to 17 years of age (6.4
million) have been diagnosed with attention deficit hyperactivity disorder (ADHD) as of 2011. Schizophrenia
spectrum and psychotic disorders emerge later in life, usually in early adulthood. Not all mental health issues
first experienced during childhood or adolescence continue into adulthood, and not all mental health issues
are first experienced before adulthood. Mental disorders can occur once, reoccur intermittently, or be more
chronic in nature. Mental disorders frequently co-occur with each other and with substance use disorders.
Because of this and because of variation in symptoms even within one type of disorder, individual situations
and symptoms are extremely varied.
Serious Mental Illness
Serious mental illness among people ages 18 and older is defined at the federal level as having, at any time
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Because of this and because of variation in symptoms even within one type of disorder, individual situations
and symptoms are extremely varied.
Serious Mental Illness
Serious mental illness among people ages 18 and older is defined at the federal level as having, at any time
during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional
impairment that substantially interferes with or limits one or more major life activities. Serious mental
illnesses include major depression, schizophrenia, and bipolar disorder, and other mental disorders that
cause serious impairment. In 2014, there were an estimated 9.8 million adults (4.1%) ages 18 and up with a
serious mental illness in the past year. People with serious mental illness are more likely to be unemployed,
arrested, and/or face inadequate housing compared to those without mental illness.
Serious Emotional Disturbance
The term serious emotional disturbance (SED) is used to refer to children and youth who have had a
diagnosable mental, behavioral, or emotional disorder in the past year, which resulted in functional
impairment that substantially interferes with or limits the child’s role or functioning in family, school, or
community activities. A Centers for Disease Control and Prevention (CDC) review of population-level
information found that estimates of the number of children with a mental disorder range from 13 to 20%, but
current national surveys do not have an indicator of SED.
Learn more about the most common mental disorders in the United States.
Learn more about mental health treatment at the Behavioral Health Treatments and Services topic.
Substance Use Disorders
Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically significant
impairment, including health problems, disability, and failure to meet major responsibilities at work, school,
or home.
In 2014, about 21.5 million Americans ages 12 and older (8.1%) were classified with a substance use disorder
in the past year. Of those, 2.6 million had problems with both alcohol and drugs, 4.5 million had problems
with drugs but not alcohol, and 14.4 million had problems with alcohol only.
Learn more about most common substance use disorders in the United States.
Co-occurring Mental and Substance Use Disorders
The coexistence of both a mental health and a substance use disorder is referred to as co-occurring disorders.
According to SAMHSA’s 2014 National Survey on Drug Use and Health (NSDUH) (PDF | 3.4 MB),
approximately 7.9 million adults had co-occurring disorders in 2014. During the past year, for those adults
surveyed who experienced substance use disorders and any mental illness, rates were highest among adults
ages 26 to 49 (42.7%). For adults with past-year serious mental illness and co-occurring substance use
disorders, rates were highest among those ages 18 to 25 (35.3%) in 2014.
Learn more about co-occurring disorders and available treatment.
SAMHSA’s Efforts
SAMHSA strives to ensure that Americans can access effective prevention and treatment services for mental
and substance use issues, particularly for those with the most serious conditions. Recovery from these
disorders is a process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. SAMHSA offers a number of programs, initiatives, and
resources to help people recognize mental and/or substance use disorders and reach out for help. Explore
more about SAMHSA’s efforts in prevention, treatment, and recovery support.
RANKINGS
Mortality
Recall that the leading causes of death in the U.S. are heart disease, cancer, chronic lower
respiratory diseases, stroke and accidents (unintentional injuries), followed by Alzheimer’s
disease and diabetes. These are all heavily influenced by lifestyle risk factors.
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The CDC recently reported that 91,757 deaths from diseases of the heart, 84,443 from cancer,
28,831 from chronic respiratory diseases, 16,973 from cerebrovascular diseases and 36,836
from unintentional injuries could potentially be prevented each year.
Source: CDC MMWR May 2, 2014
Reducing premature mortality requires risk factor reduction, screening, early intervention and
successful treatment of the disease or injury. Recall that many of the risk factors are the same
for several of the leading causes of death.
For more information on potentially preventable leading causes of death in the U.S., review the
required reading available at http://www.cdc.gov/mmwr/pdf/wk/mm6317.pdf
Morbidity
On the international level the World Health Organization identifies the leading causes of
disability, measured by disability-adjusted life years (DALYs), noting that back pain and
musculoskeletal disorders and major depressive and anxiety disorders have the greatest
influence on morbidity.
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From <https://cf.son.umaryland.edu/NRSG780/module10/subtopic1.htm>
CANCER -- MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
Cancer is the second leading cause of death in the United States. In 2016, about 595,690
people are expected to die from cancer, almost 1630 per day. The Agency for Healthcare
Research and Quality reports that direct medical costs for cancer hospitalization and outpatient
services on an annual basis is $74.8 billion. This does not include the $ cost due to lost
productivity from morbidity and premature mortality. Men have nearly a 1 in 2 chance of
developing cancer and women have a 1 in 3 chance of developing cancer. Cancer is caused by
both external factors such as tobacco, infectious organisms, radiation and chemical exposure
and internal factors such as inherited mutations, hormones, immune conditions and metabolic
mutations.
Source: http://www.cancer.org/acs/groups/content/
@research/documents/document/acspc-047079.pdf
How Information on Cancer Across the Nation Is Obtained
Medical facilities such as hospitals, doctor's offices, and pathology laboratories send information
about cancer cases to their cancer registry. Most information comes from hospitals, where
highly trained cancer registrars transfer the information from the patient's medical record to the
registry's computer software using standardized codes. The data on diagnosis, follow-up,
treatment and survival are then sent to a central cancer registry, a population-based resource
for examining cancer patterns. The first central cancer registry was established in Connecticut in
1935. Many states developed similar programs soon afterwards. However, it was not until
the National Program of Cancer Registries (NPCR) was established by Congress through
the Cancer Registries Amendment Act in 1992 that all states began collecting data on cancer
occurrence (type, extent, and location) and the type of initial treatment. The NPCR is
administered by CDC.
Together, CDC's NPCR and the National Cancer Institute's (NCI's) Surveillance,
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the National Program of Cancer Registries (NPCR) was established by Congress through
the Cancer Registries Amendment Act in 1992 that all states began collecting data on cancer
occurrence (type, extent, and location) and the type of initial treatment. The NPCR is
administered by CDC.
Together, CDC's NPCR and the National Cancer Institute's (NCI's) Surveillance,
Epidemiology and End Results (SEER) Program
collect incidence data for the entire U.S. population. CDC's National Center for Health
Statistics' National Vital Statistics System collects mortality data. This national coverage
enables researchers, clinicians, policy makers, public health professionals, and members of the
public to monitor the burden of cancer, evaluate the success of programs, and identify additional
needs for cancer prevention and control efforts at national, state, and more local levels.
Cancer registry data are used to:
• Monitor cancer trends over time
• Show cancer patterns in various populations and identify high-risk groups
• Guide planning and evaluation of cancer control programs
• Help set priorities for allocating health resources
• Advance clinical, epidemiologic and health services research.
Prevention
According to the National Cancer Institute, 80% of cancers are due to factors that have been
identified and can potentially be controlled. Not only can we potentially prevent most cancers,
we can also improve the survival rates of those people who have cancer.
A substantial proportion of cancers can be prevented through risk reduction strategies:
• Avoid Tobacco
○ Cigarette smoking
○ Cigar smoking
○ Smokeless tobacco
○ Secondhand smoke
Click here for more information on tobacco and review pages 43-47.
• Healthy Nutrition and Physical Activity
• Maintain a healthy weight
• Consume a healthy diet with emphasis on plant food
• Limit alcohol
• Adopt a physically active lifestyle
Click here for more information and review pages 47-49.
• Minimize Exposure to Environmental Cancer Risk
• Ultraviolet light
• Infectious agents including HPV, Hepatitis B and C and HIV
• Medical treatments
• Carcinogens that exist as pollutants
• Naturally occurring and occupational carcinogens
Click here to review NCI’s Cancer Prevention Overview Description of the Evidence
The number of new cancer cases can be reduced through minimizing risk exposure; many
cancer deaths can be prevented through early detection. Screening is becoming more
accessible for many cancers, and together with health education and referral services, plays a
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Click here to review NCI’s Cancer Prevention Overview Description of the Evidence
The number of new cancer cases can be reduced through minimizing risk exposure; many
cancer deaths can be prevented through early detection. Screening is becoming more
accessible for many cancers, and together with health education and referral services, plays a
key role in reduce cancer incidence and deaths. The Affordable Care Act eliminates deductibles
for many types of screening andCDC offers free or low-cost mammograms and Pap
tests nationwide and free or low-cost colorectal cancer screening - through 24 state health
departments, six universities and one American Indian tribe.
From <https://cf.son.umaryland.edu/NRSG780/module10/subtopic2.htm>
POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF CANCER
National
Since 1998, the CDC has been supporting partnerships across the U.S. to assess the burden of
cancer, determine priorities, and develop and implement cancer plans under the National
Comprehensive Cancer Control Program (NCCCP). Comprehensive control programs focus
on promoting healthy lifestyles and recommended cancer screenings, educate communities
about cancer symptoms, increase access to quality cancer care, and enhance survivors’ quality
of life.
To access a larger view of the figure above, click here.
Promote Health Equity As It Relates to Cancer Control (Priority 5)
 Partner with representatives of disparate populations  Identify and monitor health disparities 
Implement evidence-based interventions (EBIs) and promising practices to address disparities
Inputs (Grantee Resources)
 CCC National Partnership  CCC coalitions and chronic disease partners  Staffing  Funding  CDC
resources – CCC building blocks – Program evaluation and evaluation capacity building – Communication
and training – Public health translation research – Technical assistance  Evidence Base – Media,
Access, Point of decision information, Price, and Social support/services (MAPPS) – United States
Preventive Services Task Force – Agency for Healthcare Research and Quality – The Community Guide –
Morbidity and Mortality Weekly Report – Best practices for comprehensive tobacco control programs –
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and training – Public health translation research – Technical assistance  Evidence Base – Media,
Access, Point of decision information, Price, and Social support/services (MAPPS) – United States
Preventive Services Task Force – Agency for Healthcare Research and Quality – The Community Guide –
Morbidity and Mortality Weekly Report – Best practices for comprehensive tobacco control programs –
Cochrane reviews – National Cancer Institute Physician Data Query – Institute of Medicine reviews –
Research-tested intervention programs – PubMed and other systematic reviews – Individual peerreviewed published intervention
Grantee Activities with Outputs (Grantee Products)
 Manage CCC program and funding effectively  Dedicated staff with expertise needed to implement
CCC priorities  Implementation and coordination of communication plan  Responsiveness to CDC
fiscal and program reporting requirements  Number and types of trainings and technical assistance
participated in and offered to staff and partners
 Assess burden and conduct surveillance in collaboration with CDC's National Program of Cancer
Registries  Burden assessed; report completed and disseminated to partners  Burden report used
to develop, update, and revise plan
 Assemble, support, collaborate with, and sustain CCC coalition  Partnership assessment conducted
 Partnership recruitment and retention strategy in place  Partnership uses expertise of members to
facilitate change around the CCC priorities  Active participation; shared and leveraged resources
 Create and implement CCC plans using EBIs and promising practices, focusing on CCC priorities 1–4**
 Emphasize primary prevention  In collaboration with CDC's National Breast and Cervical Cancer
Early Detection Program and Colorectal Cancer Control Program, support screening provisions, service
delivery, and use of clinical preventive services, including patient navigation¶  Promote survivorship
as a model of chronic disease self management  Implement policy, systems, and environmental
changes
 Plan links to chronic programs and address NCCCP priorities  Number and types of EBIs; reach, and
adoption  Policy agenda drafted and activated
Short-Term Outcomes
 Policy changes  New or enhanced prevention policies (tobacco, alcohol, tanning)  Improved
reimbursement and health plan coverage
 Community changes  Increased environmental supports for prevention  New or enhanced
school, worksite, adult and child care policies to support cancer prevention and screening activities 
Increased evidence-based lifestyle and survivorship programs
 Health care system changes  Improved community linkages  Increased self-management
support through survivorship model  Improved systems to support quality screening  Increased
patient navigation and case management services
 Provider changes  Improved knowledge and attitudes about clinical preventive and cancer care
guidelines
 Individual changes  Improved knowledge and attitudes about cancer prevention and screening
Intermediate Outcomes
 Improved access to care and evidence-based lifestyle and survivorship support systems to increase
healthy living and enhance quality of life for survivors  Increased use of evidence-based lifestyle
programs, clinical preventive services, cancer care, and survivorship  Improved delivery of clinical
preventive services and cancer care
Long-Term Outcomes
 Risk reduction: Decreased tobacco, alcohol use, and exposure to ultraviolet radiation; increased
human papillomavirus and Hepatitis B virus vaccination and physical activity; improved diet  Increased
early detection  Improved survivorship practices
Impact
 Prevent cancer and recurrence  Decreased cancer incidence  Increased quality of life  Reduced
disparities  Decreased morbidity  Reduced costs associated with cancer  Decreased mortality
Demonstrate Outcomes Through Evaluation to Improve Programs (Priority 6)
 Evaluation plans developed and implemented  Rigorous evaluation of promising practices
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The CDC has developed a tool kit for planning and promoting cancer prevention initiatives for
the community. Explore this resource to learn more about:
• Understanding a community’s needs
• Planning a community outreach strategy
• Building community partnerships
• Evaluating efforts
• Resources available
Maryland's overall cancer mortality rate ranks 29th in the nation. .Over 27,000 new cases of
invasive cancer are diagnosed each year and over 10,000 Marylanders die from cancer each
year. The most commonly diagnosed cancers are breast, prostate, lung and bronchus and
colon and rectum cancers. Lung cancer is the leading cause of cancer mortality followed by
colorectal, breast, pancreatic and prostate. Maryland’s Comprehensive Cancer Control
Plan serves as a guide for planning, directing and implementing, evaluating or conducting
cancer control research. It identifies 3 goals and objectives to:
1. Increase cancer prevention behaviors in priority areas
○ Tobacco use and exposure
○ Healthy weight, nutrition and physical activity
○ Alcohol consumption
○ Cancer vaccines
○ Ultraviolet radiation exposure
2. Minimize exposure to known environmental and occupational hazards
○ Develop and publish an on-line state strategy to reduce radon exposure
○ Improve availability and public access to information about environmental and
occupational exposures
3. Increase quality of life for cancer survivors targeting
○ Reduction in days when poor physical or mental health prevent usual activities of
daily living
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occupational exposures
3. Increase quality of life for cancer survivors targeting
○ Reduction in days when poor physical or mental health prevent usual activities of
daily living
○ Improvement in pain management
○ Written summaries by providers of treatments received, follow-up treatment and
check-ups after completing treatment
○ Access to palliative care services by maintaining Maryland’s “A’ grade on the Center
to Advance Palliative Report Card
○ Collection of data on hospice utilization and average length of stay
For more information, review the 2016-2020 Cancer Control Plan available
at http://phpa.dhmh.maryland.gov/cancer/cancerplan/Documents/
MD%20Cancer%20Program_508C%20with%20cover.pdf
N.B. The plan is also an excellent example for developing goals and objectives and strategies
that can be useful for part 2 of your paper.
MENTAL HEALTH AND MENTAL DISORDERS—MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
The burden of mental illness in the U.S. is among the highest of all diseases and mental
disorders are among the most common causes of disability. In 2014, the National Institute of
Mental Health reported an estimated 43.6 million adults aged 18 and older, or 18.1% of the
population, with any mental illness (AMI) defined as a mental, behavioral or emotional disorder
(excluding developmental and substance use disorders) diagnosed within the past year. An
estimated 4.2%, or 9.6 million, of these adults are diagnosed with serious mental disability
(SMI) resulting in significant functional impairment which substantially interferes with or limits
one or more major life activities. Serious mental illness is associated with an estimated total
economic cost of $317 billion per year. An additional -20.2million or 8.4 % of the adult
population have a substance use disorder and 7.9 million of these adults have both a mental
disorder and a substance use disorder, defined as co-occurring disorders.
Sources:
http://www.samhsa.gov/disorders
http://www.nimh.nih.gov/health/statistics/prevalence/index.shtml
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Mental disorders are common among children in the U.S. as well. Approximately 20% of
children experience a seriously debilitating mental disorder. The following graphs show the
lifetime prevalence of a mental health disorder for 13 to 18 year olds. It also shows that
prevalence is equal for both genders, but does differ between various age groups for
adolescents.
Mental health disorders are associated with the prevalence, progression and outcome of many
of the leading causes of death. Mental illnesses, such as depression and anxiety, affect the
ability to participate in health-promoting behaviors. Physical health problems can have a serious
impact on mental health and influence the ability to participate in treatment and recovery.
Individuals with untreated mental health disorders are at high risk for unhealthy and unsafe
behaviors, including alcohol or drug abuse, violent or self-destructive behavior, and suicide.
Adults with serious mental illness die on average 25 years earlier.
Treatment
Treatment for mental illness and substance use disorders is far from ideal. Approximately 60%
of adults and 50% of children with mental illness received no mental health services in the
previous year.
Source: http://www.nami.org/NAMI/media/NAMI-Media/Infographics/GeneralMHFacts.pdf
SAMHSA’s Behavioral Health Barometer provides an overview of the issues for the state of
Maryland and the U. S. as a whole.
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Prevention
Many mental health disorders can be treated effectively and prevention of mental health
disorders is a growing area of research and practice. Early diagnosis and treatment can
decrease the disease burden of mental health disorders as well as associated chronic diseases.
The existing model for understanding mental health and mental disorders emphasizes the
interaction of social, environmental, and genetic factors throughout the lifespan. It focuses on
risk factors which predispose individuals to mental illness and protective factors which
reduce the risk of developing mental disorders at four levels: self, family, community and
society.
Individual-level risk factors include genetic predisposition to addiction or exposure to alcohol
prenatally, academic failure and scholastic demoralization, attention deficits, caring for
chronically ill or dementia patients, child abuse and neglect, chronic insomnia, chronic pain,
early pregnancies, elder abuse, emotional immaturity and dyscontrol, substance abuse,
loneliness; poor work skills and habits, reading, sensory or functional disabilities, social
incompetence and stressful life events
Individual-level protective factors can include positive self-image, self-control, social
competence, ability to face adversity, autonomy, exercise, feelings of security, mastery and
control, literacy, problem solving skills, self-esteem, conflict management skills, resiliency,
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incompetence and stressful life events
Individual-level protective factors can include positive self-image, self-control, social
competence, ability to face adversity, autonomy, exercise, feelings of security, mastery and
control, literacy, problem solving skills, self-esteem, conflict management skills, resiliency,
socioemotional growth and stress management
Family-level risk factors include parents who use drugs and alcohol or who suffer from mental
illness, child abuse and maltreatment and inadequate supervision, family conflict or
disorganization
Family-level protective factors would be parental involvement, positive attachment and early
bonding, social support of family and friends
Community-level risk factors include access to drugs and alcohol, displacement, isolation and
alienation, lack of education, transport, housing; neighborhood disorganization, peer rejection,
poverty, violence, poor nutrition, work stress and unemployment
Community-level protective factors might include the availability of faith-based resources and
after-school activities, empowerment, positive interpersonal interactions, social support and
community networks
Society-level risk factors can include norms and laws favorable to substance use, racial
injustice and discrimination, social disadvantage, lack of economic opportunity and war
Society-level protective factors include policies limiting availability of substances or anti-hate
laws, defending marginalized populations, social participation, social services, social
responsibility and tolerance
Source: http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders
_sr.pdf http://captus.samhsa.gov/prevention-practice/prevention-and-behavioralhealth/key-features-risk-protective-factors/1
In addition to advancements in the prevention of mental disorders, there continues to be steady
progress in treating mental disorders as new drugs and stronger evidence-based outcomes
become available.
POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF MENTAL HEALTH AND MENTAL
DISORDERS
National Planning Models
SAMHSA’s Strategic Prevention Framework (SPF) is a five step guide to the selection,
implementation and evaluation of evidence-based, culturally appropriate, sustainable
community-based behavioral health promotion and substance use prevention programs
The SPF includes these five steps:
• Step 1. Assess Needs
• Step 2. Build Capacity
• Step 3. Plan
• Step 4. Implement
• Step 5. Evaluation
Listen to this video to learn more about the implementation of the Strategic Planning
Framework.
SAMHSA’s Focus on Prevention is a national planning model for communities to move from
concerns about substance abuse to evidence-based solutions. A unique feature of this guide is
that it recognizes the different problems faced and the varying resources and experiences to
develop prevention programs.
The White House Office of National Drug Control Policy’s National Drug Control
Strategy focuses on a public health approach to substance use disorders and has committed
over $10 billion to this initiative.
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Strategy focuses on a public health approach to substance use disorders and has committed
over $10 billion to this initiative.
SAMHSA’s Screening, Brief Intervention and Referral to Treatment (SBIRT) is a public
health approach to the delivery of early intervention and treatment services for people with
substance use disorders and those at risk for developing those disorders that focuses on the
many different types of community settings that provide opportunities for early intervention with
at-risk substance users before more severe consequences occur.
Alcohol and drug abuse occur along a continuum in terms of level of consumption and
consequences as is noted in the treatment pyramid noted below. The pyramid has been
developed to show the role of SBIRT in addressing needs across the continuum of use. SBIRT
has three major components: screening, brief intervention and referral to treatment.
Statewide
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Source: http://bha.dhmh.maryland.gov/Documents/FY%202017%20State%20Behavioral%
20Health%20Plan-Final.pdf
The Maryland Department of Health and Mental Hygiene’s (DHMH) Behavioral Health
Administration is in the process of developing an integrated process for planning, policy and
services that will provide a coordinated system of care to residents with behavioral health
conditions. The core functions of the system include:
• Supporting coordinated services that will result in an integrated system of care
• Improving access, quality of services and recovery support through the continuum of care
• Strengthening infrastructure to enhance capacity to collect, analyze and track data to
improve outcomes
• Developing and implementing public awareness activities and population-based initiatives
to promote wellness and ensure safety of people in care, their families and communities
DHMH’s planning goals align with SAMSHA’s strategic initiatives and target mental illness,
substance-related and other addictive disorders. The goals are:
• Promote a system of integrated care to increase access, reduce disparities and support
coordinated care and services across systems
• Promote prevention and early intervention of behavioral health disorder across the lifespan
• Provide coordinated approaches to increase recovery supports
• Utilize data and health information technology to evaluate, monitor and improve the quality
of service delivery and outcomes
• Promote and integrated, aligned and competent workforce
• Work collaboratively to address trauma and justice in the community
• Increase public awareness and support for health and wellness
For more information review the Department of Health and Mental Hygiene Behavioral Health
Administration FY 2017 Behavioral Health Plan available
athttp://bha.dhmh.maryland.gov/Documents/FY%202017%20State%20Behavioral%
20Health%20Plan-Final.pdf
Applying the Strategic Prevention Framework
(SPF)
Prevention professionals use SAMHSA’s Strategic Prevention Framework (SPF) as a comprehensive guide to
plan, implement, and evaluate prevention problems.
About the SPF
SAMHSA’s Strategic Prevention Framework (SPF) is a planning process for preventing substance use and
misuse.
The five steps and two guiding principles of the SPF offer prevention professionals a comprehensive process
for addressing the substance misuse and related behavioral health problems facing their communities. The
effectiveness of the SPF begins with a clear understanding of community needs and involves community
members in all stages of the planning process.
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Download the Strategic Prevention Framework
image (JPG | 65 KB).
The steps of the SPF include:
• Step 1: Assess Needs: What is the problem, and how can I learn more?
• Step 2: Build Capacity: What do I have to work with?
• Step 3: Plan: What should I do and how should I do it?
• Step 4: Implement: How can I put my plan into action?
• Step 5: Evaluate: Is my plan succeeding?
The SPF also includes two guiding principles:
• Cultural competence: The ability to interact effectively with members of diverse population
• Sustainability: The process of achieving and maintaining long-term results
Distinctive Features of the SPF
The SPF planning process has four distinctive features. The SPF is:
Data driven: Good decisions require data. The SPF is designed to help practitioners gather and use data to
guide all prevention decisions—from identifying which substance misuse issues problems to address in their
communities, to choosing the most appropriate ways to address those problems. Data also helps
practitioners determine whether communities are making progress in meeting their prevention needs.
Dynamic: Assessment is more than just a starting point. Practitioners will return to this step again and again:
as the prevention needs of their communities change, and as community capacity to address these needs
evolve. Communities may also engage in activities related to multiple steps simultaneously. For example,
practitioners may need to find and mobilize additional capacity to support implementation once an
intervention is underway. For these reasons, the SPF is a circular, rather than a linear, model.
Focused on population-level change: Earlier prevention models often measured success by looking at
individual program outcomes or changes among small groups. But effective prevention means implementing
multiple strategies that address the constellation of risk and protective factors associated with substance
misuse in a given community. In this way, we are more likely to create an environment that helps people
support healthy decision-making.
Intended to guide prevention efforts for people of all ages: Substance misuse prevention has traditionally
focused on adolescent use. The SPF challenges prevention professionals to look at substance misuse among
populations that are often overlooked but at significant risk, such as young adults ages 18 to 25 and adults
age 65 and older.
Reliant on a team approach: Each step of the SPF requires—and greatly benefits from—the participation of
diverse community partners. The individuals and institutions you involve will change as your initiative evolves
over time, but the need for prevention partners will remain constant.
Step 1: Assess Needs
Step 1 of the Strategic Prevention Framework (SPF) helps prevention professionals identify pressing
substance use and related problems and their contributing factors, and assess community resources and
readiness to address these factors.
In Step 1 of SAMHSA’s Strategic Prevention Framework (SPF), prevention professionals gather and assess
data from a variety of sources to ensure that substance misuse prevention efforts are appropriate and
targeted to the needs of communities.
Data help practitioners identify and prioritize the substance use problems present in their community, clarify
the impact of these problems on community members, identify the specific factors that contribute to these
problems, and assess the readiness and resources needed to address these factors.
Engaging key stakeholders in all aspects of the assessment process will help ensure their buy-in and support
the sustainability of your prevention initiatives. Share your assessment findings with them and other
community members. The better they understand community needs, the more likely they will be to
participate in—and sustain—prevention outcomes.
Problems and Related Behaviors
You can use the following questions to assess the substance use problems and related behaviors in your
community:
• What substance use problems (for example, overdoses and alcohol poisoning) and related behaviors
(for example, prescription drug misuse and underage drinking) are occurring in your community?
• How often are these problems and related behaviors occurring?
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community:
• What substance use problems (for example, overdoses and alcohol poisoning) and related behaviors
(for example, prescription drug misuse and underage drinking) are occurring in your community?
• How often are these problems and related behaviors occurring?
• Where are these substance use problems and related behaviors occurring (for example, at home or in
vacant lots; in small groups or during big parties)?
• Who is experiencing more of these substance use issues and related behaviors? For example, are they
males, females, youth, adults, or members of certain cultural groups?
This information can help you identify—and determine how to most effectively address—your community’s
priority substance use problems(s). To answer these four assessment questions, you will need to do the
following:
• Take stock of existing data: Start by looking for state and local data already collected by others, such
as hospitals, law enforcement agencies, community organizations, state agencies, and epidemiological
workgroups.
• Look closely at your existing data: Examine the quality of the data that you’ve found, discard the data
that are not useful, and create an inventory of the data you feel confident about including in your
assessment.
• Identify any data gaps: Examine your inventory of existing data and determine whether you are
missing any information. This could include information about a particular problem, behavior, or
population group.
• Collect new data to fill those gaps: If you are missing information, determine which data collection
method—or combination of methods—represents the best way to obtain that information. Data
collection methods include surveys, focus groups, and key informant interviews. See finding
epidemiological data for more information.
Data may reveal that the community has multiple areas of need that are contributing to substance misuse.
You will want to establish criteria for analyzing assessment data to guide your decision on which substance
use problem(s) to make your priority.
Assessing Risk and Protective Factors
Prevention practitioners have long targeted risk and protective factors as the “influencers” of behavioral
health problems. After selecting one or more prevention priorities, practitioners need to assess the factors
that are driving or alleviating these problems. Targeting appropriate factors is key to producing real and
lasting change.
As the names suggests, risk factors increase the chance that certain problems will occur, while protective
factors reduce the likelihood of these problems occurring. Identifying which risk and protective factors exist
in a community can reveal opportunities to influence substance use patterns and behaviors. To be effective,
prevention strategies must address the underlying factors driving these patterns and behaviors. It doesn’t
matter how carefully a program or intervention is implemented. If it’s not a good match for the problem, it’s
not going to work.
Also, remember that the factors driving an issue in one community may differ from the factors driving it in
another community. Because every community is unique, it is important to determine which factors are
contributing to substance use and related problems in your community, and address those.
Learn more about risk and protective factors.
Learn more about prioritizing risk and protective factors.
Assessing Resources and Readiness
Assessing a community’s capacity to address substance misuse is a key part of the prevention planning
process. Understanding local capacity, including resources and readiness for prevention, can help you:
• Make realistic decisions about which prevention needs your community is prepared to address
• Identify resources you are likely to need, but don’t currently have, to address identified prevention
needs
• Develop a clear plan for building capacity (SPF Step 2) to address identified prevention needs
Assessing community readiness, in particular, helps prevention professionals determine whether the time is
right and whether there is social momentum towards addressing the issue or issues they hope to tackle.
Community readiness is just as important in addressing community needs as having tangible resources in
place.
Step 2: Build Capacity
Step 2 of the Strategic Prevention Framework (SPF) helps prevention professionals identify resources and
build readiness to address substance use and misuse.
The second step of the SPF involves building and mobilizing local resources and readiness to address
identified prevention needs. A community needs both human and structural resources to establish and
maintain a prevention system that can respond effectively to local problems. It also needs people who have
the motivation and willingness—that is, the readiness—to commit local resources to address identified
prevention needs.
Why? Because prevention programs and interventions that are well-supported with adequate resources and
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maintain a prevention system that can respond effectively to local problems. It also needs people who have
the motivation and willingness—that is, the readiness—to commit local resources to address identified
prevention needs.
Why? Because prevention programs and interventions that are well-supported with adequate resources and
readiness are more likely to succeed.
Learn more about resources and readiness.
Key Components of Capacity Building
Raise Stakeholder Awareness
There are two benefits to raising awareness of a community’s substance use problem(s). First, it can help you
increase local readiness for prevention: people need to be aware of a problem before stepping forward to
address it. Raising awareness can also help you garner the valuable resources needed to move your
prevention efforts forward.
The following are some strategies for raising community awareness:
• Meet one‐on‐one with public opinion leaders
• Ask stakeholders to share information in their own sectors
• Submit articles to local newspapers, church bulletins, club newsletters, etc.
• Share information on relevant websites and social media outlets
• Host community events to share information about and discuss the problem
• Convene focus groups to get input on prevention plans
It’s always helpful to think “outside the box” when looking for new ways to raise community awareness. For
example, the local high school may have a media club that may be willing to create a video about your
prevention efforts. Which individuals and groups in your community could help you reach out, spread the
word, and get others involved?
Engage Diverse Stakeholders
Engaging a broad range of stakeholders is key to unlocking a community’s capacity for prevention. Effective
prevention depends on the involvement of diverse partners—from residents to service providers to
community leaders. These people can help you share prevention information and resources, raise awareness
of critical substance use problems, build support for prevention efforts, and ensure that prevention activities
are appropriate for the populations they serve.
Build relationships with those who support your prevention efforts as well as with those who do not.
Recognize that potential community partners will have varying levels of interest and/or availability to get
involved. One person may be willing to help out with a specific task, while another may be willing to assume
a leadership role. Keep in mind that as people come to understand the importance of your prevention
efforts, they are likely to become more engaged.
Consider involving the following community sectors in your prevention initiative:
• Local businesses
• Law enforcement
• University and research institutions
• Healthcare providers
• Neighborhood and cultural associations
• Local government
• Youth‐serving agencies and institutions
Strengthen Collaborative Efforts
Substance use and misuse are complex problems that require the energy, expertise, and experience of
multiple players, working together across disciplines, to address. Collaboration can help you tap the
resources available in your community, extend the reach of your own resources by making them available to
new audiences, and ensure that your prevention efforts are culturally competent. By working in partnership
with community members and involving them in all aspects of prevention planning, implementation, and
evaluation, you demonstrate respect for the people you serve and increase your own capacity to provide
prevention services that meet genuine needs, build on strengths, and produce positive outcomes.
Partnering with others requires deliberate and strategic planning. You will want to be clear on the purpose of
the collaboration, determine how you plan to achieve that purpose, and establish clear roles and
responsibilities for all involved. Over time, you will also want to check in regularly with partners to ensure
that the relationship continues to meet their needs. Even those collaborative relationships that begin easily
and organically need to be nourished in order to stay healthy.
CAPT’s "Prevention Collaboration in Action toolkit(link is external) contains a wide selection of stories and
tools to help build prevention professionals’ capacity to initiate, strengthen, and maintain effective
collaborations to prevent substance misuse and improve health outcomes.
Prepare the Prevention Workforce
The success of any prevention effort depends on the knowledge and skills of the people at the
forefront. Workforce development is more than just preparing people to complete specific tasks. Ensuring
that prevention professionals and stakeholders have the right credentials, training, experience, cultural
competence, and expertise to address the substance use problem(s) in a community is an important
component of building capacity.
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The success of any prevention effort depends on the knowledge and skills of the people at the
forefront. Workforce development is more than just preparing people to complete specific tasks. Ensuring
that prevention professionals and stakeholders have the right credentials, training, experience, cultural
competence, and expertise to address the substance use problem(s) in a community is an important
component of building capacity.
CAPT’s Prevention Training Now! online training portal offers a variety of free online self-paced courses for
practitioners interested in planning, implementing, and evaluating effective efforts to prevent substance use
and misuse.
Step 3: Plan
Step 3 of the Strategic Prevention Framework (SPF) helps prevention professionals form a plan for addressing
priority problems and achieving prevention goals.
Strategic planning increases the effectiveness of prevention efforts by ensuring that prevention professionals
select and implement the most appropriate programs and strategies for their communities. To develop a
useful plan, practitioners need to:
• Prioritize risk and protective factors associated with identified prevention problems (see Step 1: Assess
Needs)
• Select effective interventions to address priority factors
• Build a logic model that links problems, factors, interventions, and outcomes
An effective prevention plan should reflect the input of key stakeholders, including community members.
Collaborative planning processes are more likely to address community needs and be sustained over time.
Prioritize Risk and Protective Factors
Every substance use problem is associated with multiple risk and protective factors. No community can
address all of these factors—at least not at once. During the planning phase, you will need to decide which
factors to address first. To prioritize factors, it’s helpful to consider their importance and changeability.
Importance describes how a specific risk or protective factor affects a problem. These questions can help you
determine a factor’s importance:
• How much does this factor contribute to our priority problem?
• Is this factor relevant, given the developmental stage of our focus population?
• Is this factor associated with other behavioral health issues?
Changeability describes a community’s capacity to influence a specific risk or protective factor. These
questions can help you determine a factor’s changeability:
• Do we have the resources and readiness to address this factor?
• Does a suitable intervention exist to address this factor?
• Can we produce outcomes within a reasonable timeframe?
When developing a prevention plan, it is best to prioritize risk and protective factors that are high for both
importance and changeability. If no factors are high for both, the next best option is to prioritize factors with
high importance and low changeability. Since factors with high importance contribute significantly to priority
substance use problems, addressing these factors is more likely to make a difference. And it’s easier to
increase the changeability of a factor (for example, by building capacity) than it is to increase its importance.
Select Effective Interventions
Sometimes people want to select interventions that are popular, that worked well in a different community,
or that they are familiar with. These are not good reasons for selecting an intervention. It is more important
that the prevention intervention effectively address the priority substance use problem and associated risk
and protective factors, and that the intervention is a good fit for the broader community. When choosing
appropriate prevention interventions, it is important to select programs and strategies that are:
• Evidence-based. Evidence-based interventions have documented evidence of effectiveness. The best
places to find evidence-based interventions are federal registries of model programs, such as
SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP), and peer-reviewed
journals, such as the American Journal of Public Health. It’s important to note, however, that these
sources are not exhaustive, and they may not include interventions appropriate for all problems
and/or all populations. In these cases, you must look to other credible sources of information. Since
states have different guidelines for what constitutes credible evidence of effectiveness, you could start
by talking to prevention experts—including your state-level evidence-based workgroup.
Learn more about defining which interventions are evidence-based.
• Good conceptual fit for the community. An intervention has good conceptual fit if it directly addresses
one or more of the priority factors driving a specific substance use problem and has been shown to
produce positive outcomes for members of the target population. To determine the conceptual fit, ask,
“Will this intervention have an impact on at least one of our community’s priority risk and protective
factors?”
• Good practical fit for the community. An intervention has good practical fit if it is culturally relevant
for the target population, the community has capacity to support it, and if it enhances or reinforces
existing prevention activities. To determine the practical fit of an intervention, ask, “Is this intervention
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factors?”
• Good practical fit for the community. An intervention has good practical fit if it is culturally relevant
for the target population, the community has capacity to support it, and if it enhances or reinforces
existing prevention activities. To determine the practical fit of an intervention, ask, “Is this intervention
appropriate for our community?”
Build a Logic Model
A logic model is a visual tool that shows the logic, or rationale, behind a program or process. Like a roadmap,
it tells you where you are, where you are going, and how you will get there. Prevention professionals use
logic models to show connections between:
• Problems identified by communities
• Specific risk and protective factors in a community that are influencing or contributing to those
problems
• Planned interventions
• The anticipated short- and long-term changes
Logic models can help you:
• Explain why your program or intervention will succeed. By clearly laying out the tasks of
development, implementation, and evaluation, a logic model can help you explain what you do and
why you do it.
• Identify gaps in reasoning. A logic models helps you identify any gaps in your reasoning or places
where your assumptions might be off track. The sooner mistakes are discovered, the easier they are to
correct.
• Make evaluation and reporting easier. Developing a logic model before implementing a program or
activity makes evaluation easier since it shows clear, explicit, and measurable intended outcomes.
Step 4: Implement
Step 4 of the Strategic Prevention Framework (SPF) helps prevention professionals deliver evidence-based
interventions.
During implementation, prevention professionals put their strategic prevention plans into action by
delivering their selected, evidence-based interventions. To implement programs and strategies effectively,
practitioners need to:
• Develop a clear action plan
• Balance fidelity and adaptation
• Establish implementation supports
Develop a Clear Action Plan
An action plan is a document that lays out exactly how you will implement a selected program, policy, or
strategy. It describes what you expect to accomplish, the specific steps you will take to get there, and who
will be responsible for doing what.
Work with your implementation partners—those individuals and organizations that will be responsible for or
involved in program delivery to develop your plan. Doing so will help to ensure that everyone is on the same
page and no key tasks fall through the cracks. In some cases, partners will want to make changes to the plan.
Even if they don’t, it’s important to communicate openly and make sure that all partners are onboard with
the implementation plan as you move forward.
Balance Fidelity and Adaptation
As you prepare to implement your selected prevention interventions, it is important to consider issues
of fidelity and adaptation:
• Fidelity describes the degree to which a program or practice is implemented as intended.
• Adaptation describes how much, and in what ways, a program or practice is changed to meet local
circumstances.
Evidence‐based programs are defined as such because they consistently achieve positive outcomes. The
greater your fidelity to the original program design, the more likely you are to reproduce these positive
results. Customizing a program to better reflect the attitudes, beliefs, experiences, and values of your focus
population can increase its cultural relevance. However, it’s important to keep in mind that such adaptations
may compromise program effectiveness.
Remaining faithful to the original evidence-based design while addressing the unique needs and
characteristics of your target audience requires balancing fidelity and adaptation. When you change an
intervention, you risk compromising outcomes. However, implementing a program that requires some
adaptation may be more efficient and cost-effective than designing a program from scratch.
Here are some guidelines to consider when balancing fidelity and adaptation:
• Retain core components: Evidence‐based programs are more likely to be effective when their core
components (that is, those elements responsible for producing positive outcomes) are maintained.
Core components are like the key ingredients in a cookie recipe. You may be able to omit the nuts, but
if you leave out the flour the recipe won’t work! Here are some general guidelines for maintaining core
components:
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•
•
•
•
•
•
•
components (that is, those elements responsible for producing positive outcomes) are maintained.
Core components are like the key ingredients in a cookie recipe. You may be able to omit the nuts, but
if you leave out the flour the recipe won’t work! Here are some general guidelines for maintaining core
components:
Preserve the setting as well as the number and length of sessions
Preserve key program content: It’s safer to add rather than subtract content
Add new content with care: Consider program guidance and prevention research
Build capacity before changing the program: Rather than change a program to fit with local
conditions, consider ways to develop the resources or build local readiness so you can deliver the
program as it was originally designed.
Add rather than subtract: Doing so will decrease the likelihood that you are eliminating a program
element that is important (that is, critical to program effectiveness).
Adapt with care. Even when interventions are selected with great care, there may be ways to improve
a program’s appropriateness for a unique focus population. Cultural adaptation refers to program
modifications that are tailored to the values, attitudes, beliefs, and experiences of the target audience.
To make an intervention more culturally appropriate, it is crucial to consider the language, values,
attitudes, beliefs, and experiences of focus population members. Learn more about cultural
competence.
If adapting, consult experts first: Experts can include the program developer, an environmental
strategies specialist, or your evaluator. They may be able to tell you how the intervention has been
adapted in the past and how well (or not) those adaptations worked. For cultural adaptations, you will
also want to consult with cultural leaders and members of your focus population.
Establish Implementation Supports
Many factors combine to influence the implementation and support the success of prevention interventions,
including the following:
• Favorable prevention history: An individual or organization with positive experiences implementing
prevention interventions in the past will likely be more ready, willing, and able to support the
implementation of a new intervention. If an individual or organization has had a negative experience
with—or doesn’t fully understand the potential of—a prevention intervention, then it will be important
to address these concerns early in the implementation process.
• Onsite leadership and administrative support: Prevention interventions assume many different forms
and are implemented in many different settings. To be effective, interventions require leadership and
support from key stakeholders.
• Practitioner selection: When selecting the best candidate to deliver a prevention intervention,
consider professional qualifications and experiences, practical skills, as well as fit with your focus
population.
• Practitioner training and support: Pre‐and in‐service trainings can help practitioners responsible for
implementing an intervention understand how and why the intervention works, practice new skills,
and receive constructive feedback. Since most skills are learned on the job, it is also very helpful to
connect these practitioners with a coach who can provide ongoing support.
• Program evaluation: By closely monitoring and evaluating the delivery of an intervention, practitioners
can make sure that it is being implemented as intended and improve it as needed. By assessing
program outcomes, they can determine whether the intervention is working as intended and worthy of
sustaining over time.
When prevention practitioners promote both fidelity and cultural relevance, and anticipate and support the
many factors that influence implementation, these efforts go a long way toward producing positive
outcomes. But to sustain these outcomes over time, it is important to get others involved and invested in the
prevention interventions. Find concrete and meaningful ways for people to get involved, keep cultural and
public opinion leaders well‐informed, and get the word out to the broader community through media and
other publicity efforts.
Step 5: Evaluate
The evaluation step of SAMHSA’s Strategic Prevention Framework (SPF) quantifies the challenges and
successes of implementing a prevention program.
Evaluation is the systematic collection and analysis of information about program activities, characteristics,
and outcomes. The evaluation step of the Strategic Prevention Framework (SPF) is not just about collecting
information, but using that information to improve the effectiveness of a prevention program. After
evaluation, planners may decide whether or not to continue the program.
Prevention practitioners need to evaluate how well the program was delivered and how successful it was in
achieving the expected outcomes. Once the program has been evaluated, prevention planners typically
report evaluation results to stakeholders, which can include community members and lawmakers.
Stakeholders can promote your program, increase public interest, and possibly help to secure additional
funding.
Learn more about:
• Evaluating process and outcomes
•
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Stakeholders can promote your program, increase public interest, and possibly help to secure additional
funding.
Learn more about:
• Evaluating process and outcomes
• Communicating evaluation results
Evaluation and the SPF
Prevention practitioners engage in a variety of evaluation-related activities, including identifying evaluation
expertise, designing evaluation plans, finding epidemiological data, and analyzing epidemiological data.
Evaluation is more than a final step. It should be a part of every aspect of the SPF, from assessing needs to
communicating results.
During an evaluation, prevention practitioners ask the following questions:
• How successful was the community in selecting and implementing appropriate strategies?
• Were these the “right” strategies, given the risk and protective factors the community identified?
• Were representatives from across the community involved in program planning, selection, and
implementation? In what ways were they involved?
• Was the planning group able to identify potential new partners with which to collaborate?
• What was the quality of the data used in decision making?
Engaging stakeholders who represent the populations you hope to reach greatly increases the chance that
your evaluation efforts will be successful. Stakeholders can dictate how (or even whether) evaluation results
are shared. Stakeholder involvement also helps to ensure that the evaluation design, including methods and
the instruments used, is consistent with the cultural norms of the people you serve. Learn more
about cultural competence in prevention practice.
Hello Class,
This is a correction to the initial post
After reviewing Module 10 Leading Causes of Morbidity and Mortality, choose a topic and post
your thoughts.
1. Recognizing that over 50% of cancers are preventable, identify a risk reduction strategy and
create a public health communication initiative that will increase knowledge and action on the
individual, community or population level.
2. The series of school (and other venue) shootings has prompted a public discussion on utilization
of mental health services. Given the current level of awareness and treatment for mental health
disorders, create an innovative population-level approach that explains the need to address
potential mental health issues without delay and fosters increased access to treatment
From <https://blackboard.umaryland.edu/webapps/discussionboard/do/message?action=list_messages&forum_id=_81578_1
&nav=discussion_board_entry&conf_id=_38954_1&course_id=_11041_1&message_id=_1213813_1#msg__1213813_1Id>
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Module 11: Infectious Diseases
Tuesday, April 25, 2017
11:52 AM
OVERVIEW
Despite tremendous advances in infectious disease prevention efforts, vaccinations, antibiotics
and other treatments that have resulted in increased longevity, millions of Americans still
contract infectious diseases each year. Worldwide, infectious diseases are the leading cause of
death of people under the age of 60. The purpose of this module is to provide an overview of
infectious disease transmission and interventions to control the chain of infection. It
emphasizes infectious disease prevalence and prevention strategies and population-based
initiatives on the national and state level designed to reduce the burden of infectious diseases in
general and HIV/AIDS specifically.
Objectives
At the conclusion of this module, the learner will be able to:
• Explain the modes of transmission of infectious diseases
• Identify prevention strategies for infectious diseases
• Identify prevention strategies for HIV/AIDS
• Discuss national planning models for infectious diseases
• Discuss national planning models for HIV/AIDS
• Review the state goals for addressing population-based infectious diseases prevention
• Review the state goals for addressing population-based HIV/AIDS prevention
• Describe a model community-based HIV/AIDS prevention program
Required Readings
• Centers for Disease Control and Prevention. (2011). A CDC Framework for Preventing
Infectious Diseases (2011).Overview.Available at http://www.cdc.gov/oid/docs/idframework-2pageoverview.pdf
• Trust for America’s Health and Robert Wood Johnson Foundation (2015). Outbreaks:
Protecting Americans from Infectious Diseases 2015. Introduction (pp. 4-10); Reducing
Sexually Transmitted Infections and TB (pp. 81-92). Available
at http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf409564
• AIDS.gov. (2015). HIV/AIDS Care Continuum. Available at http://aids.gov/federalresources/policies/care-continuum/
Recommended Readings
• Trust for America’s Health and Robert Wood Johnson Foundation (2015). Outbreaks:
Protecting Americans from Infectious Diseases 2015. Available
at https://www.aids.gov/federal-resources/national-hiv-aids-strategy/nhasupdate.pdf
• National HIV/AIDS Strategy for the United States: Updated to 2020. (n.d.) Available
at https://www.aids.gov/federal-resources/national-hiv-aids-strategy/nhasupdate.pdf
• AIDS.gov. (n.d.). HIV/AIDS Basics. Available at http://aids.gov/hiv-aids-basics/
Directions
Read the module content and activities. There will be no discussion board this week. Please
continue working on part two of your paper.
• Centers for Disease Control and Prevention. (2011). A CDC Framework for Preventing
Infectious Diseases (2011).Overview.Available at http://www.cdc.gov/oid/docs/idframework-2pageoverview.pdf
A CDC Framework for Preventing Infectious Diseases
A CDC Framework for Preventing Infectious Diseases: Sustaining the Essentials and Innovating for the
Future—CDC’s ID Framework—was developed to provide a roadmap for improving our ability to prevent
known infectious diseases and to recognize and control rare, highly dangerous, and newly emerging
threats through a strengthened, adaptable, and multi‐purpose U.S. public health system. While the
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threats through a strengthened, adaptable, and multi‐purpose U.S. public health system. While the
primary purpose of the ID Framework is to guide CDC’s infectious disease activities, the document also
seeks to advance collective action to prevent and control infectious diseases—recognizing the realities
of the current fiscal climate and our changing public health and healthcare environments. The complete
ID Framework is available online at www.cdc.gov/OID.
Meeting Challenges and Pursuing Opportunities in a New Public Health Environment
Today’s infectious disease challenges are broader and more complex than they were in 1998, when CDC
last issued a comprehensive plan to guide national efforts to prevent and control emerging infectious
threats.* Since then, new microbes or new forms of old ones have been discovered nearly every year,
and infectious disease outbreaks triggering international responses have been reported on nearly every
continent. We have recent real‐life examples of disease threats such as severe acute respiratory
syndrome (SARS) and H5N1 and H1N1 influenza that emerged from animal reservoirs and clearly
underscore the need and value of a “One‐Health” approach to disease prevention linking human,
animal, and environmental health efforts.
While our changing, globalized world has provided increased opportunities for emergence and spread of
infectious diseases, it has also brought significant advances toward their control. The ID Framework
takes into account many of the scientific, demographic, technological, and economic developments
currently modifying efforts to protect public health, challenging us to re‐think our processes and
strategies and take advantage of new ways to prevent disease and improve health.
CDC’s Role
CDC provides leadership and technical expertise to public health and healthcare communities in
conducting the fundamental public health functions that protect populations and individuals from
infectious diseases, in responding rapidly to outbreaks and unusual health events, and in improving the
understanding of infectious diseases. CDC is also expanding its role in helping healthcare and
community partners increase their focus on prevention to improve health and reduce health‐related
costs. The fulfillment of CDC’s vision of a strong, vigilant U.S. public health system—ready and able to
prevent and control endemic diseases and respond to new and emerging threats—requires the
sustained, coordinated, and complementary efforts of many individuals and groups.
Elements and Priorities Outlined in CDC’s ID Framework
The ID Framework outlines three critical elements in these efforts: strong public health fundamentals,
including infectious disease surveillance, laboratory detection, and epidemiologic investigation; high ‐
impact interventions; and sound health policies. The document also describes priority activities for
achieving these essential components of public health, highlighting opportunities afforded through
scientific and technological innovations, new partnerships, and the changing U.S. public health and
healthcare systems.
Elements and Priorities
Element 1: Strengthen public health fundamentals, including infectious disease surveillance, laboratory
detection, and epidemiologic investigation
• Modernize infectious disease surveillance to drive public health action
• Expand the role of public health and clinical laboratories in disease control and prevention
• Improve capacity for epidemiologic investigations and public health response
• Advance workforce development and training to sustain and strengthen public health practice
Element 2: Identify and implement high‐impact public health interventions to reduce infectious diseases
• Identify and validate high‐impact tools for disease reduction, including new vaccines; strategies and
tools for infection control and treatment; and interventions to reduce disease transmitted by animals or
insects
• Use proven tools and interventions to reduce high‐burden infectious diseases, including vaccine‐
preventable diseases; healthcare‐associated infections; HIV/AIDS; foodborne infections; and chronic
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preventable diseases; healthcare‐associated infections; HIV/AIDS; foodborne infections; and chronic
viral hepatitis
Element 3: Develop and advance policies to prevent, detect, and control infectious diseases
• Ensure the availability of sound scientific data to support the development of evidence‐based and
cost‐ effective policies
• Advance polices to improve prevention, detection, and control of infectious diseases, with specific
focus on those that help integrate clinical infectious disease preventive practices into U.S. healthcare;
increase community and individual engagement in disease prevention efforts; strengthen global capacity
to detect and respond to outbreaks with the potential to cross borders; address microbial drug
resistance; and promote “One‐Health” approaches to prevent emergence and spread of zoonotic
diseases
Examples of CDC Activities to Address Infectious Disease Issues of Special Concern
• Provide expertise in reducing antimicrobial resistance, working to monitor the effectiveness of current
antibiotics and the emergence of resistant strains and work to advance broad collaborations to ensure
appropriate use of antimicrobials in communities and healthcare settings
• Expand educational campaigns to increase awareness of chronic viral hepatitis, including information
on its risk factors, the need for testing, and advances in treatment
• Improve food safety, including improving coordination among food safety surveillance networks to
more rapidly detect outbreaks, identify their sources, and contain their spread
• Sustain and advance efforts to reduce healthcare‐associated infections, working to change them from
inevitable aspects of healthcare to rare, unacceptable events
• Improve targeted efforts to reduce HIV incidence, increase access to care and improve health
outcomes for HIV‐infected persons, and reduce HIV‐related health disparities
• Help monitor and prevent acute respiratory infections such as pneumonia, influenza, and tuberculosis
in the United States and globally, working with partners to rapidly recognize and contain outbreaks
• Reduce diarrheal disease, particularly among children, by improving global access to safe water,
adequate sanitation, and improved hygiene
• Reduce vaccine‐preventable diseases through efforts to ensure broad immunization coverage and
availability of recommended vaccines, to detect and respond to outbreaks of vaccine‐preventable
diseases, and to monitor the impact and safety of vaccines and communicate their efficacy and public
health significance
• Develop and advance new, multi‐disciplinary approaches to preventing and controlling zoonotic and
vectorborne diseases
Trust for America’s Health and Robert Wood Johnson Foundation (2015). Outbreaks:
Protecting Americans from Infectious Diseases 2015. Introduction (pp. 4-10); Reducing
Sexually Transmitted Infections and TB (pp. 81-92). Available
at http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf409564
Introduction
Infectious diseases, from antibiotic-resistant superbugs to Salmonella to the seasonal flu, disrupt lives
and communities and cost the country more than $120 billion each year.
Since the 1940s, there have been tremendous advancements in infectious disease prevention efforts,
vaccinations, antibiotics and other treatments that have saved countless lives. The successes in
infectious disease control have made it possible for the majority of Americans to live significantly longer
lives — which also means most Americans reach the ages where they develop and live with a range of
chronic diseases — often for decades. This sea change in the health of Americans has also led to a shift
in attention and resources toward managing and treating chronic disease — but it is important to
remember the threat that infectious diseases continue to pose.
Fighting infectious disease requires constant vigilance. Policies and resources must be in place to allow
scientists and public health and medical experts to have the tools they need to: control ongoing
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scientists and public health and medical experts to have the tools they need to: control ongoing
outbreaks — such as HIV/AIDS, bacterial infections in hospitals and foodborne illnesses; detect new or
reemerging outbreaks — such as Middle East Respiratory Syndrome (MERS), whooping cough and drug
resistant infections; and even monitor for potential bioterrorist threats — such as anthrax or smallpox.
Reports from the Centers for Disease Control and Prevention (CDC), the Institute of Medicine (IOM) and
other expert organizations have stressed the importance of having fundamental abilities in place to
detect and control the transmission of infectious diseases and ensure consistent, basic levels of
protection across the country
Millions of Americans still contract infectious diseases each year and, worldwide, they are the leading
cause of death of people under the age of 60
CDC’s Framework for Preventing Infectious Diseases: Sustaining the Essentials and Innovating for the
Future stresses the importance of:
Strengthening public health fundamentals, including infectious disease surveillance, laboratory
detection and epidemiologic investigations;
Identifying and implementing high-impact strategies — such as vaccinations, infection control, rapid
diagnosis of disease and optimal treatment practices — to limit the spread of diseases and systems to
reduce the diseases transmitted by animals or insects to humans; and
Developing and advancing policies such as integrating clinical infectious disease preventive practices
into U.S. healthcare; educating and working with the public to understand how to limit the spread of
diseases; and working with the global health community to quickly identify new diseases and reduce
rates of existing diseases.
However, efforts to prevent and control infectious diseases continue to be hampered by outdated
systems and limited resources.
Protecting the country from infectious disease threats is a fundamental role of government, and all
Americans have the right to basic protections no matter where they live
The Trust for America’s Health (TFAH) and Robert Wood Johnson Foundation (RWJF) issued the
Outbreaks: Protecting Americans from Infectious Diseases report to examine the country’s policies to
respond to ongoing and emerging infectious disease threats.
Government at all levels has the ability to set policies and establish practices based on the best science
available to better protect Americans from infectious disease threats.
To help assess policies and the capacity to protect against infectious disease outbreaks, this report
examines a range of infectious disease concerns and a series of indicators in each state that, taken
collectively, offer a composite snapshot of strengths and vulnerabilities as well as a range of national
and global infectious disease priorities. While federal, state and local health departments and healthcare
providers all have roles to play, states have the primary legal jurisdiction and responsibility for the
health of their citizens.8 These indicators help illustrate the types of fundamentals that are important to
have in place not just to prevent the spread of disease in the first place but also to detect, diagnose and
respond to outbreaks. In addition, fighting infectious diseases requires more than just governmental
action, it also requires cooperative efforts with the healthcare sector; pharmaceutical, medical supply
and technology companies; community groups, schools and employers; and families and individuals.
The Outbreaks report provides the public, policymakers and a broad and diverse set of groups involved
in public health with an objective, nonpartisan, independent analysis of the status of infectious disease
policies; encourages greater transparency and accountability of the system; and recommends ways to
assure the public health system meets today’s needs and works across boundaries to accomplish its
goals. The report focuses on areas with high-priority policy concerns for infectious disease prevention
and control, including: I. Foundational Capabilities and Funding for Public Health Indicator 1: State Public
Health Budgets II. Vaccine-Preventable Diseases Indicator 2: Whooping Cough Vaccination of Children
Indicator 3: Human papillomavirus (H PV) Immunization Laws Indicator 4: Flu Vaccination Rates III.
Emerging Infectious Diseases Indicator 5: Climate Change and Infectious Diseases Indicator 6:
Mandatory Reporting of Healthcare Associated Infections IV. Emergency Outbreaks: Bioterrorism and
High-Risk New Diseases Indicator 7: Laboratory Capabilities for Tracking Novel Disease Outbreaks
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High-Risk New Diseases Indicator 7: Laboratory Capabilities for Tracking Novel Disease Outbreaks
Indicator 8: Laboratory Capacity to Transport Disease Samples for Testing Indicator 9: Laboratory
Capabilities during Emergency Events or Drills V. Foodborne and Waterborne Illnesses VI. HIV/AIDS, Viral
Hepatitis and Tuberculosis (TB) Prevention Indicator 10: Medicaid Coverage of Routine Human
Immunodeficiency Virus (HIV) Screening
Infectious disease control and prevention is a concern in every state. Policies and programs vary from
state-to-state. This report includes a series of 10 indicators based on high-priority areas and concerns. It
is not a comprehensive review, but collectively, it provides a snapshot of the efforts that states are
taking to prevent and control infectious diseases. The indicators were selected after consulting with
leading public health and healthcare officials. Each state received a score based on these 10 indicators.
States received one point for achieving an indicator and zero points if they did not. Zero is the lowest
possible score and 10 is the highest. Scores ranged from a high of eight in New Hampshire to a low of
two in Georgia, Nebraska and New Jersey. Scores are not intended to serve as a reflection of the
performance of a specific state or local health department, since they reflect a much broader context,
including resources, policy environments and the health status of a community, so many of the
indicators are impacted by factors beyond the direct control of health officials.
The Flu: An average of 62 million — or 20 percent of — Americans get the seasonal flu each year.
Between 3,000 and 49,000 Americans die each year from the flu and 226,000 are hospitalized, leading
to economic losses of more than $10 billion in direct medical expenses and more than $16 billion in lost
earnings.9, 10 Experts also warn that flu pandemics — novel strains of the flu virus that humans have
little-to-no immunity against — emerge three to four times a century.11 Only 41.5 percent of adults
were vaccinated against the flu last year, and only 72.0 percent of healthcare workers were
vaccinated.12 l Only 12 states vaccinated at least half of their population (ages 6 months and older) for
the seasonal flu in 2012. l Whooping Cough, Measles: Childhood vaccinations prevent an estimated 14
million cases of disease and save $9.9 billion in direct healthcare costs and $33.4 billion in indirect costs
for each birth cohort vaccinated. More than 2 million children under the age of 3 do not receive all
recommended vaccinations, leaving them vulnerable for preventable diseases like measles and
whooping cough, which have both experienced recent resurgences in areas of the United States. l Only
two states and Washington, D.C. meet the U.S. Department of Health and Human Services (HHS) goal of
vaccinating 90 percent of young children — ages 19- to 35-months old — against whooping cough. l
Human Papillomavirus and Cervical Cancer: 79 million Americans carry HPV, which leads to 20,000 new
cases of cancer in women and 12,000 in men each year.13 Only 33 percent of female teens receive the
recommended vaccinations to help prevent HPV and thus cervical cancer. l Only 24 states and
Washington, D.C. require the HPV vaccine for teens or fund HPV vaccination efforts or educate the
public about the HPV vaccine. l Emerging and Re-emerging Threats: Since 2012, CDC and global health
agencies have been tracking two serious new threats: As of October 25, 2013, there have been 136
confirmed cases of a new strain of the flu — H7N9, first reported in China — which has led to 45 deaths
(as of November 2013), and as of November 12, 2013, 153 cases (42 percent fatal) in nine countries of
the new MERS coronavirus. In the United States in recent years, CDC and state and local health officials
have been tracking a number of reemerging infectious diseases, including the largest outbreak of West
Nile Virus (WNV) since 2003 and the highest rates of malaria cases in the United States since 1970
(1,925 cases in 2011). Climate change, increased international travel and increased food imports are
some factors that contribute to the rise of new diseases or the re-emergence of diseases that were
thought to be largely under control. As of 2000, World Health Organization (WHO) had identified more
than 200 new diseases that were first spread to humans by animals or insects, including severe acute
respiratory syndrome (SARS), pandemic flu and HIV/AIDS.14 l Only 15 states have completed climate
change adaptation plans, which includes understanding and planning for the changing risk for emerging
and re-emerging infectious diseases due to changing temperatures and weather patterns
MAJOR INFECTIOUS THREATS AND KEY FINDINGS
Healthcare-Associated Infections (HAIs): Approximately one out of every 20 hospitalized patients will
contract an HAI. Risk of infection increases if a person is having invasive surgery, if they have a vein or
bladder catheter, if they are on a ventilator or are on a prolonged course of antibiotics. There were an
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bladder catheter, if they are on a ventilator or are on a prolonged course of antibiotics. There were an
estimated 98,987 deaths due to HAIs in 2002, the last year an official estimate was released. l Only 35
states and Washington, D.C. require that healthcare facilities in their state report healthcare -associated
infections to CDC’s National Healthcare Safety Network (NHSN) or another system
Superbugs/Antibiotic Resistance: CDC has identified 18 priority strains of infections that are resistant to
treatment by antibiotics — ranging from diseases as commonplace as strep throat and ear infections to
tuberculosis (TB) and Salmonella to Methicillin-resistant Staphylococcus aureus (MRSA) and other
healthcare-associated infections. Each year more than two million Americans develop antibioticresistant infections, and at least 23,000 of these individuals die as a result. These are considered to be
very conservative estimates, since current surveillance and data collection capabilities cannot capture
the full burden. Antibiotic resistance leads to more than eight million extra days Americans spend in the
hospital a year and costs the country an extra $20 billion in direct medical costs and at least $35 billion
in lost productivity. The number of antibiotics currently prescribed for humans per year in the United
States is enough to treat four out of five Americans.
Kentucky had the highest rate of antibiotics prescribed per person, Alaska had the lowest, as of
2010.
Emergency Outbreaks and Bioterrorism: In 2001, through a deliberate act of bioterrorism, at least 22
Americans victims contracted anthrax, with five people dying from the infection. Since 2001, the country
has prioritized developing strategies to respond to major disease outbreaks and other health
emergencies, whether caused by nature, accident or a bioterrorism.
Only 37 state public health laboratories and Washington, D.C. report having a plan and capability
to handle a significant surge in testing over a six to eight week period in response to an outbreak
that increases testing over 300 percent — which is what could be needed during a major new
disease outbreak. (July 1, 2012 to July 30, 2013).
46 state public health laboratories and Washington, D.C. report having the capacity in place to
assure the timely transportation (pick-up and delivery) of samples 24/7/365 to the appropriate
Public Health Laboratory Response Network (LRN) Reference Laboratory in the last year (July 1,
2012 to July 30, 2013).
Only 27 state public health laboratories reported evaluating the functionality of their Continuity of
Operations Plan (COOP) via a real event or an exercise last year (July 1, 2012 to July 30, 2013)
Foodborne and Waterborne Illnesses: More than 48 million Americans suffer from foodborne illnesses
each year. These illnesses result in 128,000 hospitalizations and around 3,000 deaths. In addition, more
than 4,100 persons become ill from contaminated drinking water and more than 13,000 persons
become ill from recreational water disease outbreaks annually in the United States.
The leading pathogen responsible for foodborne illness is Norovirus, while Salmonella is the
leading cause of hospitalization and death.
Produce (a combination of six plant food categories) is the top cause of illness, while meat and
poultry (a combination of four animal food categories) are the top causes of death
HIV/AIDS: More than 1.1 million Americans are living with HIV/AIDS, and almost one in five do not know
they are infected. Since the epidemic began more than 636,000 Americans have died from AIDS. There is
an alarming increase in new infections among gay men — accounting for the majority of the nearly
50,000 new HIV diagnoses in 2011.20
Only 33 states and Washington, D.C. cover routine HIV screening under their Medicaid programs.
Knowing HIV-status is important to help get individuals into treatment and stop the spread of the
disease.
Hepatitis B Virus (HBV) and C (HCV): Around 5 million Americans have HBV or HCV, but between 65 and
75 percent do not know they have it. HBV and HCV put people at risk for developing serious liver
diseases and cancer. Two-thirds of Americans infected with HCV are Baby Boomers, and one in 10 Asian
Americans has HBV.
TB: From 1953 to 1984, tuberculosis declined from 84,304 cases, with a rate of 52.6 per 100,000 people
in the United States (the first year for which national statistics were compiled), to 22,255 cases and a
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in the United States (the first year for which national statistics were compiled), to 22,255 cases and a
rate of 9.4 per 100,000. However, the country experienced a TB resurgence in the mid -1980s due to
deficient public health infrastructure, drug-resistant TB, HIV/AIDS and changing immigration patterns
with more people arriving from countries with a high TB burden. Health officials responded with
improvements in treatment, case finding, laboratory capacity and infrastructure and cases began to
decline. There were nearly 10,000 cases of TB in the United States in 2012 with 63 percent of these
cases occurring in persons born outside the United States.
Funding for Public Health: 34 states cut funding for public health from Fiscal year (FY) 2011 to 2012 to FY
2012 to 2013, diminishing their capacity to respond to infectious disease outbreaks in addition to other
public health priorities. In addition, at a federal level, CDC’s overall budget sustained a $577 million cut
from FY 2012 to FY 2013, according to the American Public Health Association (APHA)
TRANSMISSION
Infectious diseases arise from the complex interactions between
the agent, host and environment.
Transmission occurs when the agent leaves its reservoir or host through a portal of exit, is
conveyed by some mode of transmission, and enters through an appropriate portal of
entry to infect a susceptible host. This sequence is referred to as the chain of infection
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Agent/Pathogen—virus, bacterium or parasite that causes the disease in humans
Reservoir—place where the agent lives and multiplies in the environment or another human or
animal species
Portal of Exit/Mode of Transmission—how the agent travels from one host to another
(aerosols, sexual contact, body fluids, blood-borne) or from a reservoir to a new host (inanimate
objects or vectors e.g. insects, food, water
Portal of Entry—how the agent enters a new host (aerosols, fecal-oral, skin, mucous
membranes, blood)
Susceptible host— depends on genetic or constitutional factors, specific immunity or nonspecific factors that protect against infection, e.g., skin, mucous membranes, gastric acidity,
respiratory cilia or nonspecific immune response, and factors that increase susceptibility to
infection, e.g., malnutrition, alcoholism or disease or therapy that impairs the nonspecific
immune response
Understanding the portals of exit and entry and modes of transmission serves as the basis for
determining control measures which are often directed toward the segment in the chain of
infection that is most susceptible to intervention and include:
• Controlling or eliminating agents at their source of transmission
• Protecting portals of entry
• Increasing host resistance
Major Infectious Disease Threats
Many factors contribute to the growth and spread of infectious diseases:
• Global travel
• Urbanization
• Immigration
• Housing
• Health care practices
• Public health infrastructure
• Food production and preparation
• use and misuse of antibiotics
• microbial adaptation
• human behavior
These factors, compounded by the ability of micro-organisms to evolve and adapt to changing
populations, environments, practices and technologies, create ongoing threats to health and
continually challenge efforts to prevent and control infectious diseases.
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POPULATION-BASED INITIATIVES TO REDUCE INFECTIOUS DISEASES
National Programs
The Trust for America’s Health in its compelling report entitled Outbreaks: Protecting
Americans from Infectious Diseases 2015 emphasizes that fighting infectious disease
requires constant vigilance and tools to control ongoing outbreaks, detect new and reemerging
outbreaks and monitor for potential bioterrorist threats. The report highlights the following major
infectious threats:
• Superbugs
• Middle East Resporatory Syndrome
• Foodborne Illnesses
• HIV/AIDS and Viral Hepatitis
• Healthcare-associated Infections
• Influenza (The Flu)
• Global Public Health Capacity
For more information, review the required reading (pp. 4-10) available
at http://healthyamericans.org/assets/files/TFAH-2015-OutbreaksRpt-FINAL.pdf
The report ranks the states on the ten following indicators with zero being the lowest possible
score and ten the highest:
1. Public Health Funding
2. Flu Vaccination Rates
3. Childhood Immunization School Requirement Policies
4. HIV/AIDS Surveillance
5. Syringe Exchange Programs
6. Climate Change and Infectious Disease
7. Central Line-associated Bloodstream Infections
8. Public Health Laboratories with Biosafety Professionals
9. Public Health Laboratories that Provide Biosafety Training
10. Food Safety
Scores ranged from 8 (best) in Delaware, Kentucky, Maine, New York and Virginia to - 3 (worst)
in Idaho, Kansas, Michigan, Ohio, Oklahoma, Oregon and Utah.
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Source:http://healthyamericans.org/assets/files/TFAH-2015-OutbreaksRpt-FINAL.pdf
The CDC Framework for Preventing Infectious Diseases is the U.S. guide for improving the
country’s ability to prevent known infectious diseases and to recognize and control rare, highly
dangerous and emerging infectious diseases.
The framework targets three essential elements:
1. Strengthen public health fundamentals including infectious disease surveillance, laboratory
detection and epidemiological investigation
2. Identify and implement high-impact public health interventions to reduce infectious
disease.
3. Develop and advance policies to prevent, detect and control infectious diseases
The framework highlights nine diseases:
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For more information, review the required reading available
at http://www.cdc.gov/oid/docs/id-framework-2pageoverview.pdf
Click here for more information on the CDC Framework for Preventing Infectious Diseases
National Notifiable Disease Surveillance System (NNDSS)
The CDC maintains the National Notifiable Disease Surveillance System, based on voluntary
reporting of infectious and non-infectious diseases and outbreaks from 57 states and territories.
The NNDSS facilitates the sharing of health information to monitor, control and prevent the
occurrence and spread of state-reportable and nationally notifiable diseases and conditions. It is
also used to improve and standardize public health surveillance systems for state and local
health departments as well as with health information technology systems used by hospitals,
laboratories and private providers.
Take a few minutes to review the list of National Notifiable Infectious Diseases
Statewide Programs
The Maryland Department of Health and Mental Hygiene’s (DHMH) infectious disease efforts
are housed within the Prevention and Health Promotion Administration.
DHMH’s Infectious Disease Bureau includes specific centers that focus on the following:
• General Infections and Outbreaks
• Zoonotic & Vectorborne Diseases
• Vaccine Preventable Diseases
• Sexually Transmitted Infections (STI)
• Human Immunodeficiency Virus (HIV)
• Emerging Infections
• Healthcare-Associated Infections
• Tuberculosis
• Hepatitis
• Immigrant Health
Reportable Diseases
DHMH also maintains the registry of diseases, conditions, outbreaks and unusual
manifestations that are reportable under the Code of Maryland Regulations (COMAR)
10.06.01.03 C. These regulations stipulate what conditions should be reported, who should
report, primarily health care providers and laboratories, how reporting should occur, where
reports are sent, important time lines and when laboratories should submit specimens to the
state public health laboratory.
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state public health laboratory.
Reporting cases of known or suspected infectious diseases protects the public's health by
ensuring the proper identification and follow-up of cases. Public health workers at both local and
state levels follow individual cases to ensure proper treatment, identify potential sources of
infection, provide education to reduce the risk of transmission, identify susceptible contacts and
take other measures aimed at reducing the spread of disease. Analysis of data across all cases
helps to monitor the impact of those conditions, measure trends, identify areas of risk, detect
outbreaks, monitor control efforts and allocate resources effectively.
Take a few minutes to review the list of mandated reportable diseases for Maryland.
Click here for more information on DHMH’s Infectious Disease Bureau.
HIV/AIDS PREVALENCE AND PREVENTION
The CDC estimates that 1.2 million people are living with HIV infection in the U.S., 13% of
whom (1 in 8) are unaware of their infection. During the last ten years, the number of people
living with HIV has increased, while the annual number of new HIV infections has declined by
19% from 2005 to 2014. In the U.S., HIV is spread mainly by having sex or by sharing injection
drug-use equipment with an infected person.
As noted in the graph below, gay, bisexual and other men who have sex with men (MSM) are
most seriously affected by HIV.
Source: http://www.cdc.gov/hiv/statistics/basics/ataglance.html
Source: http://www.cdc.gov/hiv/statistics/overview/
New HIV diagnoses disproportionately affect men having sex with men.
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Young people aged 13-24 account for more than 1 in 5 new HIV diagnoses or nearly 10,000
individuals. Eighty-one percent occur in the 20-24 year old age group. In the age group 18-24
approximately 44% are unaware they have HIV.
No group is immune. Women are also at risk for HIV.
U.S. Geographic Distribution
Significant variations in the HIV and AIDS epidemic exist across the country. It is primarily
concentrated in urban areas and higher rates were reported in the South.
Prevention
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Prevention
HIV is transmitted through blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids and
breast milk from an infected person. These fluids must come into contact with a mucous
membrane or damaged tissue or be directly injected into the bloodstream for transmission to
occur. Click here for more information on HIV transmission.
HIV can be prevented by avoiding exposure to the fluids that can transmit the virus through
using condoms correctly and consistently, limiting the number of sexual partners, never sharing
needles and through biomedical options such as pre-exposure and post-exposure prophylaxis.
Click here for more information on HIV prevention.
Prevention efforts are challenged by the facts that of the 1.1 million Americans living with HIV:
1. approximately 15% are unaware of their serostatus and
2. only 30% are virally suppressed.
To better understand the disparities in HIV prevention at all levels click on this video and review
the required reading at http://aids.gov/federal-resources/policies/care-continuum/
Inroads have been made in advancing early treatment and routine testing for HIV. For more
information review the CDC website for HIV testing available
at https://www.cdc.gov/hiv/testing/.
Health care workers follow Universal Precautions for Preventing Transmission of
Bloodborne Infections to prevent infection from HIV/AIDs. Click here for more information.
WHAT IS THE HIV CARE CONTINUUM?
The HIV care continuum—sometimes also referred to as the HIV treatment cascade—is a model that
outlines the sequential steps or stages of HIV medical care that people living with HIV go through from
initial diagnosis to achieving the goal of viral suppression (a very low level of HIV in the body), and shows
the proportion of individuals living with HIV who are engaged at each stage.
In 2011, Dr. Edward Gardner and colleagues
observed that “for individuals with human immunodeficiency virus (HIV) to fully benefit from potent
combination antiretroviral therapy, they need to know that they are HIV infected, be engaged in regular
HIV care, and receive and adhere to effective antiretroviral therapy.” They acknowledged, however, that
various obstacles contribute to poor engagement in HIV care, substantially limiting the effectiveness of
efforts to improve health outcomes for those with HIV and to reduce new HIV transmissions. So, the
researchers set out to describe and quantify the spectrum of engagement in HIV care.
The result of the researchers’ work was the HIV care continuum (or “cascade”), which they defined as
having the following stages: diagnosis of HIV infection, linkage to care, retention in care, receipt of
antiretroviral therapy, and achievement of viral suppression. Many in the HIV field at the Federal, state,
and local levels have since used or adapted this HIV care continuum to better identify gaps in HIV
services and develop strategies to improve engagement in care and outcomes for people living with HIV.
In 2013, the HIV Care Continuum Initiative was established as the next step in the implementation of the
National HIV/AIDS Strategy. The Initiative directed Federal departments to accelerate efforts to increase
HIV testing, care, and treatment to better address drop-offs along the HIV care continuum and increase
the proportion of individuals in each stage along the continuum. An HIV Care Continuum Federal Working
Group was established to support the Initiative and coordinate Federal efforts, and this Working Group
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Group was established to support the Initiative and coordinate Federal efforts, and this Working Group
developed a series of recommendations. These recommendations were fully integrated into the Steps
and Actions of the National HIV/AIDS Strategy: Updated to 2020.
Different research studies present the stages of the HIV care continuum in different ways. A November
2014 Vital Signsreport published by the Centers for Disease Control and Prevention (CDC) discusses the
following stages of the continuum:
• HIV testing and diagnosis —The HIV care continuum begins with a diagnosis of HIV infection. The only way to know for
•
•
•
sure that you are infected with the HIV virus is to get an HIV test. People who don't know they are infected are not accessin g
the care and treatment they need to stay healthy. They can also unknowingly pass the virus on to others. CDC recommends that
all adolescents and adults be tested for HIV infection at least once, and that persons at increased risk for HIV infection be tested
at least annually.
Getting and staying in medical care—Once you know you are infected with the HIV virus, it is important to be connected
to an HIV healthcare provider who can offer you treatment and prevention counseling to help you stay as healthy as possible
and prevent passing HIV on to others. Because there is no cure for HIV at this time, treatment is a lifelong process. To stay
healthy, you need to receive regular HIV medical care.
Getting on antiretroviral therapy— Antiretrovirals are drugs that are used to prevent a retrovirus, such as HIV, from
making more copies of itself. Antiretroviral therapy (ART)is the recommended treatment for HIV infection. It involves using a
combination of three or more antiretroviral drugs from at least two different HIV drug classes every day to control the
virus. U.S. clinical guidelines recommend that everyone diagnosed with HIV receive treatment, regardless of their
CD4 cell count or viral load. Treatment with ART can help people with HIV live longer, healthier lives, and has been
shown to reduce sexual transmission of HIV by 96 percent.
Achieving viral suppression—By taking ART regularly, you can achieveviral suppression, meaning a very low level of HIV in
your blood. You aren’t cured. There is still some HIV in your body. But lowering the amount of virus in your body with medici nes
can help you stay healthy, live longer, and greatly reduce your chances of passing HIV on to others.
Read “Understanding the HIV Care Continuum (PDF) ,” a CDC fact sheet that describes the HIV care
continuum, discusses various approaches and data used to develop the HIV care continuum, and
explains how CDC uses the continuum to help guide the nation’s response to HIV.
WHAT DOES THE HIV CARE CONTINUUM SHOW?
According to the latest CDC data, of the 1.2 million people living with HIV in the U.S. in 2011, an estimated
86% were diagnosed. This means that 14% (approximately 1 in 7 people living with HIV) were unaware of
their infection and therefore not accessing the care and treatment they need to stay healthy and reduce
the likelihood of transmitting the virus to their partners.
In addition, people living with HIV are dropping off at every subsequent stage in the continuum. Of the 1.2
million Americans living with HIV in 2011, CDC data showed that 40% were engaged in HIV medical care,
37% were prescribed ART, and 30% had achieved viral suppression. In other words, only 3 out of 10
people living with HIV had the virus under control.
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The CDC’s 2014 analysis also provided further information about the 70% of people living with HIV who
did NOT have their virus under control in 2011. Among the nearly 840,000 who had not achieved viral
suppression:
•
•
•
•
20% did not yet know they were infected
66% had been diagnosed, but were not engaged in regular HIV care
4% were in HIV care, but were not prescribed ART
10% had been prescribed ART, but had not yet achieved viral suppression.
The percentage of Americans with HIV who achieved viral suppression has remained roughly stable over
the past few years (26 percent in 2009 vs. 30 percent in 2011).
This underscores the importance of continued and intensified efforts to reach more people with testing
and to make sure that those with the virus receive prompt, ongoing care and treatment to help them live
longer, healthier lives and prevent the spread of HIV to others.
In addition, on February 23, 2015, CDC published a study in JAMA Internal Medicine providing the first U.S.
estimates of the number of HIV transmissions from people engaged at the five stages of the HIV care
continuum. The study shows that 91.5 percent of new HIV infections in 2009 were attributable to people
with HIV who were not in medical care, including those who didn’t know they were infected. In
comparison, less than six percent of new infections could be attributed to people with HIV who were in
care and receiving antiretroviral therapy. In other words, according to this research, 9 in 10 new HIV
infections in the United States could be prevented through early diagnosis and prompt, ongoing care and
treatment.
POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF HIV/AIDS
National
The National HIV/AIDS Strategy (NHAS) is the country's comprehensive coordinated HIV/AIDs
roadmap with measurable targets to be achieved by 2020. It was developed based on public
input and ideas from individuals living with HIV as well as other stakeholders and interested
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input and ideas from individuals living with HIV as well as other stakeholders and interested
parties
NHAS goals and targeted strategies are:
• Reducing the number of people who become infected with new HIV infections
○ Intensify HIV prevention efforts in communities where HIV is most heavily
concentrated
○ Expand efforts to prevent HIV infection using a combination of effective evidencebased approaches
○ Educate all Americans with easily accessible, scientifically accurate information
about HIV risks, prevention and transmission
• Increasing access to care and improving health outcomes for people living with HIV
○ Establish seamless systems to link people to care immediately after diagnosis and
support retention in care to achieve viral suppression that can maximize the benefits
of early treatment and reduce transmission risk
○ Take deliberate steps to increase the capacity of systems as well as the number and
diversity of available providers of clinical care and related services for people living
with HIV
○ Support comprehensive, coordinated, patient-centered care for people living with
HIV, including addressing HIV-related co-occurring conditions and challenges
meeting their basic needs, such as housing
• Reducing HIV-related health disparities and health inequities
○ Reduce HIV-related disparities in communities at high risk for HIV infection
○ Adopt structural approaches to reduce HIV infection and improve health outcomes in
high-risk communities
○ Reduce stigma and discrimination against people living with HIV
• Achieving a more coordinated national response to the HIV epidemic
○ Increase the coordination of HIV programs across the Federal government and
between Federal agencies and State, territorial, Tribal and local governments
○ Develop improved mechanisms to monitor and report on progress toward achieving
national goals
To learn more about the NHAS, review the Executive Summary of the national report (pp. 1-14)
available at https://www.aids.gov/federal-resources/national-hiv-aids-strategy/nhasupdate.pdf.
Statewide
The Maryland Department of Health and Mental Hygiene’s Centers for HIV Prevention and
Care Services focus on:
• reducing the transmission of HIV,
• helping the over 34,000 Marylanders living with HIV/AIDs live longer and healthier lives
through the development, and
• implementation of comprehensive, compassionate and quality services for both prevention
and care.
Its 2012-2014 Comprehensive HIV Plan is based on the National HIV/AIDS Strategy and
serves as Maryland’s roadmap for the development of a comprehensive system of HIV care in
the state.
The plan includes four components:
1. Description of Maryland’s HIV/AIDs epidemic
○ estimates of people living with HIV/AIDS who are unaware of their status and those
that are aware of their status but not in continuous care
○ resources for HIV services including Ryan White-funded and non-Ryan White-funded
services
○ effects of state and local budget cuts on the current continuum of care
○ gaps and barriers to care
2. Vision and values that guide the goals and principles for HIV services and how they
support the National HIV/AIDs strategy
3. Overall goals that guide HIV service programs in Maryland:
○ Increase the number of persons living with HIV/AIDS who are aware of their HIV
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○ Increase the number of persons living with HIV/AIDS who are aware of their HIV
serostatus
○ Increase the number of persons living with HIV/AIDS who are engaged in ongoing,
high-quality HIV medical care
○ Reduce high-risk behaviors among persons living with HIV AIDS
○ Reduce high-risk behaviors among HIV-negative persons at high risk for HIV
infection
○ Reduce disparities in HIV infection and care and services received between
subpopulations
4. Monitoring and evaluating progress toward performance goals, quality of care
goals/outcomes and client-level outcomes
Click here for more information on the Maryland HIV Plan 2012-2014.
The Jacques Initiative: A Baltimore Exemplar Program
The JACQUES Initiative (JI) program of the University of Maryland Institute of Human Virology
is a holistic care delivery model that provides long-term treatment success for urban populations
infected with HIV. Its goal is to decrease the morbidity and mortality associated with HIV through
care delivery and providing early intervention services through activities including testing,
outreach and linkage to care. The JI focuses on providing a “safe place” for individuals living
with HIV through delivered services and providing access to research for all through the Journey
to Wellness. There are five steps in the journey—engage, prepare, treat, support and develop.
Watch these two videos PTF Testing and LTC Video and Living Proof on the impact of this
model on patient care.
The JI’s Preparing the Future (PTF) model program incorporates health, psychosocial and legal
resources that facilitate HIV testing and linkages to care more routine and normalized. A central
component of PTF brings together graduate students into teams from the University's dentistry,
law, medicine, nursing, pharmacy, and social work schools to address the goals of National
HIV/AIDS Strategy (NHAS), including identifying new infections of HIV and increasing access to
care for people living with HIV. PTF has been identified by the White House Office of National
AIDS Policy as a model for communities across the country.
From <https://cf.son.umaryland.edu/NRSG780/module11/subtopic4.htm>
NSG 780Final Page 105
Module 12: Environmental Health, Occupational Health,
Unintended Injuries and Violence
Tuesday, April 25, 2017
12:38 PM
OVERVIEW
The purpose of this module is to provide an overview of major issues in environmental health,
occupational health, unintended injuries and violence. It highlights the magnitude of the
problem, prevention strategies and population-based initiatives on the national and state level
designed to reduce the burden of morbidity and mortality resulting from environmental and
occupational risks and unintended injuries and violence.
Objectives
At the conclusion of this module, the learner will be able to:
• Explain the magnitude of the problem resulting from environmental risk factors
• Explain the magnitude of the problem resulting from occupational risk factors
• Explain the magnitude of the problem resulting from unintended injuries and violence
• Identify prevention strategies for addressing environmental risk factors
• Identify prevention strategies for addressing occupational risk factors
• Identify prevention strategies for addressing unintended injuries and violence
• Discuss national planning models for reducing environmental risk factors
• Discuss national planning models for reducing occupational risk factors
• Discuss national planning models for reducing unintended injuries and violence
• Review state initiatives for reducing environmental risk factors
• Review state initiatives for reducing occupational risk factors
• Review state initiatives for reducing unintended injuries and violence
Required Readings
• Centers for Disease Control and Prevention (CDC). (n.d.). NCEH/ATSDR Strategic plan:
Fiscal years 2014-2016. Available
at http://www.cdc.gov/nceh/information/nceh_atsdr_strategic_plan_2014_final.pdf
•
•
•
•
•
•
NCEH/ATSDR Priorities. Available
at https://www.cdc.gov/nceh/information/ncehatsdr_priorities_2014_final.pdf
Centers for Disease Control and Prevention (CDC). What is total worker health? (2016).
Available at http://www.cdc.gov/niosh/twh/totalhealth.html
Evans, L. (2014). Traffic fatality reductions: United States compared with 25 other
countries. American Journal of Public Health, 104(8), 1501-1507. Available
at http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2014.301922
Evans, L. (2014). Twenty thousand more Americans killed annually because U.S. traffic
safety policy rejects science, American Journal of Public Health, 104(8), 1349-1351.
Available at http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2014.301919
Healthy People 2020. (2016). Environmental health. Available
at http://www.healthypeople.gov/2020/topics-objectives/topic/environmental-health
Johns Hopkins Center for Injury Research and Policy. (2012). Preventing injuries in
Maryland: A resource for state policy makers. Available
at http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-forinjury-research-andpolicy/publications_resources/CenterPubs/PolicyResource2012/JHCIRP_POSTbook
.pdf
U.S. Department of Health and Human Services (DHHS). (2016). Stay safe at work.
Available at http://www.healthfinder.gov/HealthTopics/Category/everyday-healthyliving/safety/stay-safe-at-work
Recommended Reading
• CDC Injury Center Research Center Research Priorities (2016) Available
at https://www.cdc.gov/injury/pdfs/researchpriorities/cdc-injury-researchpriorities.pdf
• Healthy People 2020. (2016). Environmental Health: Objectives, Interventions and
Resources. Available at http://www.healthypeople.gov/2020/topicsobjectives/topic/environmentalhealth/objectives and http://www.healthypeople.gov/2020/topicsobjectives/topic/environmental-health/ebrs
• Leigh, J.P., Markis, C.A., Iosif, A., & Romano. P. (2014). California’s nurse-to-patient ratio
law and occupational injury. International Archives of Occupational and Environmental
Health. Available at http://link.springer.com/article/10.1007%2Fs00420-014-0977y#page-1
• NORA Healthcare and Social Assistance Sector Council (NORA). (2016). National
healthcare and social assistance agenda. Available
at http://www.cdc.gov/niosh/nora/default.html
• Review the Total Worker Health website Available
at https://www.cdc.gov/niosh/programs/totalworkerhealth/
Directions
Read the module content and activities. Then complete the assignment for the module.
ASSIGNMENTS
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View the discussion board and provide a single paragraph response to the following:
Morbidity and mortality resulting from environmental and occupational risks and
unintended injuries and violence is largely preventable. Identify a risk reduction strategy
and create a public health communication initiative that will increase knowledge and action
on the individual, community or population level for one of the environmental,
occupational, unintentional injury or violence risk factors.
Comment on one of your colleagues’ postings.
NCEH/ATSDR Priorities. Available
at https://www.cdc.gov/nceh/information/ncehatsdr_priorities_2014_final.pdf
1. Reduce asthma morbidity and mortality.
Key Actions:
1. Link public health and clinical care at the local, state, and national level to improve access to
asthma services, asthma quality of care, and quality and availability of asthma-related data.
2. Provide decision support tools, data, evidence-based interventions, and guidance to identify
and protect vulnerable groups from asthma and health effects of air pollution.
3. Disseminate best practices in asthma self-management and environmental management.
4. Collaborate with the Center for Medicare and Medicaid Innovation, states, and other partners
to incorporate asthma strategies in the State Innovation Models, the Healthcare Improvement
Awards, and other programs to drive quality and innovation in healthcare delivery.
5. Reduce the number of homes where children with asthma are exposed to secondhand smoke.
6. Make site-based recommendations to reduce exposures to chemical contaminants associated
with asthma (H2S, PM, SO2, etc.)
2. Protect children from the health risks of harmful exposures and conditions.
Key Actions:
1. Develop and implement a national strategy to protect children from harmful exposures related
to the siting of daycare and early learning centers.
2. Implement a nationwide health education campaign to protect school aged children from
exposures to mercury and recover mercury from schools, homes, and abandoned facilities.
3. Strengthen the collection and analysis of data describing children’s exposures through
additional laboratory testing, more robust modeling, and expanded data systems.
4. Develop innovative strategies and interventions to reduce and prevent children’s exposure to
emerging and re-emerging environmental health concerns (particularly lead, vapor intrusion,
carbon monoxide).
5. Build the knowledge and skills of health care providers and emergency responders regarding
the unique vulnerability of children to harmful exposures, for example by incorporating children’s
environmental health into medical curricula and promoting the adoption of risk reduction
counseling techniques into clinical practice.
6. Ensure that children are a routinely examined subpopulation within land-use and transportation
Health Impact Assessments.
3. Ensure safe drinking water.
1. Build state and local capacity to identify and utilize data related to federally unregulated
drinking water sources (FUDWS) to characterize exposures, hazards, and health outcomes.
2. Fund a national assessment of FUDWS owners’ knowledge, attitudes, and practices to create
and implement evidence-based actions.
3. Create and apply a model in partnership with USGS to predict arsenic concentrations in
individual FUDWS.
4. Influence EPA to adopt ATSDR recommendations to eliminate exposures to emerging chemicals
in drinking water at sites.
5. Help hospitals plan for water disruptions through CDC’s Emergency Water Supply Planning
Guide for Hospitals and Health Care Facilities. 6. Provide technical assistance to state, local, and
international partners to respond to water related public health emergencies.
4. Use innovative laboratory methods to detect, diagnose, and prevent environmental disease.
1. Complete biomonitoring measurements for 250+ priority environmental chemicals in a twoyear NHANES sample in order to assess exposure among the U.S. population.
2. Develop or improve methods for detecting human exposure to 15 priority environmental
chemicals per year.
3. Provide biomonitoring measurements for 60 studies per year that investigate exposure to
environmental chemicals and adverse health effects, including studies that identify exposed
populations at ATSDR sites.
Centers for Disease Control and Prevention (CDC). What is total worker health?
What is Total Worker Health®?
Total Worker Health® is defined as policies, programs, and practices that integrate protection
from work-related safety and health hazards with promotion of injury and illness prevention
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from work-related safety and health hazards with promotion of injury and illness prevention
efforts to advance worker well-being.
Traditional occupational safety and health protection programs have primarily concentrated on
ensuring that work is safe and that workers are protected from the harms that arise from work itself.
Total Worker Health (TWH) builds on this approach through the recognition that work is a social
determinant of health; job-related factors such as wages, hours of work, workload and stress levels,
interactions with coworkers, and access to leave and healthful workplaces all can have an important
impact on the well-being of workers, their families, and their communities. TWH explores
opportunities to not only protect workers, but also advance their health and well-being by targeting
the conditions of work. Scientific evidence now supports what many safety and health professionals,
as well as workers themselves, have long suspected—that risk factors in the workplace can contribute
to health problems previously considered unrelated to work. For example, there are work-related risk factors
for abnormal weight fluctuations, , sleep disorders,
cardiovascular disease, depression
and other health conditions. In recognition of these emerging relationships, the TWH approach
focuses on how environmental, workplace factors can both mitigate and enhance overall worker
health beyond traditional occupational safety and health concerns.
In June 2011, NIOSH launched the Total Worker Health (TWH) Program as an evolution of the
NIOSH Steps to a Healthier US. Workforce and the NIOSH WorkLife Initiatives. The TWH Program
supports the development and adoption of ground-breaking research and best practices of
approaches that emphasize the opportunities to sustain and improve worker safety and health
through a primary focus on the workplace. The TWH approach integrates workplace interventions
that protect safety and health with activities that advance the overall well-being of workers.
Establishing policies, programs, and practices within the workplace that focus on advancing the
safety, health and well-being of the workforce may be helpful for individuals, their families,
communities, employers and the economy as a whole. The original scientific rationale for expanding
research on the benefits of integrated programs to improve worker health and workplace safety was
published in 2012 in a research compendium of three seminal papers on the science and practice of
integrating health protection and health promotion.
Keeping Workers Safe is Fundamental to Total Worker Health
With the Congressional mandate "to assure so far as possible every man and woman in the Nation
safe and healthful working conditions and to preserve our human resources," NIOSH recognizes
keeping workers safe is the foundation upon which Total Worker Health is achieved. Employers and
employer-employee partnerships wishing to establish effective workplace programs that sustain and
improve worker health must first consider the foundational principles of occupational safety and
health that are dedicated to keeping workplaces safe and workers protected. First-dollar investments
must address hazardous working conditions. Only after these safeguards are in place can
organizations move their workforce toward a state of total worker health. Employers who opt for
wellness programs in the absence of adequate workplace safety and health protections are
not applying the principles of Total Worker Health.
Published in 2010, the NIOSH Essential Elements of Effective Workplace Programs and Policies for
Improving Worker Health and Wellbeing identifies twenty components of a comprehensive workbased Total Worker Health program and includes both guiding principles and practical direction for
organizations seeking to develop effective workplace programs. After understanding these guiding
principles and necessary worker protections, organizations will be better positioned to develop an
approach that addresses occupational safety and health, worker health and well-being, and the
psychosocial work environment at environmental, organizational, and individual levels, all to move
more closely to a safer, healthier and thriving workplace.
The following graphic “Issues Relevant to Advancing Worker Well-being Through Total Worker
Health®” illustrates a wide-ranging list of issues that are relevant to advancing worker well-being
through a Total Worker Health approach. The list of issues relevant to Total Worker Health was
revised, retitled and published in November 2015 with input from stakeholders. This updated list
reflects an expanded focus for TWH that recognizes that new technologies, new working conditions,
NSG 780Final Page 108
reflects an expanded focus for TWH that recognizes that new technologies, new working conditions,
and new emerging forms of employment present new risks to worker safety, health and wellbeing. Understanding and reducing those risks are important elements of TWH. Additionally, this
expanded focus recognizes that there are linkages between health conditions that may not arise
from work but that can be adversely affected by work. A Total Worker Health approach advocates for
the integration of all organizational policies, programs and practices that contribute to worker safety,
health and well-being, including those relevant to the control of hazards and exposures, the
organization of work, compensation and benefits, built environment supports, leadership, changing
workforce demographics, policy issues, and community supports.
Issues Relevant to Advancing Worker Well-being Through Total Worker Health
Control of Hazards and Exposures • Chemicals • Physical Agents • Biological Agents • Psychosocial
Factors • Human Factors • Risk Assessment and Risk Management
Organization of Work • Fatigue and Stress Prevention • Work Intensification Prevention • Safe Staffing •
Overtime Management • Healthier Shift Work • Reduction of Risks from Long Work Hours • Flexible
Work Arrangements • Adequate Meal and Rest Breaks
Built Environment Supports • Healthy Air Quality • Access to Healthy, Affordable Food Options • Safe
and Clean Restroom Facilities • Safe, Clean and Equipped Eating Facilities • Safe Access to the
Workplace • Environments Designed to Accommodate Worker Diversity
Leadership • Shared Commitment to Safety, Health, and Well-Being • Supportive Managers,
Supervisors, and Executives • Responsible Business Decision-Making • Meaningful Work and
Engagement • Worker Recognition and Respect
Compensation and Benefits • Adequate Wages and Prevention of Wage Theft • Equitable Performance
Appraisals and Promotion • Work-Life Programs • Paid Time Off (Sick, Vacation, Caregiving • Disability
Insurance (Short- & Long-Term • Workers’ Compensation Benefits • Affordable, Comprehensive
Healthcare and Life Insurance • Prevention of Cost Shifting between Payers (Workers’ Compensation,
Health Insurance) • Retirement Planning and Benefits • Chronic Disease Prevention and Disease
Management • Access to Confidential, Quality Healthcare Services • Career and Skills Development
Community Supports • Healthy Community Design • Safe, Healthy and Affordable Housing Options •
Safe and Clean Environment (Air and Water Quality, Noise Levels, Tobacco-Free Policies) • Access to
Safe Green Spaces and NonMotorized Pathways • Access to Affordable, Quality Healthcare and WellBeing Resources
Changing Workforce Demographics • Multigenerational and Diverse Workforce • Aging Workforce and
Older Workers • Vulnerable Worker Populations • Workers with Disabilities • Occupational Health
Disparities • Increasing Number of Small Employers • Global and Multinational Workforce
Policy Issues • Health Information Privacy • Reasonable Accommodations • Return-to-Work • Equal
Employment Opportunity • Family and Medical Leave • Elimination of Bullying, Violence, Harassment,
and Discrimination • Prevention of Stressful Job Monitoring Practices • Worker-Centered Organizational
Policies • Promoting Productive Aging
New Employment Patterns • Contracting and Subcontracting • Precarious and Contingent Employment
• Multi-Employer Worksites • Organizational Restructuring, Downsizing and Mergers • Financial and Job
Security
• Evans, L. (2014). Traffic fatality reductions: United States compared with 25 other
countries. American Journal of Public Health, 104(8), 1501-1507
Traffic Fatalities Reductions: United States Compared with 25 Other Countries
Objectives. I compared US traffic fatality trends with those in 25 other countries. Methods. 1 have
introduced a new measure for com paring safety in different countries: traffic deaths in a specific year
relative to largest annual number recorded. I used only data from the International Road Traffic
Accident Database. Results. The United States is a unique outlier. Fatalities in all 25 other countries
NSG 780Final Page 109
Accident Database. Results. The United States is a unique outlier. Fatalities in all 25 other countries
declined further after reaching their maxim um values. For example, the United States and the
Netherlands both reached maximum values in 1972. From 1972 to 2011 US deaths declined by 41%,
whereas those in the Netherlands declined by 81%. If US fatalities had declined by 81% there would
have been 22 000 fewer US road deaths in 2011. If the United States matched percentage declines of 6
additional countries, US deaths would have declined by more than 20,000. Conclusions. If US traffic
deaths had declined by the same percentage as in any 1 of 7 other countries, more than 20 000 fewer
Americans would have been killed in 2011.
Harm from road traffic crashes is arguably the largest public health problem facing the United States.
Annually, more than 30 000 Americans are killed on our roads. *That is more than 90 deaths per day.
(Also, there are more than 3000 injuries per day.) Large though these numbers are, they reflect
inadequately the harm from traffic crashes. Unlike victims of diseases, those killed in traffic are
overwhelmingly young and, absent their crash, could have looked forward to a life of normal longevity in
normal health. The victims include more than 500 children younger than 7 years killed annually, which
surely should be more than adequate to terminate any discussion that the victims are all responsible for
their fate. Additionally, many die in the womb.
Three reasons help explain why harm from traffic is not recognized as the massive public health problem
it is:
1. The word “accident” conveys a sense of inevitability, a belief that crashes are owing to fate and that
nothing can be done. Perhaps this is what gives “accident” its most potent appeal—the sense that it
exonerates participants and, more importantly, policymakers from responsibility. Although many safety
professionals and publications10'11 no longer use this term, it is still in wide general use.
2. Harm in traffic is still not regarded in the United States as a component of public health to be
addressed by public health countermeasures.12 Traffic safety has all too often been seen as an irritating
appendage to transportation. Speed enforcement, a highly effective safety intervention13’14 if
deployed properly, is often aimed more to raise revenue than to prevent deaths. There is no other
aspect of public health that is viewed as a potential source of government revenue rather than a
government duty to protect its citizens from being harmed by others.
3. Policymakers are often unaware that traffic safety has been studied as a science for more than 75
years. Insights in the 1938 article in the American Journal of Psychology titled “A theoretical field
analysis of automobile driving” are routinely ignored. An edifice of scientific understanding supported by
a deep technical literature has blossomed since then. Despite this, all too many Americans, from
adolescents to the highest ranking policymakers, think they are traffic safety experts because they drive.
This is akin to thinking they are pulmonology experts because they breathe.
The launching pad for this research appears in my 2004 book Traffic Safety}-25'26 I compared US traffic
safety policy with that in 3 other countries—Great Britain, Canada, and Australia—which were chosen
because they have much in common with the United States in terms of language, culture, beliefs, and
traditions, and because suitable data were available. I compared performance over the 23-year period
1979-2002, the latest data available when I performed the earlier research. I chose 1979 as a reference
year because in the late 1970s and early 1980s US traffic safety policies began to diverge from those in
other countries. Comparing raw fatalities was 1 of 3 measures I examined 25 The others were fatalities
per registered vehicle and fatalities for the same travel distance. In all cases the results of the
comparisons were similar. US performance was so dramatically worse than that of the comparison
countries that an additional more than 10 000 deaths per year were occurring on US roads in 2002 or,
when summed over the period 1979-2002, an additional 200 000 American deaths. One of the most
common questions from Americans to these findings was “What is so special about the comparison
countries that they do so enormously better than the United States?” One purpose of the research is to
more definitively answer whether it is the United States or the comparison countries that are special.
Questions lingered regarding the earlier study. Perhaps the 3 comparison countries were exceptional at
reducing fatalities. Perhaps the comparison countries simply did exceptionally well in the 197 9 -2 0 0 2
period, but the United States would experience similar success later as progress in the comparison
countries stagnated or faltered.
I have addressed 3 questions: (1) Do the conclusions derived from data through 2002 persist? (2) Are
claims that the 3 comparison countries were not “special” validated by other countries? (3) Are even
stronger conclusions now validated with even more clarity and confidence?
RESULTS From 1979 to 2002 fatalities in the United States declined by 16% (from 51 093 in 1979 to 43
005 in 2002; Table 1). Taken in isolation this might look like impressive progress. Indeed, US officials
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005 in 2002; Table 1). Taken in isolation this might look like impressive progress. Indeed, US officials
hailed it as showing that their policies were highly successful. However, when the US 16% reduction is
compared with the average reduction of 49% computed from Table 1 for the 3 comparison countries, an
entirely different conclusion is unavoidable. Figure 1 a provides no evidence that after 2002 the large
difference between the United States and the comparison countries was cancelled. On the contrary, the
United States barely kept parallel with Canada and Australia but fell even further behind Great Britain.
Figure 1b shows the evolution of fatalities in the United States and the 3 comparison countries since
each attained its maximum number (Equation 1). Plots have different numbers of points because each
country achieved its maximum in a different year (listed in the last column in Table 1).
Figure 2 a shows the United States and the 3 comparison countries compared with a number of other
countries that achieved larger reductions than did the 3 comparison countries. Japan, Sweden, and
other countries are not plotted because their data largely overlap with those of Great Britain, the
original comparison country that attained the largest fatality reductions.
Clearly, the original 3 comparison countries were not uniquely successful. If I had chosen other
countries, the measured difference between them and the United States would have been even larger.
Figure 2b, which includes all the graphs in Figure 2a, shows data for all 26 countries. In this
representation the individual countries are not always distinct. The striking feature is the way the United
States stands out from all the others—fatalities in each of the other 25 countries dropped further from
their highs than occurred in the United States.
DISCUSSION The conclusions as determined by data through 2002 persist, the earlier comparison
countries were not particularly special, and the conclusions, now supported with enormously more data,
are even more firmly established. All the fatality rates examined declined in the United States over the
past 4 decades. However, they declined more rapidly in each of the other 25 countries, in most cases far
more rapidly. In terms of declines after reaching a maximum number of fatalities, the United States is a
unique outlier. All 25 other countries declined further and faster. The differences found are of such
enormous magnitude as to be largely unaffected by explanations in terms of confounding factors, which
in any event are mainly rendered moot by the Equation 1 measure and additionally by the other
measures in Figure 3. The United States was the safest country in the world in the 1970s. By 2011 the
United States dropped from number 1 to number 19 in terms of traffic fatalities per registered vehicle
and to number 13 (out of 19 countries providing data) in terms of traffic fatalities for the same travel
distance. The failure of the United States in traffic safety is of near incomprehensible magnitude. By
simply matching the road safety changes in a number of other unremarkable countries, the United
States could prevent 20 000 traffic deaths per year. US safety policy continues to be a public health
catastrophe. If the United States could only match the far from perfect safety performance of a number
of other countries, 20 000 fewer Americans would be killed annually and almost a million injuries
prevented. An explanation of why this happens is given in an editorial43 in this issue. As a US citizen and
member of the US National Academy of Engineering, it pains me to come to these conclusions.
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member of the US National Academy of Engineering, it pains me to come to these conclusions.
However, the data speak for themselves, and the conclusions are inescapable. They apply only to road
safety; the United States is the world leader in other safety areas, such as air travel.
Evans, L. (2014). Twenty thousand more Americans killed annually because U.S. traffic safety
policy rejects science, American Journal of Public Health, 104(8), 1349-1351.
Twenty Thousand More Americans Killed Annually Because US Traffic-Safety Policy Rejects Science
If traffic fatalities in the United States had declined by the same percentage as occurred in any one of
seven other countries, 20 000 fewer Americans would be killed each year. So concludes an article in this
issue.1 Here I propose that these additional Americans die because the United States excludes science
from influencing traffic-safety policy. This happens largely because of the uniquely powerful role of
litigation in the United States. The 20 000 value was derived by straightforward quantitative analyses.
A similar process cannot explain why the United States performs so poorly. My explanation here flows
from a more than four-decade career devoted to the science of traffic safety. I have personally observed
and discussed traffic in 58 countries, and have addressed professional traffic safety audiences in 30 of
them, learning from colleagues from all over the world.
My explanation also draws upon perspectives gained from growing into adulthood outside the United
States. When my 1991 book2 was being written, US traffic safety was nearly the best in the world. By my
2004 book,3 other countries had far outperformed the United States. This precipitated a chapter titled
“The Dramatic Failure of US Safety Policy.” My 2014 article1 analyzes vastly more data and leads to even
more certain, stark, and robust conclusions.
KEY TO US FAILURE IS REJECTION OF SCIENCE
Traffic safety has been studied as a science for more than 75 years. A 1938 article in the American
Journal o f Psychology4 was an early contribution to what is now a vast scientific literature supporting a
solid scientific edifice. In the early 1970s the National Highway Traffic Safety Administration (NHTSA)
sponsored a study in which multidisciplinary teams of experts examined in detail thousands of crashes.5
The study concluded that the road user was a sole or contributing factor in 94% of crashes. The vehicle
was the sole contributor in 2% of crashes, the same percentage as found in a British study. The vehicle
factors identified were generally maintenance related (worn brakes, bald tires, etc.). These have more to
do with road user behavior than vehicle design or manufacture
U S Policy Not Random , But Topsy-Turvy
Copious research confirms with ever-solidifying reliability what might be called a fundamental traffic
safety “law”: vehicle factors are important, but less important than roadway factors, which are far less
important than road-user factors. Despite sponsoring research confirming this law, NHTSA spearheads
misinformation that safety is mainly to do with vehicles, with its ongoing emphasis on recalls, crash test
results, new vehicle safety technology, and biomechanics research. Science shows that all of these have
relatively little to do with traffic safety. The core of the resulting topsyturvy policies is an obsessive focus
on the least important factor, vehicles, leaving insufficient energy for the most important factor, drivers.
Another component of NHTSA’s focus on vehicles was a multidecade obsession with airbags. These can
affect safety, but far less than behavioral changes (belt wearing, reduced speeds, reduced drunk-driving,
etc.). NHTSA might be better named the National VEHICLE Safety Administration. While NHTSA has
certainly done much good, the following conclusion seems inescapable. The net effect of NHTSA is to
increase the number of US road deaths.
An Example: Toyota Phantom Acceleration An allegation that 19 deaths were associated with sudden
unintended acceleration in Toyota vehicles triggered an all-day televised session of a US Congressional
Committee on February 24, 2010. A contrite Toyota acknowledged that a poorly fitting carpet could
sometimes impede the accelerator pedal from reverting to its neutral position. The matter generated
massive media coverage, providing the lead item in nearly all news coverage. The 19 deaths were
alleged to have occurred in the previous decade.6 Over that same 2000-2009 decade, 22 574 people
were killed traveling in Toyota vehicles7 (Table 1). Almost none of these deaths had anything to do with
technology, defective or otherwise. The problem was overwhelmingly intended acceleration. The nation
was obliged to squander resources looking for an alleged electronic flaw in the vehicle in response to
other claims.8 Those familiar with the subject (and a similar 1985 Audi 500 case) knew the search was
futile. Identical vehicles sold outside the United States did not exhibit the alleged hazard.
Why Science Is Not Relevant To Policymaking
Over the decade in which 19 people were killed in crashes for which a sticky Toyota pedal was identified
as one factor, 419 483 people died on the roads of the United States. Yet the US Congress, responsible
for the nation’s laws, grandstands 19 deaths while almost ignoring 419 483. US policy is driven not by
science, nor even by bare facts or even simple arithmetic, but by financial gain for lawyers.
The money paid out by Toyota for sudden acceleration claims includes, as just one item, a $1.6 billion
settlement of a class-action suit,9 with a final total estimated at $3.1 billion. Plaintiffs’ lawyers likely
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settlement of a class-action suit,9 with a final total estimated at $3.1 billion. Plaintiffs’ lawyers likely
pocket more than a billion dollars. Settlement details are kept secret—yet another example of “damn
the public interest” in favor of lawyers’ interests. The recipients of such largess are well situated to
contribute to the politicians who created and maintain this killing system. The problem is not so much
the lawyers doing lawyering, but the lawyer legislators making laws that benefit themselves but plunder
and kill their constituents.
The Role of the Media
The Toyota case is an example of the way the media misinforms the public that safety has to do with
vehicles. Even more harmful is the almost daily bombardment under the banner of “safety,” of stories
like “A million xyz manufacturer vehicles were recalled because of a safety defect in such and such a
system. No injuries are reported.” Of what possible relevance to safety can this be to citizens in a nation
in which 90 people are killed daily, and around 3000 injured?
How US Safety Policy Is Made
Influence on policy is largely a question of lobbying with cash. The legislators are themselves nearly all
lawyers and sympathetic to the arguments and interests of other lawyers. NHTSA employs many
excellent, indeed some outstanding, safety scientists. Yet, in late 2013,10 the most senior traffic safely
official in the United States, the NHTSA Administrator, is a lawyer. His boss, the Secretary of
Transportation, is a lawyer (married to another lawyer), and his boss, the President of the United States,
is a lawyer (married to another lawyer). What they all additionally have in common is that none has any
technical qualification. Goals and skills of lawyers and scientists are fundamentally opposite. The duty of
an “ethical" lawyer is to persuade others to favor their clients’ position, regardless of its justice, logic, or
merits, or whether it harms the public It is not necessary for policymakers to be technical. However, for
technical subjects like traffic safety, they should recognize, respect, and seek technical expertise, and
should favor interventions that scientific research shows will improve public health.
How to Reduce Traffic Deaths
The finding of 20 000 additional American deaths was based on comparisons with other countries. All
countries fall well short of ideal. Laws in democracies are made by legislators keenly interested in being
reelected. The better performing countries support traffic safety research institutions and take seriously
the scientific knowledge they provide. Their top safely officials are often a members of the same
scientific community to which I belong. Their citizens are more likely to have a reasonable
understanding of what is important to traffic safety than are Americans. Since the terrorist attacks that
killed 3000 Americans on September 11, 2001, deaths on US airlines have been rare events, averaging
less than 20 per year. Since that date, more than 450 000 Americans have been killed in traffic crashes,
including more than 8000 children aged seven years or younger. When 20 children of similar age were
killed at Sandy Hook Elementary School, President Obama became prominently involved, as he did again
on the one-year anniversary of the tragedy. Yet there is little governments can do to protect against
deranged gunmen. They strike in many countries, the largest loss of life being a 2011 incident in
Norway.
In sharp contrast, every aspect of traffic involves government. Governments design and build roads,
regulate and inspect vehicles, pass and enforce traffic laws, and license and discipline drivers, ft is
government’s responsibility to take unremarkable steps that already apply in other countries to prevent
the deaths of 20 000 Americans (including more than 300 children aged seven years or younger). Traffic
deaths can be sharply reduced by sensible traffic laws sensibly enforced for a public aware that by far
the biggest risk to them and their families is from vehicular traffic.3 At core is the sober driver problem.
Speed is key—modest speed reductions produce large risk reductions. If alcohol were eliminated
completely we would still kill more than 20 000 per year. Speeders can be restrained by radar speed
detection technology already successfully deployed in some countries. The goal must be to reduce
injuries by preventing speeding, not to punish speeders. US safety policy continues to be a public health
catastrophe. Government and other institutions (media, insurance industry, and auto industry) endlessly
reinforce that traffic safely is largely about vehicles. This orgy of toxic misinformation causes massive
death and injury. Science shows that traffic safety is overwhelmingly about road-user behavior. The
United States can make sharp reductions in casualties only when public policy loudly proclaims this in
law and daily media coverage.
• U.S. Department of Health and Human Services (DHHS). (2016). Stay safe at work. Available
at http://www.healthfinder.gov/HealthTopics/Category/everyday-healthyliving/safety/stay-safe-at-work
Stay Safe at Work
The Basics: Overview
Staying safe at work is very important. If you don't work in a safe way, you can get hurt or become
sick. The good news is that there are things you can do – both at work and at home – to lower your
chances of getting hurt.
Take these steps to prevent injuries at work:
• Lift things safely.
• Arrange your equipment to fit your body.
• Take short breaks and stretch.
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• Take short breaks and stretch.
• Wear protective equipment.
• Ask about health resources at work.
Your overall health can also affect how you feel and perform at work. To be able to work safely, it's
important for you to:
• Get enough sleep.
• Eat a healthy diet.
• Stay active.
• Watch your weight.
• Take steps to manage stress.
ENVIRONMENTAL HEALTH ISSUES--MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
Environmental health encompasses preventing and controlling disease, injury and disability
related to the interactions between individuals and their environment. The WHO defines
environment as it relates to health as “all the physical, chemical, and biological factors external
to a person, and all the related behaviors.”
Approximately 10% of premature morbidity and mortality in the U.S. is attributed to
environmental causes. On the international level, the WHO estimates that nearly 25% of the
total disease burden and 25% of deaths can be attributed to environmental factors that include:
• Exposures to hazardous substances in the air, water, soil and food
• Natural and technological disasters
• Physical hazards
• Nutritional deficiencies
• The built environment
In 2010 the American Nurses Association recognized the critical need to understand
environmental health issues and added an Environmental Health Standard to its Scope and
Standards of Practice.
Prevention
The Precautionary Principle enunciated in the 1998 Wingspread Statement as “when an
activity raises threats of harm to human health or the environment, precautionary measures
should be taken even if some causes and effect relationships are not fully established
scientifically,” is a fundamental tenant for all environmental health endeavors.
Population and community-based strategies that target reducing environmental health risks
include:
• Decreasing air pollution
• Protecting and minimizing drinking water and recreational water from infectious or
chemical agents
• Reducing exposure to toxic substances and hazardous waste
• Maintaining healthy homes and communities by reducing exposure to indoor air pollution,
inadequate heating and sanitation, structural problems, electrical and fire hazards and
lead-based paint hazards
• Building capacity to measure and respond to environmental health hazards
• Increasing access to adequate water and sanitation facilities (global priority)
Poor environmental quality has its greatest impact on people whose health status is already at
risk. As a result, environmental health initiatives must also address the societal and
environmental factors that increase the likelihood of exposure and disease.
For more information review the required reading:
Healthy People 2020. (2016). Environmental health. Available
at http://www.healthypeople.gov/2020/topics-objectives/topic/environmental-health
POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF ENVIRONMENTAL HEALTH
ISSUES
National
The CDC National Center for Environmental Health (NCEH) and the Agency for Toxic
Substances and Disease Registry (ATSDR) Strategic Plan for Fiscal Years
2014-2016 emphasize investigating the relationship between environmental factors and health
and developing guidance and building partnerships to support healthy decision making.
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Its goals are:
1. Implement environmental health programs and interventions to protect and promote
health
○ Build capacity of the state, tribal, local and territorial workforce to anticipate, assess
and respond to environmental exposures and conditions
○ Strengthen collaborations between environmental public health and healthcare
○ Reduce asthma morbidity and mortality through comprehensive asthma control
activities
○ Ensure safe drinking water by assessing, preventing or mitigating waterborne
exposures and diseases associated with unregulated drinking water sources
○ Develop strategies to prevent and minimize adverse effects from known and
emerging environmental health challenges, including unsafe food, air pollution and
climate change
○ Investigate, reduce and prevent environmental threats in neighborhoods and
communities, with particular focus on vulnerable populations or those bearing a
disproportionate burden
○ Develop and strengthen interventions and practices to promote healthy land use,
healthy land use, healthy and safe community design initiatives and safe home and
indoor environments
2. Prepare for and respond to public health emergencies including chemical, biological,
radiological and nuclear incidents, natural disasters and extreme weather events
○ Enhance the nation’s capacity to respond to environmental health emergencies
through the use of epidemiology, laboratory science and integrated preparedness
and responsive planning with federal, state, tribal and local partners
○ Provide support to people, communities and environmental public health systems to
recover and rebuild after environmental incidents
○ Guide threat assessment, risk reduction and resilience building efforts to lessen the
impact of environmental threats and promote healthy community environments
3. Identify, characterize and monitor health outcomes and environmental health
exposures to guide actions that protect and promote health.
○ Develop and use new tools and technologies to better anticipate and quantify
exposures in populations, especially vulnerable sub-populations such as children,
the elderly, low-income individuals and minority groups
○ Provide more complete, relevant timely and accurate data through environmental
health surveillance and tracking
○ Advance the development and interpretation of human health risk estimates from
exposure to environmental hazards
○ Provide laboratory science that improves the detection, diagnosis, treatment and
prevention of disease resulting from exposure to environmental hazards
For more information of the NCHE/ATSDR Strategic Plan review the required reading:
Centers for Disease Control and Prevention (CDC). (n.d.). NCEH/ATSDR Strategic plan: Fiscal
years 2014-2016. Available
at http://www.cdc.gov/nceh/information/nceh_atsdr_strategic_plan_2014_final.pdf
Statewide
The Maryland Department of Health and Mental Hygiene’s Environmental Health
Bureau focuses on:
• Surveillance of environmental, occupational and injury conditions and exposures
• Regulation and control of hazards in food, home environments and the community
• Response to new and emerging hazards and environmental threats such as global climate
change
Click here for more information on environmental health in Maryland. click here.
Alliance of Nurses for Healthy Environments: An international effort started by the University of
Maryland School of Nursing
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Maryland School of Nursing
The Alliance of Nurses for Healthy Environments (ANHE) is an international network of
nurses who are acting on the premise that the environment and health are inextricably
connected. ANHE is working to integrate environmental health intro nursing education, green
health care workplaces, incorporate environmental exposure questions into patient histories,
provide anticipatory guidance to pregnant women and parents about environmental risks to
children, implement research that addresses environmental health questions and advocate for
environmental health in the workplace and governmental institutions.
Watch this video to get a sense of the work of ANHE.
The University of Maryland School of Nursing offers an on-line certificate in Environmental
Health. For more information click here.
OCCUPATIONAL HEALTH ISSUES--MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
The National Institute for Occupational Safety and Health (NIOSH) is dedicated to the safety
and health of the 155 million workers in the U.S. NIOSH focuses on research needed to prevent
the societal cost of work-related fatalities, injuries and illnesses which are estimated at $250
billion in medical costs and productivity in addition to the huge toll on workers, their families,
businesses, communities and the nation’s economy.
The Bureau of Labor Statistics reports that 4,821 work-related injury deaths occurred in 2014.
This averages to 92 deaths a week or more than 13 deaths a day. Construction fatalities rank
number one with over 20% or one in five worker deaths. The leading causes of worker deaths
in construction are falls followed by struck by an object, and caught-in/between.
The estimated annual burden of occupational disease mortality resulting from selected
respiratory diseases, cancer, cardiovascular disease, chronic renal failure and hepatitis is
49,000, with a range of 26,000 to 72,000. When occupational disease and injury data are
combined, an estimated 55,200 deaths occur annually for occupational disease or injury with a
range of 32,000 to 78,200. Occupational deaths are estimated to be the 8th leading cause of
death in the U.S.
Sources:
Bureau of Labor Statistics Total Fatal injuries in all sectors Available
at http://data.bls.gov/timeseries/FWU00X00000080N00
National Institute for Occupational Safety and Health Factsheet (2015) Available
at https://www.cdc.gov/niosh/docs/2013-140/pdfs/2013-140.pdf
Steenland, K., Burnett, C., Lalich, N., Ward, E, & Hurrell, J. (2003). Dying for work: The
magnitude of US mortality from selected causes of death associated with occupation. American
Journal of Industrial Medicine, 43(5), 461-82. Available
at http://www.ncbi.nlm.nih.gov/pubmed/12704620
U.S. Department of Labor. (n.d.). Commonly use statistics. Available
at https://www.osha.gov/oshstats/commonstats.html
Prevention
Workers spend a quarter of their lifetime and up to half of their waking lives at work or
commuting.Therefore, the workplace provides a unique setting for public health action. DHHS
identifies back injuries as the leading cause of workplace disability and recommends the
following basics to reduce the risk of injury or illness:
• Lift things safely
• Arrange equipment to fit and prevent repetitive motion injuries
• Take short breaks and stretch muscles
• Eat a healthy diet and stay active
• Maintain a healthy weight
• Get enough sleep
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• Get enough sleep
• Take steps to manage stress
• Identify health resources in the workplace
For additional information review the required reading:
U.S. Department of Health and Human Services (DHHS). (2016). Stay safe at work. Available
at http://www.healthfinder.gov/HealthTopics/Category/everyday-healthyliving/safety/stay-safe-at-work
Addressing occupational safety and health is challenged by several key factors:
• Increasing diversity of the workforce resulting in some workers having increased risks of
work-related diseases and injuries, particularly: racial and ethnic minorities, recent
immigrants, younger and older workers, workers with genetic susceptibilities and workers
with disabilities
• Workplaces are rapidly evolving as jobs in the current economy continue to shift from
manufacturing to services
• Changes in the way work is organized—longer hours, compressed work weeks, shift work,
reduced job security, part-time and temporary work
• New chemicals, materials, processes and equipment are being developed at an
accelerating pace which poses emerging risks to worker health
OSHA is actively involved in promoting injury and illness preventions programs for the
workplace. Click here for general guidance.
POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF OCCUPATIONAL HEALTH
ISSUES
National
The National Occupational Research Agenda (NORA) is a partnership program to foster
innovative research and improved workplace practices. Since 1996 NORA has served as the
research agenda for NIOSH and the nation.
NORA Priorities are based on:
• Number of workers at risk for a particular injury or illness
• Seriousness of the hazard or issue
• Probability that new information and approaches will make a difference
NORA is comprised of ten sectors that include:
• Agriculture, Forestry and Fishing
• Construction
• Healthcare and Social Assistance
• Manufacturing
• Mining
• Oil and Gas Extraction
• Public Safety
• Services
• Transportation, Warehousing and Utilities
• Wholesale and Retail Trade
The Healthcare and Social Assistance sector includes an estimated 19 million paid workers in
ambulatory healthcare services, hospitals, nursing and residential care facilities and social
assistance settings who face risks including infectious diseases, workplace violence,
overexertion, chemicals, shift-work and psycho-social stressors. The Healthcare and Social
Assistance sector focuses on the information needed to reliably protect caregivers’ health and
safety and ensure patient safety, given the high hazard nature and risk of injury in this work
sector. Its agenda includes ten strategic goals designed to address top safety and health
concerns and to promote the greatest opportunities to increase protections within the
sector. Five goals focusing on healthcare workers specifically include:
1. Promote safe and healthy workplaces and optimize safety culture in healthcare
organizations
2. Reduce the incidence and severity of musculoskeletal disorders (MSDs) among workers in
the healthcare and social assistance sector
3. Reduce or eliminate exposures and adverse health effects caused by hazardous drugs
and other chemicals
4. Reduce sharps injuries and their impacts among all healthcare personnel
5. STOP transmission of infectious diseases in healthcare and social assistance settings
among workers, patients and visitors.
For additional information on the National Healthcare and Social Assistance Agenda, review
the recommended reading:
NORA Healthcare and Social Assistance Sector Council (NORA). (2013). National healthcare
and social assistance agenda. Available
at http://www.cdc.gov/niosh/nora/comment/agendas/hlthcaresocassist/pdfs/HlthcareSoc
AssistFeb2013.pdf
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AssistFeb2013.pdf
For more information on the Healthcare and Social Assistance sector click here.
To review the workplace violence prevention course designed specifically for nurses developed
by a team of experts including the SON’s Jane Lipscomb, PhD, RN, FAAN, professor,
Community/ Public Health, click here.
For information on priorities for other NORA sectors, click here.
Total Worker Health (TWH) Program
In 2011, NIOSH launched the Total Worker Health (TWH) Program which integrates
occupational safety and health protection with health promotion to prevent worker injury and
illness and to advance worker health and well-being. TWH involves the comprehensive
development and implementation of organizational programs, policies and practices that
minimize or eliminate workplace physical, biological and psychosocial hazards and risks,
promote healthy behaviors and provide resources for maintaining and optimizing a safe, healthy
and productive workforce on and off of the job.
TWH strategies and interventions include:
• Provision of mandated respiratory protection programs that simultaneously and
comprehensively address and provide supports for tobacco cessation
• Ergonomic consultations that discuss work design, joint health and arthritis prevention and
management strategies
• Provision of onsite, comprehensive workplace screenings for work and non-work related
health risks
• Models that combine occupational health services with workplace primary care
• Regular communication and demonstration of senior leadership and management
commitment to support a culture of health of safety and health across the organization
• A systems-level approach that coordinates the organizational alignment (i.e., reporting,
funding) of traditional safety and environmental health programs, occupational health
clinics, behavioral health, workplace health promotion programs, health benefits and
compensation and disability management
For more information click on the required reading on TWH
at http://www.cdc.gov/niosh/twh/totalhealth.html
Statewide Programs
Maryland Occupational Safety and Health (MOSH) is housed within the Maryland
Department of Labor, Licensing and Regulation. Its mission is to promote and assure workplace
safety and health and reduce workplace fatalities, injuries and illnesses. MOSH has jurisdiction
over all public and private sector workplaces in the state, with the exception federal employees
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over all public and private sector workplaces in the state, with the exception federal employees
and private sector maritime activities which are covered under OSHA jurisdiction. MOSH
focuses on serious hazards and dangerous workplaces; it enforces workplace laws and
regulations, conducts inspections, provides consultation services and compliance assistance,
offers outreach, education and cooperative programs and maintains statistical data on fatal and
non-fatal workplace injuries and illnesses. The MOSH Strategic Plan for 2013-2017 available
at http://www.dllr.state.md.us/labor/mosh/moshplan.shtmlidentifies the following goals:
• Improve workplace safety and health through compliance assistance and enforcement of
occupational safety and health regulations
• Promote a safety and health culture through compliance assistance, cooperative programs
and strong leadership
• Secure public confidence though excellence in the development and delivery of MOSH
programs and services.
For more information on MOSH view the YouTube video
at http://www.dllr.state.md.us/labor/mosh/moshvideos.shtml
UNINTENDED INJURIES AND VIOLENCE—MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
Unintentional injuries and acts of violence are among the top 15 causes of death in the
U.S. Unintentional injury is the leading cause of death for ages 1-44 and the fourth leading
cause of mortality in the U.S.
Injury Deaths Compared to Other Leading Causes of Death for Persons Ages 1–44, United
States, 2011
More than 199,800 deaths from injury occur each year, one person every three minutes.
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Source: http://www.cdc.gov/injury/images/lccharts/leading_causes_of_death_age_group_2014_1050w760h.gif
Healthy People 2020 identifies injuries are a leading cause of disability for all ages, regardless
of sex, race, ethnicity or socioeconomic status. CDC estimates that 2.5 million people are
hospitalized and 26.9 million people are treated in emergency departments for injury each
year. Unintentional falls are the leading cause of nonfatal injuries treated in hospital emergency
departments and twice as prevalent as the non-fatal injuries that follow including unintentional
struck by/against, unintentional overexertion, unintentional motor vehicle accidents.
Violence and injuries extend beyond the injured person to family members, friends co-workers,
employers and communities and cost more than $671 billion in medical care and lost
productivity each year. Each year in Maryland, more than $200 million in emergency
department charges and $835 million in hospitalization charges are incurred as a result of injury.
Sources:
Centers for Disease Control and Prevention. (2016). Leading causes of death. Available
at http://www.cdc.gov/injury/overview/leading_cod.html
Johns Hopkins Center for Injury Research and Policy. (2012). Preventing injuries in
Maryland: A resource for state policy makers. Available
at http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-injuryresearch-andpolicy/publications_resources/CenterPubs/PolicyResource2012/JHCIRP_POSTbook.pdf
Source: http://www.cdc.gov/injury/images/lc-charts/leading_cause_of_nonfatal_injury_
2013-a.gif
Factors that affect unintentional injury and violence:
• Individual behaviors—alcohol use or risk-taking
• Physical environment in the home and community can increase/decrease risk of falls, fire
road traffic injuries, drowning and violence
• Access to health services, ranging from prehospital to acute care to rehabilitation, effect
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• Access to health services, ranging from prehospital to acute care to rehabilitation, effect
the consequences of injuries including death and long-term disability
• Social environment
○ Individual level—social norms, education, victimization history
○ Social relationships—parental monitoring and supervision, peers, family interactions
○ Community environment—cohesion in schools, neighborhoods, communities
○ Societal-level factors—cultural beliefs, attitudes, incentives and disincentives, laws
and regulations
Prevention
Violence and injuries can be prevented and their consequences reduced. Healthy People
2020 identifies efforts to prevent unintentional injuries that include:
• Modifications of the environment
• Improvements in product safety
• Legislation and enforcement
• Education and behavior change
• Technology and engineering
Healthy People 2020 identifies efforts to prevent violence that include:
• Changing social norms regarding the acceptability of violence
• Improving problem-solving skills
• Changing policies to address social and economic conditions the promote violence
The track record for success in prevention of unintentional injury and violence is strong. CDC
identifies:
• School-based programs to prevent violence have been shown to cut violent behavior 29%
among high school students and 15% across all grade levels.
• Comprehensive graduated drivers licensing programs show reductions of 38% in fatal and
40% in injury crashes among 16 year old drivers
• Seat belts have saved an estimated 255,000 lives between 1975 and 2008.
• Ignition interlocks, or in-car breathalyzers, can reduce the rate of re-arrest among drivers
convicted of driving while intoxicated by a median of 67%
Source: Centers for Disease Control and Prevention (CDC). (2016). Saving lives and protecting
people from violence and injuries. Available
at http://www.cdc.gov/injury/overview/index.html
International comparison studies show that traffic fatalities can be reduced substantially, if the
U.S. begins to focus on scientific evidence when establishing traffic-safety policy. Estimates
are as high as 20,000 lives saved each year in the U.S., if road user behavior is modified
through sensible traffic laws targeting modest speed reductions and sober driver
enforcement. Current studies show that road user behavior is responsible for 94% of crashes
and it is not being adequately addressed. In the U.S., emphasis has been on vehicle design
and manufacture which account for only 2% of deaths as compared to other countries where
road user behavior is the focus.
Traffic fatality changes in the U.S. compared to Great Britain, Canada and Austria
For more information review the required readings on potential traffic fatality reductions:
• Evans, L. (2014). Traffic fatality reductions: United States compared with 25 other
countries. American Journal of Public Health, 104(8), 1501-1507. Available
at http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2014.301922
• Evans, L. (2014). Twenty thousand more Americans killed annually because U.S. traffic
safety policy rejects science, American Journal of Public Health, 104(8), 1349-1351.
Available at http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2014.301919
POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF UNINTENDED INJURIES AND
VIOLENCE
National
CDC’s Injury Center is the U.S. focal point for the public health approach to preventing
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CDC’s Injury Center is the U.S. focal point for the public health approach to preventing
violence and injuries and their consequences by bridging science and implementation. Its
current focus areas include:
• Motor vehicle injury
• Prescription drug overdose
• Child abuse and neglect
• Older adult falls
• Sexual violence
• Youth sports concussion
CDC Injury Center Research Priorities
Unintentional Injury Prevention
•
•
•
•
Prescription drug overdose
Falls among older adults
Motor vehicle injury
Traumatic brain injury
Violence Prevention
• Cross cutting violence prevention
• Child abuse and neglect
• Youth violence
• Intimate partner violence
• Sexual violence
• Self-directed violence
Click here to learn more about the research priorities.
Statewide
The Maryland Department of Health and Mental Hygiene Bureau of Environmental Health
houses both the Program for Injury Prevention and the Rape and Sexual Assault Prevention
Program. The Injury Prevention Program focuses on:
• Fall prevention
• Bicycle related health injuries
• Fire safety
• Heat related illnesses
• Motor vehicle facts
• Pedestrians
• Playground safety
• Shaken baby syndrome
• Water safety
The Rape and Sexual Assault Prevention Program provides education, training and support
services for victims, health professionals and the general public aimed at sexual violence
prevention and early intervention. Its programs target:
• School-based sexual harassment/assault prevention
• Community-based rape and sexual assault prevention
• College-based sexual assault prevention
For more information on the Injury Prevention Program
click http://phpa.dhmh.maryland.gov/ohpetup/Pages/eip.aspx
For more information on the Rape and Sexual Assault Prevention Program
click http://phpa.dhmh.maryland.gov/ohpetup/Pages/rsapp_home.aspx
Click here for more information on injury prevention and epidemiology.
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Click here to learn more about the strategic plan.
The strategic plan for the future of injury and violence prevention in Maryland 2006-2016 in
conjunction with the Partnership for a Safer Maryland aims to elevate injury and violence
prevention in Maryland to a level that is commensurate with the tremendous toll that injuries
cause. The plan emphasizes:
• Building a solid infrastructure for injury prevention
• Collecting and analyzing state data
• Designing, implementing and evaluating interventions
• Providing technical assistance and support
• Affecting public policy
• Providing a structure for addressing injury topics through a series of three year risk factor
reduction campaigns
Johns Hopkins Center for Injury Research and Policy has an ongoing series of reports on
preventing injuries in the state that serve as a resource for policy makers. It identifies how
unintentional injuries and violence affect Marylanders and how the state is addressing the
problem in the following areas:
• Alcohol and injury
• All-terrain vehicle safety
• Distracted driving
• Falls among older adults
• Home fires
• Intimate partner violence
• Motorcycle safety
• Poisoning
• Teen drivers
• Trauma and trauma systems
Source: http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-forinjury-research-andpolicy/publications_resources/CenterPubs/PolicyResource2012/JHCIRP_POSTbook.pdf
For more information click here and review the required reading….
Johns Hopkins Center for Injury Research and Policy. (2012). Preventing injuries in Maryland: A
resource for state policy makers. Available at http://www.jhsph.edu/research/centers-andinstitutes/johns-hopkins-center-for-injury-research-andpolicy/publications_resources/CenterPubs/PolicyResource2012/JHCIRP_POSTbook.pdf
NSG 780Final Page 123
policy/publications_resources/CenterPubs/PolicyResource2012/JHCIRP_POSTbook.pdf
From <https://cf.son.umaryland.edu/NRSG780/module12/subtopic6.htm>
NSG 780Final Page 124
Module 13: Critical Issues in Population Health
Tuesday, May 2, 2017
9:59 AM
OVERVIEW
The purpose of this module is to survey critical national and international population health
issues and to examine national and international approaches for prioritizing and building
partnerships to address these issues.
Objectives
At the conclusion of this module, the learner will be able to:
• Review the 5Ps: Populations, Prevention, Priorities, Partnerships and Policies
• Reinforce the importance of setting priorities and establishing partnerships to address
critical issues in population health
• Discuss the National Prevention Strategy
• Explain the importance of integrating primary care and public to address critical health
issues
• Discuss transnational trends in global health
• Describe critical health priorities on the international level
Required Readings
• page=17&Institute of Medicine (IOM). (2012). Primary Care and Public Health: Exploring
Integration to Improve Population Health. Introduction (pp. 17-44). Available
at http://www.nap.edu/openbook.php?record_id=13381
• CDC National Prevention Strategy: America’s Plan for Better Health and Wellness
Available at http://www.cdc.gov/Features/PreventionStrategy/
• National Prevention, Health Promotion and Public Health Council. (2011). National
Prevention Strategy: America’s Plan for Better Health and Wellness. (pp. 2-13). Available
at https://www.surgeongeneral.gov/priorities/prevention/strategy/
• World Health Organization (WHO). (2013). Global Action Plan for Prevention of Noncommunicable Diseases 2013-2020. (pp. 1-13). Available
at http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf
Directions
Read the module and suggested readings within the module. Then complete the assignment for
the module.
PRIORITIES AND PARTNERSHIPS
Reducing the leading causes of morbidity and mortality in the U.S. and globally requires a public
health rather than a case by case approach.
Recall the 5 Ps: The Public Health Approach = P5
1. Populations
Target for intervention: the country as a whole; a specific state, county, city, neighborhood
or specific group such as people at risk or with a particular disease
2. Prevention
Prevention Levels
○ Primary
○ Secondary
○ Tertiary
Prevention Strategies
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High-risk: focuses on identifying the relatively small number of individuals who are at
high risk in order to reduce their risk factor(s) and subsequent development of
disease
Population-based: focuses on changing behavior in large numbers of people, most of
whom have low or no risk at present, in order to prevent the development of risk
factors and disease
3. Partnerships
Activities undertaken within the formal structure of government
Associated efforts of private and voluntary organizations and individuals
4. Priorities
Resources are limited; therefore priorities must be established
5. Public Health Workforce
Assuring a competent public health and personal health care workforce
Given the risk factors and associated health issues highlighted throughout the semester, it is
critical to establish priorities, as both financial and manpower resources are limited. Using the
Public Health Framework for Priority Setting it is essential to consider the following questions:
• What is the magnitude of the problem?
• Have modifiable risk factors for the problem been identified?
• Does a reduction in the underlying risk factors lessen the magnitude of the problem?
• Have effective strategies for reducing these risk factors been developed?
• How much does it cost to reduce the risk factors?
• Can the program set rigorous goals and objectives and can they be accomplished?
NATIONAL PREVENTION STRATEGY
In 2011 the National Prevention, Health Promotion and Public Health Council issued
the National Prevention Strategy, a critical component of the Affordable Care Act that
establishes priorities to help our country improve its health status. Its vision is:
"Working together to improve the health and quality of life for individuals, families and
communities by moving the nation from a focus on sickness and disease to one based
on prevention and wellness.”
It builds upon evidence from:
• Healthy People 2020
• Guide to Community Preventive Services
• US Preventive Services Task Force
• IOM Reports
• Cochrane Reviews
The National Prevention Strategy prioritizes reducing risk for the five leading causes of
premature mortality – heart disease, cancer, chronic lower respiratory diseases, stroke, and
unintentional injury. It identifies lost productivity and costs in excess of $1 trillion due to chronic
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unintentional injury. It identifies lost productivity and costs in excess of $1 trillion due to chronic
physical and mental illness, which causes Americans to miss 2.5 billion days of work each year.
The National Prevention Strategy has established seven priority areas:
• 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
It focuses on building partnerships among federal, state, tribal and territorial governments;
business, industry and other private sector partners; philanthropic organizations; community and
faith-based organizations and ordinary citizens to improve health through prevention to create:
• Healthy and Safe Community Environments
• Expand Clinical and Community-based Preventive Services
• Empower People to Make Healthy Choices
• Eliminate of Health Disparities
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The National Prevention Strategy has also established 10-year morbidity and mortality
objectives for each of the priority areas.
For more information on the National Prevention Strategy, review the required reading:
National Prevention, Health Promotion and Public Health Council. (2011). National Prevention
Strategy: America’s Plan for Better Health and Wellness. (pp. 2-13). Available
at https://www.surgeongeneral.gov/priorities/prevention/strategy/report.pdf
INTEGRATING PRIMARY CARE AND PUBLIC HEALTH
Collaboration and Partnerships
The National Prevention Strategy is grounded in a collective approach to addressing health
priorities. It shifts from the conventional model of considering clinical medicine and public health
as two separate entities to developing a stronger model that includes an intersection between
clinical practice and public heath emphasizing partnerships and collaborations to enhance the
health of patients and the public.
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The movement toward collaboration and partnerships is taking hold on both the national and
international levels. It is being led by health professionals and students across the world and will
become one of the prevailing forces in health care in the 21st century. A landmark report on the
power of collaboration and the increasing dependence of the clinical and the public health
sectors in addressing health problems was issued by the New York Academy of Medicine in
1997.
Click here to review a monograph titled Medicine & Public Health: The Power of Collaboration.
Watch this video on Primary Care and Public Health to see examples of the powerful results of
collaboration.
Notes on video:
The integration of primary care and public health can enhance the capacity of both sectors to
carry out their respective missions and link with other stakeholders to catalyze a collaborative,
intersectoral movement toward improved population health.
Primary care MD's see pts on individual level, help people but can't address environmental
factors of disease
Public health officials monitor people and environmental things, don't see people one on
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Public health officials monitor people and environmental things, don't see people one on
one
Primary care and Public health need to integrate to make bigger strides
Align policy with investment
Example: Durham North Carolina- integrated Medicaid Providers, Health Department and
Local Hospitals to make and Outreach program for asthma education- went to schools,
churches and community gatherings, saw huge drop in ER rates in weeks, now used
across North Carolina
Something similar in Denver Colorado, educated patients and primary care MD's on best
asthma treatment
EMR's making data sharing better and it track reportable diseases
18% of adults have no consistent access to health care. 43 in infant mortality of list of
countries
IOM Reports on a Healthier Future
Interprofessional practice and enhancing the public health infrastructure is the dictate of recent
Institute of Medicine (IOM) reports on investing in a healthier future.
Institute of Medicine. (2012). For the Public's Health: Investing in a Healthier Future.
Washington, DC: The National Academies Press.
rimary Care and Public Health: Exploring Integration to Improve Population HealthInstitute
of Medicine. (2012). P. Washington, DC: The National Academies Press.
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Institute of Medicine. (2012). An Integrated Framework for Assessing the Value of
Community-Based Prevention. Washington, DC: The National Academies Press.
TRANSNATIONAL TRENDS
World health is a priority for all. This is a foundation of the medicine and public health
initiative. Many health problems transcend national boundaries and the health status of the
populations of all countries directly affects the global economy. Two million people cross
international borders every day.
The pace of international travel makes the spread of communicable diseases a priority for
everyone. In addition to influenza, Avian Flu, SARS, West Nile Virus, STDs, HIV/AIDS, TB and
Ebola, vaccine resistance and antibiotic resistance have alerted the general public to the
vulnerability of the population.
Global health is negatively affected by the spread of toxic and hazardous agents – fumes,
asbestos, fire, weapons, banned and illegal substances and the marketing of unhealthy
products across national boundaries.
Political changes can dramatically influence the health of a nation. The experience of
Afghanistan and Iraq showcase how political change and war influence global economies,
negatively affect the health status of populations and change the mindset of generations.
Review the WHO summary in the graphic below.
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Click here to view a larger image of the above graphic.
Transnational trends in global health:
•
•
•
•
•
•
•
•
•
•
•
Double burden of communicable and non-communicable diseases
Population growth and demographic changes
Environmental degradation
Globalization of markets with increased free trade
Increasing urbanization and rural deprivation
Widening gap between rich and poor
Continuing reduced opportunity and lower status of women
Changing nature of community and social support systems and societal democratization
Development of communication
Rising aggression, conflicts and human made catastrophes
Increasing transfer of hazardous work to developing countries
As noted throughout the semester, although health indicators for the U.S. show that our health
is generally improving, in too many sectors of the population the health indicators reflect those
of many developing countries, particularly among the poor and rural populations.
In terms of the socioeconomic status of the world’s population, over 80% of the world’s
population live in nations that collectively possess less than 20% of the world’s wealth and
productive capacity. The poorest 40% of the world’s people have less collective wealth than the
top 400 wealthiest people in the world. The gap between rich and poor nations is getting wider.
Economic and social development and health improvement are often hard to achieve among the
poorest of nations. Inadequate natural resources that have to be shared among too many
people, poor planning and misuse of resources, corruption and military turmoil influence the
health of many countries.
Key Factors Influencing World Health
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Key Factors Influencing World Health
Population Growth
The population experienced linear growth until the late 18th century, exponential growth until the
1950s, and remains in a period of hyperexponential growth. In North America, this has been
further compounded by migration. Despite advances in technology, the rate will reach a
maximum capacity or ecological limit.
Migrations
Migrations have brought people across borders, across continents and from rural to urban
environments. At the beginning of the 20th century, 90% of the population was rural. Now,
more than 50% is urban. The growth of cities presents a series of complex problems,
particularly in developing countries. Water, food supply, sanitary services, fuel and shelter are
often inadequate to cope with the numbers. This translates into increased transmission of
infectious disease, drug abuse and social unrest.
Health Problems
Many health problems are associated with the interaction of three forces:
• infectious disease, especially among infants and children
• malnutrition
• uncontrolled population growth
One billion serious illnesses each year are a result of common infectious diseases. Each year in
Africa, over one million deaths are due to malaria. Three million children die each year of
diarrhea, four million from respiratory infections, and three million from vaccine preventable
diseases and malnutrition. AIDS cases in Africa alone are in excess of four million.
Industrial development is causing serious environmental damage and occupational diseases.
Much of this is by multinational corporations that are assured of a supply of cheap labor, often
child labor, and can avoid regulations enacted in developed countries that protect the health of
workers and environmental quality. Laws governing worker compensation are often nonexistent. Some of the worst health harming habits of industrialized nations, cigarette smoking
and traffic injury are becoming increasingly common in developed countries.
How to Enhance Health Status of Developing Nations
A series of problems have been identified that, if addressed, can work to enhance the health
status of developing nations.
1. Increase access to health services
○ Preventive services are not a priority-- infectious disease remains at an unacceptable
level and the health status of women and children, in particular, is poor in many
regions
○ Many international health professionals are prepared outside of their home countries
and do not return to their home country, of if they do, they return to urban, not rural
areas
○ Training programs often emphasize western medicine rather than preventive
services
○ Many professionals decide to practice where they can use the skills that they were
trained for
○ Restrictions on educational opportunities for women affect the number of trained
health professionals
○ The lack of administrators to build health care programs is a compounding problem
2. Invest appropriately in technology
Many high tech tools cannot be maintained or their purchase may not be the best use of
scarce resources.
3. Gather health information
It is difficult to ascertain needed services when no system of gathering health information
exists. There is a need to set up registries either for whole countries or defined regions.
For example, the rates of disease are unknown in many countries. The cancer registry in
Jordan was only established in the past twenty years and after the king was diagnosed
with cancer.
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with cancer.
4. Prevent the breakdown of communication
Telephones, computers, internet connections break down. We saw this with Hurricanes
Katrina and Sandy and other environmental disasters in our own country.
5. Make health care a higher priority
Heavy emphasis on military in many developing countries has made health a low priority.
Landmines and the consequences of war result in over 400,000 deaths per year, and have
dramatically influenced the health of many nations.
All of these trends have major economic, sociocultural, political and environmental
consequences that are too large to be satisfactorily addressed by individual countries alone. By
combining efforts, transnational health issues can be addressed to shift current global trends to
a more positive health outcome.
GLOBAL STRATEGIES AND PRIORITIES
World Health Organization
WHO is the lead international organizer in addressing population health. Its Health for
All initiative has provided the focus for establishing priorities and inroads for success. Since its
inception in the late 1940s, it has expanded its focus from the control of communicable diseases
to include non-communicable or chronic disease.
WHO directs and coordinates international health through:
• Providing leadership on matters critical to health
• Shaping the health research agenda
• Defining norms and standards for health
• Articulating policy options for health
• Providing technical support and building capacity to monitor health trends
Review the WHO six leadership priorities in the graphic below:
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Click here for a larger view of the above graphic
Infographic of WHO Leadership Priorities:
1. Universal Health Coverage:
2. The International Health Regulations (2005)
3. Increase Access to Medical Products
4. Social, Economic and Environmental Determinants
5. Noncommunicable Diseases
6. Health Related Millennium Development Goals
WHO directs and coordinates international health by: providing leadership on matters critical to
health shaping the health research agenda defining norms and standards for health articulating
policy options for health providing technical support and building capacity to monitor health
trends
WHO--Communicable Disease Efforts
WHO’s malaria initiatives have become more intensive in the past decade and are mounted
worldwide.
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Similarly, WHO’s efforts to eliminate TB have escalated.
WHO’s 3 by 5 initiative was one of its first campaigns aimed at getting 3 million people living
with HIV/AIDS in developing and middle income countries on antiviral treatment by the end of
2005. It was a major step towards the goal of providing universal access of HIV/AIDS services
for all who need them as a human right.
WHO continues to advance the agenda for reducing HIV/AIDs…
…and intensive efforts to address HIV have been strengthened by partnerships with the Global
Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. President’s Emergency Plan for AIDS
Relief, and the UNAIDS initiative.
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Source: http://apps.who.int/iris/bitstream/10665/246178/1/WHO-HIV-2016.05-eng.pdf?ua=1
Watch this video on the World AIDS Day 2015 message that shows the gains in HIV
treatment and reduced infections worldwide.
WHO is continuing to provide leadership in HIV/AIDS by bringing the best research and practice
professionals together to share information.
WHO is spearheading the international efforts in the re-emerging crisis of ebola and the zika
virus. Click here to review the ebola virus disease website and the story map to learn about
the chain of transmission across the globe. Click here to review the latest WHO updates on
ebola.
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Clikk here for WHO’s update declaring that the Zika emergency is over but that it remains a
serious threat.
World Health Organization – Non-Communicable Disease Efforts
In the area of chronic diseases, often referred to internationally as non-communicable diseases,
WHO has been working to check the double burden of infectious and chronic disease that
affects the majority of the world’s population.
Watch this video (6:21) on the WHO global non-communicable disease priorities and
partnership network.
Video notes:
Non-communicable diseases and accidents account for 70% of all deaths in the world and
most are in developing nations. Have huge economic impact
Healthy eating and being active, designing primary care screening programs for diseases.
Need partnerships with governments to achieve, need to focus on noncommunicable
diseases
WHO has an international mandate for developing and implementing a Global Strategy on
Diet, Physical Activity and Health as a leading public health priority.
A few largely preventable risk factors account for most of the world's disease burden. This
reflects a significant change in diet habits and physical activity levels worldwide as a result
of industrialization, urbanization, economic development and increasing food market
globalization. Recognizing this, WHO has adopted a broad-ranging approach and has
developed, under a May 2002 mandate from Member States, a Global Strategy on Diet,
Physical Activity and Health, which was endorsed by the May 2004 World Health
Assembly.
Source: http://www.who.int/chp/action/en/
A joint WHO/FAO expert report, Diet, Nutrition and the Prevention of Chronic
Diseases (2003), examines the scientific data and makes recommendations for the
development of regional and national guidelines to reduce the burden of nutrition related
diseases: obesity, diabetes, CVD, cancer, osteoporosis and dental disease.
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WHO’s Global Action Plan for Prevention of Non-communicable
Diseases 2013-2020 focuses on reducing:
“… the preventable and avoidable burden of morbidity, mortality and disability due to
noncommunicable diseases by means of multisectoral collaboration and cooperation at national,
regional and global levels, so that populations reach the highest attainable standards of health
and productivity at every age and those diseases are no longer a barrier to well-being or socioeconomic development.”
The Global Action Plan for prevention of Non-Communicable Diseases established
focused targets are noted below.
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For more information on the WHO Global Action Plan, review the required reading:
World Health Organization (WHO). (2013). Global Action Plan for Prevention of Noncommunicable Diseases 2013-2020. (pp. 1-13). Available
at http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf
VISION: A world free of the avoidable burden of noncommunicable diseases.
GOAL: To reduce the preventable and avoidable burden of morbidity, mortality and disability due
to noncommunicable diseases by means of multisectoral collaboration and cooperation at
national, regional and global levels, so that populations reach the highest attainable standards of
health and productivity at every age and those diseases are no longer a barrier to well-being or
socioeconomic development.
Objectives:
1. To raise the priority accorded to the prevention and control of noncommunicable diseases in
global, regional and national agendas and internationally agreed development goals, through
strengthened international cooperation and advocacy.
2. To strengthen national capacity, leadership, governance, multisectoral action and partnerships to
accelerate country response for the prevention and control of noncommunicable diseases.
3. To reduce modifiable risk factors for noncommunicable diseases and underlying social
determinants through creation of health-promoting environments.
4. To strengthen and orient health systems to address the prevention and control of
noncommunicable diseases and the underlying social determinants through people-centred
primary health care and universal health coverage.
5. To promote and support national capacity for high-quality research and development for the
prevention and control of noncommunicable diseases.
6. To monitor the trends and determinants of noncommunicable diseases and evaluate progress in
their prevention and control.
Targets:
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Targets:
A 25% relative reduction in risk of premature mortality from cardiovascular diseases, cancer, diabetes,
or chronic respiratory diseases.
At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context.
A 10% relative reduction in prevalence of insufficient physical activity.
A 30% relative reduction in mean population intake of salt/sodium.
A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years.
A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised
blood pressure, according to national circumstances.
Halt the rise in diabetes and obesity.
At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to
prevent heart attacks and strokes.
An 80% availability of the affordable basic technologies and essential medicines, including generics,
required to treat major noncommunicable diseases in both public and private facilities.
On November 21, 2016 the WHO Shanghai Declaration on Health Promotion was issued at the
9th Global Conference on Health Promotion. The declaration commits to make bold political
choices for health, emphasizing the connection between health and well-being. Watch
this video (2:45) on WHO’s commitment to health promotion.
Video notes: need to make sure people know what the healthy choices are and help
accessing those options. May need to pass laws to do things like making no smoking
areas and potentiating active life styles
The University of Maryland School of Nursing offers a Global Health Certificate. Click here for
more information.
Click here to learn how our faculty and students are creatively and strategically addressing
global health problems, and read pages 24-31.
MAPPING THE FUTURE OF Global Health: Nurses are key to addressing health inequity around the
world—and the School of Nursing is leading the way to help expand nursing capacity in the most
underserved regions.
All over the map” describes a typical workday for Jeffrey Johnson, PhD, director of the School of
Nursing’s Office of Global Health (OGH). Whether fielding phone calls from Saudi health officials,
meeting with a visiting nurse from Singapore, or reviewing reports on a project in Nigeria, Johnson
has a to-do list that spans the globe, with a heavy concentration on African countries. Every task,
however, contributes to the singular vision of the office he leads: to build nursing capacity,
NSG 780Final Page 141
however, contributes to the singular vision of the office he leads: to build nursing capacity,
strengthen health systems, and improve health around the world. “Nurses are the most numerous
of health professionals in most parts of the world,” Johnsons explains. “They are critical to
addressing global health problems, yet they are often underutilized.”
Increasing nursing capacity is an important first step in addressing the enormous gap in health
inequity between developed and developing countries, which Johnson refers to as the global
north and the global south. “Ninety percent of the burden of disease is falling on poor countries in
the global south, yet they have only 10 percent of the overall health resources,” he says, adding
that the situation in Africa is particularly dire. “What we’re trying to do in the OGH is help these
countries take care of their own needs by expanding the capacity of their nursing workforce to
enable them to better address the disease burdens they face. And we can do that by doing what
we’re good at— educating nurses.” Johnson views the OGH as the bridge that connects the energy
and capacity of the School of Nursing to the interests and needs of the global community. “We are
a strong school with a lot of diversity in many different program areas,” he says. “That’s what we
bring to the table to help in the development of nursing globally—and that’s why countries are
interested in working with us.”
Global Health Summit On September 25, Jeffrey Johnson, PhD, director of the School of Nursing’s
Office of Global Health, represented the School at the closing session of the 2012 Clinton Global
Initiative’s annual meeting in New York City. The School of Nursing was recognized for its
participation in the Human Resources for Health (HRH) Program, the pioneering initiative led by
Rwanda’s Ministry of Health with support from the Clinton Health Access Initiative. It was a
thrilling experience for Johnson to meet President Clinton and some of the most prominent
figures in global health. “We were all waiting in the ‘green room’ for two hours, meeting each
other and talking. It was a real opportunity for me to meet some people who have influenced my
thinking,” he says. “Just being invited to participate in this national effort is very wonderful for us
as a school.”
A Paradigm Shift in Rwanda In August, Kathryn Schaivone, MPA, director of the School of
Nursing’s Clinical Education and Evaluation Laboratory, packed her bags and headed to Rwanda as
part of the Human Resources for Health (HRH) Program. HRH Rwanda is an unprecedented effort
spearheaded by the Rwanda Ministry of Health with support from the Clinton Health Access
Initiative. The goal of the pioneering program is to strengthen the capacity of Rwanda’s health
workforce and improve the quality and quantity of care. The program is exceptional in many ways.
First of all, notes Schaivone, the School of Nursing’s in-country coordinator, the program aims to
address the country’s health system as a whole, rather than tackling individual diseases, or one
geographical area—the common approach for development projects. Secondly, the scale and
duration of the infusion of U.S. mentors is unparalleled. Usually, one or two faculty members from
a single U.S. institution travel for a few weeks to offer consultation services during a one- to fiveyear grant cycle. However, traveling around the same time as Schaivone were six School of
Nursing faculty members, including three alumni, plus 93 other nurses and physicians. More than
100 U.S. faculty members from 13 of the top-ranked schools in the U.S will spend a minimum of
11 months over the next seven years to train 500 health care providers. Schaivone, who had never
previously worked outside of the U.S., says that the Rwandans have wholeheartedly embraced
this approach. “The people are so grateful we’re here and doing more than the typical
international ‘go in, provide care, get out’ approach,” she explains. “Everyone knows we’re in it for
the long haul.” The third, and the most unique, aspect of the program is that faculty and
universities are making a financial sacrifice to participate. Minimal overhead will go to the
universities, and individual faculty members have taken a significant cut in salary and benefits.
They have chosen to invest in HRH Rwanda, Shaivone says, to be a part of a revolutionary
approach—perhaps a paradigm shift—to international partnerships for health system change.
Notes President Clinton: “These universities have agreed to work for only 7 percent overhead and
will probably lose money. In the past, developed country universities charged overheads of more
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will probably lose money. In the past, developed country universities charged overheads of more
than 35 percent so half of the money is spent in the U.S. before it ever gets to its destination. With
this program, $0.93 of every dollar will be spent in Rwanda. This has never been done in my
lifetime.” Schaivone understands why significant, sustainable change to Rwanda’s health
workforce will take time—although the country on its own has made impressive strides after the
1994 genocide that killed an estimated 800,000. “In addition to the loss of life (including nurses
and doctors), the health care system itself was destroyed as were institutions such as schools of
nursing,” she says. While access to hospitals and primary care has dramatically improved, the
burdens of conditions associated with infectious diseases and poverty (AIDS, TB, malnutrition, a
high infant mortality rate) are accompanied by an increase in chronic diseases. In rural areas,
nurses are often called upon to perform jobs they have not been trained to do. They are running
entire health centers on their own, functioning as doctors without the necessary resources.
Midwives also must manage difficult and complicated births without a physician present. Fetal
monitoring is virtually non-existent outside of the hospital setting, and most women give birth in
the small health centers in their communities, Schaivone says. Knowing that a better-educated
nursing and midwife workforce is critical to the health of its population, Rwanda is committed to
significantly increasing the number of nurses and midwives with advanced training and education.
Schaivone’s School of Nursing colleagues—Rani Khan, Sarah Horwath, Caroline Orwenyo, and
Melody Brooks—are assigned to various parts of Rwanda, some in rural hospitals, where there is
intermittent electricity, lack of clean running water, and a scarcity of both medical supplies and
people who speak English. Despite the significant challenges, these nurses are successfully training
Rwandan nurses about best practices in labor and delivery and emergency care. Says Marik Moen,
MSN, MPH, RN, assistant professor at the School of Nursing and Rwanda project coordinator, “We
are so proud of the U.S. faculty members who are making significant sacrifices to promote the
progress of nurses in Rwanda. They will agree that their Rwandan counterparts are the true
heroes, given what they are called upon to do every day in these conditions and at one-eighth of
the salary of the lowest paid nurse in the U.S.” Having spent almost two years in Rwanda working
with the President’s Emergency Plan For AIDS Relief (PEPFAR), Moen recognizes the challenges
faced by the U.S. faculty as well. Making the transition between nursing in the U.S. to nursing in a
low-resource setting isn’t easy. “We are used to identifying a problem and trying to fix it right
away, especially when it comes to life-and-death situations. But in another country, one must
observe and learn and then slowly plan and facilitate change in a culturally and contextually
appropriate way.” Moen knows the road will be long, but the focus on Rwandan nurses should pay
off. “Keep in mind that Rwanda is the size of Maryland without the Eastern Shore—and with 10
million people, extremely densely populated. Meeting the mostly rural population’s health care
needs is largely dependent on performance of nurses,” she says. “Changing the way in which
nurses are educated and elevating their capacity should in theory improve practice and result in
better health outcomes.” Schaivone says the experience is worth any sacrifice. “I am honored to
be here—and so encouraged by the Rwandan nurses’ willingness to listen and accept new ideas
and balance that with the realities in their country.”
Nigeria: Toward Improving Neonatal Care The School of Nursing continues to strengthen
partnerships with three universities in Nigeria, where efforts are focused on increasing nursing
capacity and improving neonatal care. Leading the School of Nursing’s involvement in Nigeria is
Yolanda Ogbolu, PhD ’11, MS ’05, BSN ’04, RN, CRNP, whose work in the country dates to 1998.
This summer, she presented her research, “Nursing and Neonatal Mortality in Nigeria,” at the
University of Nigeria at Enugu. Nigeria has one of the highest infant mortality rates in the world,
Ogbolu reports, with an estimated 240,000 infants each year dying in their first month of life.
Combating this crisis requires more nurses with access to more advanced training. During her visit,
Ogbolu worked with faculty at Obafemi Awolowo University in Ile Ife to plan for the coming year
and also advised several university doctoral students on their dissertation projects. “We’re in the
third year of our partnership with Nigeria—and it doesn’t just happen, Ogbolu explains. “It’s all
about relationship building. When you have that relationship, it builds a more sustainable
partnership.” In addition to having Global Health Certificate students visit Nigeria in the future,
Ogbolu looks forward to welcoming Nigerian health officials and nurses to the U.S. The
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Ogbolu looks forward to welcoming Nigerian health officials and nurses to the U.S. The
International Scholars Program at the School of Nursing helps build faculty capacity from other
countries, and several Nigerian nurses have already submitted applications to participate in the
program. They will be the first International Scholars from sub-Saharan Africa.
Kenya: Matters of Life and Death As a Kenyan woman prepares for the birth of her child, she has
an important decision to make: have the baby in a modern health facility or use a traditional birth
attendant. Her decision directly influences her own health, as well as the health of her baby.
Determining what factors influence the choice of birth location is the focus of a study that was
conducted by the School of Nursing in partnership with the University of Nairobi School of
Nursing. Lynnee Roane, MS, BSN ’85, RN, nurse coordinator at the School, was one of two Global
Health Certificate students who traveled to Kenya last summer to conduct research. The other
student was Nwamaka Oparaoji, MS, RN. “Women should not die as they bring life into the
world,” Roane comments. “It’s very important that we figure out why women are not seeking the
lifesaving care they need.” During their six-week stay, Roane and Oparaoji visited both urban and
rural health care sites to assess nursing care, patient needs, and outcomes, with particular
attention to maternal mortality. At two of Kenya’s larger immunization clinics, they interviewed
many mothers who indicated they chose to have their babies in health care facilities because they
felt that it was safer, especially if complications arose. However, the cost and quality of care at the
facilities is often a deterrent. Some mothers explained that their decision to have babies at home
was based on not having received compassionate or respectful care at other facilities. Research
results are now being analyzed, but Roane hopes the study will help nursing administrators in
Kenya develop interventions that would increase the use of health care facilities for childbirth,
with the ultimate goal of reducing maternal mortality
Malawi: Resourceful Solutions Last July and August, a dozen students from all six University of
Maryland, Baltimore professional schools traveled to Malawi to study maternal/child health
services. The students administered the World Health Organization’s Safe Motherhood Survey in
the rural district of Chikwawa, one of the largest and most populated districts in Malawi and also
one of the poorest. Assistant Professor Mary Regan, PhD, RN, and two School of Nursing students
(and former faculty member Barbara Smith, PhD, RN, FAAN) were among those who participated
in the six-week trip. For Regan, it was especially meaningful to see students from the different
schools working together. “I think they learned from each other as much as they did from being in
a different country,” she says. Each day, students conducted research at two hospitals and 10 rural
health care centers, surveying staff, reviewing hospital records and supply inventories, and
interviewing women who were receiving prenatal care. At the end of the six weeks, the students
shared survey results with staff at participating hospitals and health care centers. The survey
revealed that health care providers in the district are stretched to the limit by not enough
personnel and resources— a problem compounded by few transportation options when a rural
center needs to transfer a patient to another location for more sophisticated care. The survey also
revealed the admirable and creative ways that health care workers in the district use the scarce
resources at their disposal, such as using plastic sheeting to make hospital gowns. Vera KuffourManu, MS ’10, RN, a PhD and Global Health Certificate student at the School of Nursing, was
impressed by the resourcefulness of the nurses she met in Malawi. With no umbilical cord clamps,
nurses would instead use a string or cord. The nurses also worked with limited supplies and
equipment, such as alcohol pads, gloves, thermometers, blood pressure cuffs, gauze, and other
essential medical items. With no intravenous pumps, the nurses used drop rate to run IV fluids.
“These nurses are experts. I could not do what they’re doing,” Kuffour-Manu says. Global Health
Certificate student Dorothy Njathi, MS ’12, BSN ’10, RN, agrees: “In most facilities that we visited,
nurses were practicing under dismal conditions and with very few resources— yet they are able to
provide optimal care to their patients and actually report job satisfaction.” “My Malawi
experience is one that I would wish on every nursing student,” Njathi continues. “There was so
much to learn, but it boils down to basics. It is no longer OK to just do your job. It’s everyone’s
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much to learn, but it boils down to basics. It is no longer OK to just do your job. It’s everyone’s
duty to educate, encourage, assist, and provide a service that can improve the health of a friend, a
family member, a neighbor, a community, a nation, and the world.”
Haiti: Training Has Paid Off After Haiti’s devastating earthquake in 2010, Marik Moen, MSN, MPH,
RN, spearheaded the development of an infectious disease-training program in collaboration with
the University of Notre Dame of Haiti (UNDH) nursing school. Still going strong, the joint effort is
funded by the Centers for Disease Control and led by University of Maryland’s Institute of Human
Virology, School of Medicine, and School of Nursing, along with Catholic Relief Services, a network
of Catholic hospitals, and UNDH Schools of Medicine and Nursing. To date, six faculty candidates
have completed the faculty training program, and 10 Haitian nurses have completed the postgraduate certificate program. The junior faculty members now do most of the preparation and
delivery of training sessions, Moen says. “These nurses went from minimal computer usage to
preparing professional PowerPoint presentations, reading literature, and integrating lessons
learned into health care practice. It’s pretty amazing how much they have progressed.” Moen
works closely with Yveline Auguste, her counterpart in Haiti, who does the lion’s share of
executing the training and day-to-day aspects of the program. Both are pleased to see how
training has helped nurses to assume more responsibility in patient care— such as taking patient
histories, conducting physical exams, executing key nursing interventions, and advocating on
behalf of patients. “They’re modeling some of the best nursing behavior I’ve seen in Haiti,” Moen
says. On a recent visit, she witnessed an infant in severe respiratory distress in the hallway of an
emergency room. “While facility staff seemed too overwhelmed to react, the junior faculty
members jumped in and did everything necessary to try to save the baby.”
Saudi Arabia: “Knowledge Workers” in Demand Three faculty spent six days in Saudi Arabia last
summer evaluating the country’s nursing profession and identifying possible areas for
collaboration. The trip was in response to an invitation from the Office of His Highness Prince
Ahmad Bin Bandar Bin Ahmed Al Sudairy, a member of the Saudi royal family who is responsible
for encouraging new health initiatives. Jeffrey Johnson, PhD, director of the School’s Office of
Global Health; Professor Mary Etta Mills, ScD, RN, FAAN; and Associate Professor Kathryn
Montgomery, PhD, RN, NEA-BC, met with representatives from the Saudi Ministry of Health, as
well as with senior administrators, physicians, and nurses from both public and private hospitals.
With these and other officials, they discussed current challenges in Saudi nursing education and
practice, including the shortage of nurses who are Saudi compared with expatriates. The country
plans to send a delegation to the School of Nursing to further explore collaborative projects. “It
was a fabulous trip, culturally and professionally,” Montgomery says. “Everyone we talked to
clearly articulated that nursing at a professional level is critical to the health of their nation.”
Physicians want nurses who are “knowledge workers,” she says— able to practice independently
at a critical level of judgment. Saudi health officials have moved to an all-baccalaureate approach
to nursing education, with more prerequisites and higher expectations. “They’re taking a longterm view, which is very refreshing,” Montgomery says. For Mills, the visit highlighted the
complexities of designing and implementing educational programs and managing nursing in
practice settings. “Saudi Arabia is challenged with how best to simultaneously provide staffing and
patient care in a culturally appropriate way while also considering the needs of staff and hospital
nursing requirements,” she explains. These concepts are important as future nurse leaders
prepare for advanced roles in more culturally diverse environments.
Liberia: Understanding the Needs The School of Nursing recently signed a memorandum of
understanding with Liberia’s top nursing school, Stella Maris Polytechnic University: Mother
Patern College of Health Sciences. As the first step in this collaboration to build nursing capacity in
Liberia, Yolanda Ogbolu, PhD ’11, MS ’05, BSN ’04, RN, CRNP, deputy director of the Office of
Global Health, and Pujeeta Lawot-Pfau, MS ’08, BSN, and Global Health certificate student, visited
Liberia last summer. The two met with key stakeholders—including staff of the Ministry of Health,
nursing boards, and chief nursing officers— to examine the current state of nursing in the primary
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nursing boards, and chief nursing officers— to examine the current state of nursing in the primary
health care sector and to help identify the specific health needs of the country. Currently, Liberia
is facing a crisis with maternal and neonatal mortality and hopes to collaborate with Mother
Patern College to develop a program that builds the capacity of nurses, midwives, and physician
assistants to address the country’s most immediate health needs. “Our visit was a very positive
experience, and it opened our eyes to the needs on the ground,” Ogbolu says. Ogbolu and LawotPfau toured two hospitals and five primary health care centers in rural areas. They spoke with
nurses and physicians assistants interested in pursuing advanced training and degrees. For LawotPfau, these conversations were vital to her understanding of how global health works—and the
importance of considering the unique needs of the country and those already providing care. “You
have to make good contacts, understand the needs, do basic research, and consider
sustainability,” she says. “You have to take the time to think of long-term implications. We want to
make sure we’re thinking 10 years ahead.”
Concluding Comments
In the final analysis, to address any population issue, successful interventions require:
• an awareness that the problem exists
• an understanding of what causes the problem
• a capability to deal with the problem
• a sense of values that the problem matters
• political will to control the problem
The final two steps are often described as redefining the unacceptable, which identifies
the ethical foundation of public health.
The miracle of science could and should be shared equally in the world. There is a growing
chasm between those of us that are rich, powerful and healthy and those of us who are poor,
weak and suffering from preventable diseases. If we are to improve health, we must concentrate
on existing disparities to opportunities, resources, education and access to health programs.
Only to the extent that we can eliminate these inequalities will our dream for global health in the
21st century be realized.
Jimmy Carter
Critical Issues in Global Health (2002)
Primary Care and Public Health: Exploring Integration to Improve Population Health.
Introduction (pp. 17-44). Available at http://www.nap.edu/openbook.php?record_id=13381
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Introduction
Health is influenced by an array of factors, including social, genetic, environmental, and other factors
that cut across a number of different sectors. Improving the health of populations therefore will require
a collaborative, intersectoral effort that involves public and private organizations and individuals. At the
same time, both health problems and community needs, resources, and circumstances vary among
localities, so no single approach to combating health problems can be applied.
Primary care and public health are uniquely positioned to play critical roles in tackling the complex
health problems that exist both nationally and locally. They share a similar goal of health improvement
and can build on this shared platform to catalyze intersectoral partnerships designed to bring about
sustained improvements in population health. In addition, they have strong ties at the community level
and can leverage their positions to link community organizations and resources. Thus, the integration of
primary care and public health holds great promise as a way to improve the health of society. The
purpose of this report is to explore how this promise can be realized.
CURRENT OPPORTUNITIES
It is well documented that the nation’s health system is expensive and does not translate into excellent
outcomes for all (AHRQ, 2011; United Health Foundation, 2011). The opportunity currently exists to shift
the system in significant ways to improve on this situation. Investments in the current model of health
care are not focused in the most effective way.
While these patterns of investment have produced what is arguably the best biomedical research and
specialty care system in the world, the nation has failed to balance its investments in primary care,
public health, prevention, and the broader determinants of health, a problem clearly demonstrated by
its low rankings in overall health status. McGinnis and Foege (1993) estimated that nearly half of all U.S.
deaths that occurred in 1990 were attributable to behavioral and environmental factors. It has
repeatedly been shown that such factors have a substantial influence on health outcomes, yet the
current health system devotes most of its resources to treating disease and much less to the underlying
causes of illness (CDC, 1992; Miller et al., 2012). Financial incentives and a medical culture focused
overly on acute care and heroic cures encourage giving most attention to individuals who are already
sick rather than promoting an effective balance of treatment and personal and community-based
prevention. As a result, the current health system is inadequately equipped to provide critical health
promotion and preventive services.
A number of relatively new developments have converged to create opportunities for improving the
nation’s health. First, there is growing recognition that the status quo is unacceptable. The
unsustainable rise in health care costs has created an urgent need for innovative ways to deliver health
care more efficiently. This imperative has been evident not only in the activities of government health
organizations but also in the private sector. As purchasers of health care, many employers have been
exploring ways to reduce the growth in these costs. A recent survey by Towers Watson and National
Business Group on Health (2010) found that many employers are incentivizing a number of healthy
lifestyle activities for their employees, including weight management, smoking cessation, and
screenings. The concern about health care expenditures has opened the door for innovative approaches
to improving health and health care.
Adding momentum to the recognition that the status quo is unacceptable, health research continues to
clarify the importance of social and environmental determinants of health (Marmot and Wilkinson,
2006; McMichael, 1999) and the limitations of the acute care medical system in addressing prevention
and care needs in chronic illness. At the same time, the science with respect to primary prevention has
grown and developed (The New York Academy of Medicine, 2009). As a result of these factors, a shift in
the way health is approached in the United States is taking place.
Another development is the increased availability of health-related data. Advances in data collection
techniques and health informatics have presented an opportunity to facilitate the utilization and sharing
of data among health professionals. Recent endeavors have begun to capitalize on these opportunities.
For instance, the Health Information Technology for Economic and Clinical Health (HITECH) Act
encourages the collection and use of patient-level data through electronic health records.1 In addition to
improvements in how data are collected and used, more data sets are becoming available for
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improvements in how data are collected and used, more data sets are becoming available for
widespread use. And the Health Data Initiative, led by the Department of Health and Human Services
(HHS), has made a wide array of health-related data available to the public (HHS, 2011b). These newly
available data are providing communities, health care providers, and researchers with an
unprecedented opportunity to access and analyze information that can aid in understanding and
addressing community-level health concerns. The new opportunities presented by these data give
primary care and public health a solid foundation upon which they can initiate integration.
Finally, and most important, the recent national focus on health care reform and the adoption of the
Patient Protection and Affordable Care Act (ACA) present an overarching opportunity to change the way
health care is organized and delivered. The ACA is discussed in more detail later in the report.
The convergence of these opportunities makes this a pivotal time to achieve sustainable improvements
in population health. When discussing the term “population health,” the committee chose to adopt
Kindig and Stoddart’s definition (2003, p. 381): “the health outcomes of a group of individuals, including
the distribution of such outcomes within the group.” In this report, population health is viewed as an
ultimate goal toward which the strategies and reforms discussed in subsequent chapters would move
the health system.
THE PATH TO IMPROVING POPULATION HEALTH
Improving population health will require activities in three domains: (1) efforts to address social and
environmental conditions that are the primary determinants of health, (2) health care services directed
to individuals, and (3) public health activities operating at the population level to address health
behaviors and exposures. There is abundant evidence for the benefit and value of activities in each of
these domains for achieving the aim of better and more equitable population health (Andrulis, 1998;
Commission on Social Determinants of Health, 2008; WHO, 2003).
A clear challenge for achieving improved population health is generating an appropriate balance in
investment across and within these three domains, clarifying the appropriate roles and tasks for
stakeholders in each domain, and improving the integration of activities at the interfaces among the
domains. It is in this context that primary care and public health have
critical roles. Their integration can not only improve the efficiency and effectiveness of each of their
functions but also lead to collaboration with other entities that will assist in the improvement of
population health. Integration of primary care and public health can serve as a catalyst for cooperation
across the entire health system, connecting key stakeholders in communities nationwide.
KEY TERMS
To discuss the integration of primary care and public health, it is necessary to understand what these
terms mean broadly and how they are used in this report.
Primary Care
In 1996, the IOM Committee on the Future of Primary Care defined primary care as “the provision of
integrated, accessible health care services by clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained partnership with patients, and practicing
in the context of family and community” (IOM, 1996, p. 1). The committee emphasized that “primary”
means care that is first and fundamental, and declared that primary care is not a specialty or a discipline
but an essential function in health care systems. The inclusion of the words “integrated,” “sustained
partnership,” and “context of family and community” reflects a prominent population perspective, as
well as a responsibility to connect with other actors in the health system.
Also embedded in the 1996 report is the inextricable link between mental health and primary care. A
paper commissioned for that report, and included as an appendix, asserts that “a sensible vision of
primary health care must have mental health care woven into its fabric” (IOM, 1996, p. 285). Primary
care providers address a broad range of health issues to which mental health concerns are integral.
Mental, behavioral, and physical health are so closely entwined that they must be considered in
conjunction with one another. While the nature and role of primary care have been debated and
studied at length, it is generally recognized that primary care has the four key features listed in Box 1-1.
The importance of primary care is well known and researched. In their review of the literature, Starfield
and colleagues (2005) found that areas with the highest numbers of primary care providers have the
best health outcomes; people who consistently receive care from a primary care provider have better
health outcomes than those who do not; and the characteristics themselves of primary care are
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health outcomes than those who do not; and the characteristics themselves of primary care are
associated with good health. Additionally, primary care was found to be associated with a reduction of
health disparities both in the United States and among international populations (Starfield et al., 2005).
Primary care is the foundation of the U.S. health system. In the United States, more individuals receive
care in primary care settings than in any other setting of formal health care. On average, primary care
settings see 11 percent of the entire population each month, compared with 1.3 percent for emergency
departments and 0.07 percent for academic medical center hospitals (Green et al., 2001). Of interest,
these proportions have not changed substantially since the 1950s and 1960s despite the stunning
progress of medical knowledge, new technology, and expansion of health services (White et al., 1961).
The primary care system in the United States comprises both private providers and those supported by
government agencies, such as the Veterans Health Administration and the Health Resources and
Services Administration (HRSA). HRSA-supported health centers serve nearly 20 million patients a year
(HRSA, 2011) and provide a safety net for society’s most vulnerable populations. Although most primary
care is delivered through the private sector, both private and government-supported primary care share
common features. For example, in its policy paper on primary care, the National Business Group on
Health, which represents more than 300 large employers providing health care coverage for 55 million
people, asserts that primary care should be the key to efficiency, effectiveness,
and quality improvement in the nation’s health system (National Business Group on Health, 2010). Both
sectors also share the same challenges.
As a whole, primary care currently is facing a workforce shortage. The primary care workforce remains a
relatively small proportion of the overall workforce compared with other health fields (Bodenheimer et
al., 2009; Canadian Labour and Business Centre, 2003; European Observatory on Health Systems and
Policies, 2006). During the last decade, the proportion of primary care providers fell from nearly a third
to now less than a fourth of the output of the graduate medical education system (COGME, 2010;
Phillips et al., 2011; Salsberg et al., 2008). This decline goes beyond physicians to include nurse
practitioners and physician assistants as well (HRSA, 2010; Jones, 2007). Primary care also faces a
chronic problem of relative shortage due to workforce maldistribution (Zhang et al., 2008). Regional
shortages have seen little improvement despite federal and state loan repayment programs and the
rapid growth of safety net clinics over the last decade (GAO, 2003).
In addition to workforce shortages, the increase in chronic diseases has posed challenges for primary
care and served to motivate its transformation. Chronic diseases are linked to a number of unhealthy
behaviors, such as lack of physical activity, poor nutrition, and tobacco use, but primary care often has
struggled to address these behaviors adequately. In recognition of the difficulties associated with
treating chronic diseases, the Chronic Care Model (Wagner et al., 2001) was implemented. This initiative
emphasized a systematic and more efficient means of improving chronic care management for
individual patients (Coleman et al., 2009). In its fullest expression, the Chronic Care Model contained six
critical elements—community resources and policies, health care organization, self-management
support, delivery system design, decision support, and clinical information systems—and effectively
bridged patient care across the practice setting, the delivery system, and the broader community
(Bodenheimer et al., 2002)
The success of the Chronic Care Model in revitalizing the management of patients with chronic
conditions by relying on an interdisciplinary primary care team with aligned objectives and methodology
generated interest in redesigning the entire practice of primary care. This interest in reinventing primary
care led in turn to interest in the “medical home,” a model first proposed in the 1960s for providing care
for children with special needs (Rosenthal, 2008). In the last few years, intensive activity has focused on
implementing the “patient-centered medical home,” spurred by funding and research supported by the
Centers for Medicare & Medicaid Services (CMS), the Commonwealth Fund, HRSA, and a number of
other groups. These efforts are aimed at stimulating new models of care delivery, with primary care
teams at the core of the delivery structure.
A fully realized patient-centered medical home encompasses the principle
that individual patients are members of a broader community, and that activity within the construct of
individual clinical encounters includes links that can be leveraged to generate wellness and prevention
beyond the individual patient. A systematic approach to population health, called community-oriented
primary care (COPC), is employed in other health systems and has previously been studied by the
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primary care (COPC), is employed in other health systems and has previously been studied by the
Institute of Medicine (IOM, 1984). This approach to primary care helped launch the community health
center movement in the United States and is still used in some communities. COPC, which is discussed in
more detail later in the chapter, offers a model of primary care that more fully embraces public health.
There is already some evidence that the foundational relationship between patient and primary care
provider can generate dividends for the broader community. Several integrated service delivery
networks, such as the Geisinger Health System, Group Health Cooperative of Puget Sound, and
HealthPartners, are providing early evidence that accountable care for patient panels and populations
can reduce mortality, costs, and unnecessary utilization, and in some cases can improve the fiscal health
of hospitals as well (Flottemesch et al., 2011; Grumbach and Grundy, 2010; IOM, 2010).
Primary care is well positioned to work with public health on improving the health of local populations.
The research networks of major primary care provider groups could assist in this effort. Some of primary
care’s major concerns include factors that are not present in a clinical setting, such as circumstances at
the onset of illness, predisposing factors that increase the risk of death and disease, and precipitating
factors that lead people to seek care (White, 2000). One of its strengths is that primary care often holds
a position of trust in communities and is able to leverage that position in addressing community
concerns. This community relationship is exemplified by health centers and other primary care delivery
systems, particularly those that use a community-oriented approach. Thus, primary care is working in
areas that largely overlap with public health and is strategically placed at the interface of people in
communities and the rest of the health care system.
Public Health
Public health is a dynamic field that continues to evolve to meet the needs of society. While the concept
of modern public health emerged in response to the conditions that resulted from industrialization and
the subsequent rise in infectious diseases (Rosen, 1993), the issues confronting public health look very
different today. Although the primary focus of public health has shifted from infectious to chronic
diseases, which are more prevalent in today’s society, its emphasis has remained on improving
conditions where people spend their lives outside of health care settings.
While it is generally recognized that a critical component of public health is the services provided under
the legal authority of government through health departments, articulating broadly what public health
is and does is no easy task.
A number of key reports published over the last few decades have presented a vision for public health.
The 1988 IOM report The Future of Public Health provides two critical definitions. The first is the
mission of public health, defined as “fulfilling society’s interest in assuring conditions in which people
can be healthy” (IOM, 1988, p. 140). The second is the substance of public health, defined as “organized
community efforts aimed at the prevention of disease and promotion of health. It links many disciplines
and rests upon the scientific core of epidemiology” (IOM, 1988, p. 41). Although the report emphasizes
the importance of government health agencies and argues that strengthening the role of health
departments would be crucial in moving public health forward in the future, its overall conception of
public health is much broader, involving the private sector, community organizations, public–private
partnerships, and others.
In 2002, the IOM released The Future of the Public’s Health in the 21st Century, which reinforces
the idea that public health’s broad mission of ensuring healthy communities requires interactions
among a number of health-influencing actors, such as communities, businesses, the media,
governmental public health, and the health care delivery system (IOM, 2002). The report notes that
health departments are not alone in carrying out the essential public health services listed in Box
1-2. Figure 1-1 depicts
an interconnected system of sectors that influence a population’s health, with government public health
being one of several actors (IOM, 2002).
BOX 1-2
Essential Public Health Services
• Monitor health status to identify community health problems.
• Diagnose and investigate health problems and health hazards in the community.
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• Diagnose and investigate health problems and health hazards in the community.
• Inform, educate, and empower people about health issues.
• Mobilize community partnerships to identify and solve health problems.
• Develop policies and plans that support individual and community health efforts.
• Enforce laws and regulations that protect health and ensure safety.
• Link people to needed personal health services, and assure the provision of health care when
otherwise unavailable.
• Assure a competent public health and personal health care workforce.
• Evaluate effectiveness, accessibility, and quality of personal and populationbased health services.
• Research for new insights and innovative solutions to health problems.
SOURCE: Public Health Functions Steering Committee, 1994.
From <https://www.nap.edu/read/13381/chapter/3#24>
The intersectoral public health system. FIGURE 1-1
SOURCE: IOM, 2002.
Ensuring the Conditions for Population Health:
Employers and Business
The Media
Academia
Communities
Health Care Delivery System
Government Public Health Infrastructure
More recently, the IOM published two in a series of reports called For the Public’s Health, looking at
public health in the context of measurement and law (IOM, 2011a,b). A third report, on financing, was
published in 2012 (IOM, 2012). These reports provide an opportunity to revisit public health in light of
changes in health status in the United States since the IOM’s 1988 report was published. For example,
obesity tripled among children and doubled among adults between 1980 and 2008 (CDC, 2011).
Recognizing the complex nature of health challenges facing society today, the IOM committee
responsible for the report on measurement noted that it is the “complex interactions of multiple sectors
that contribute to the production and maintenance of the health of Americans” (IOM, 2011b, p. 21). The
prevention of disease, which is a pillar of public health’s work, requires the engagement of all segments
of a community. For instance, combating the rise in obesity requires encouraging individuals to improve
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of a community. For instance, combating the rise in obesity requires encouraging individuals to improve
their
diet and increase physical activity. These efforts require multiple partners, such as schools, employers,
urban planners, and policy makers. These various stakeholders may provide one or more of the essential
public health services. For example, a community-based organization may implement a health outreach
campaign to educate people about health issues, or a public–private partnership may be engaged to
mobilize the community to solve a particular health problem.
Traditionally, public health has worked with systems, policy, and the environment to reduce the burden
of infectious disease. Improvements in sanitation, food preparation, and water treatment are successful
examples of this work. To address more current concerns, public health has turned its attention to
fighting chronic disease. Community-based interventions undertaken by public health for the prevention
of chronic diseases have proven to be effective (The New York Academy of Medicine, 2009). In addition,
some research suggests that making system, policy, and environmental changes may be effective; for
example, French and colleagues (2004) found that an intervention aimed at the school environment
resulted in students purchasing healthier foods. In general, the field would benefit from additional
efforts to evaluate the effectiveness of these interventions in terms of implementation and outcomes.
Public health faces a number of challenges, including insufficient funding to fulfill its mission, a shrinking
workforce, and inadequate investments in health information technology (HIT). In its report on public
health funding, the Trust for America’s Health found that public health funding had been reduced at the
federal, state, and local levels (ASTHO, 2011; NACCHO, 2011; Trust for America’s Health, 2011). Not
surprisingly, a reduction in the public health workforce has also been documented (ASTHO, 2011;
NACCHO, 2011; Trust for America’s Health, 2011). Another concern for public health is the lack of
investment, relative to the health delivery system, in HIT. This disparity is exemplified by the distribution
of HIT funding in the American Recovery and Reinvestment Act of 2009, which designated $17.2 billon of
the total $19.2 billion appropriated for HIT for incentives to be paid to physicians and hospitals to
promote the use of electronic health records (Steinbrook, 2009). This lack of investment could pose
challenges for public health in managing population-level data.
Despite these challenges, public health today continues to meet the changing needs of communities. It
encompasses a diverse group of public and private stakeholders (including the health care delivery
system) working in a variety of ways to contribute to the health of society. Uniquely positioned among
these stakeholders is governmental public health. Because health departments are legally tasked with
providing the essential public health services, they are required to work with all sectors of the
community.
This allows them to serve as a catalyst for engaging multiple stakeholders to confront community health
problems. In addition, their assessment and assurance functions put them in close contact with the
community and in touch with its health needs. Public health defined broadly is much more than
governmental public health, yet health departments play a fundamental role in creating healthy
communities.
Integration
Integration is an imprecise term that encompasses a wide variety of definitions. Accordingly, the
committee decided it would be too limiting and not helpful to use a narrow definition. For this report,
integration of primary care and public health is defined as the linkage of programs and activities to
promote overall efficiency and effectiveness and achieve gains in population health. Because integration
can take many forms, the committee chose to think conceptually about the variables that influence
integration, which include the level at which it takes place, the partners involved, the actions entailed,
and the degree to which integration occurs.
Levels
Integration can take place on many different levels. For this report, two major levels—the agency and
local community levels—are addressed. The agency level refers to HRSA, the Centers for Disease Control
and Prevention (CDC), and other federal agencies. Integration at this level involves largely joint efforts
among the leadership of these agencies, as well as the appropriate programmatic staff working
together.
At the local level, integration efforts are responsive to local health needs and relate to local resources
and partners available and willing to work together. While innovative actions are being taken at the local
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and partners available and willing to work together. While innovative actions are being taken at the local
level, many of which are improving the health of local populations, the committee attempted to
distinguish clearly between which of these initiatives involve primary care–public health integration and
which are innovative but do not necessarily involve integration. The other variables discussed below
were used to make this distinction. It should also be noted that at one extreme, either primary care or
public health can adopt approaches typical of the other, thereby integrating these functions within an
organization. For example, some public health departments deliver primary care. This report, however,
focuses on more formal integration efforts between local primary care and public health organizations.
Partners
At the agency level, most primary care–public health linkages in this report refer to HRSA and CDC
working directly together, although there are some cases in which it would be beneficial for HRSA and
CDC to work jointly with other federal agencies. In some cases, it would also make sense to partner with
national provider and public health groups. Thus, the partners for the agency level are HRSA; CDC; and,
as available and willing, other federal agencies and national groups.
Partners at the local level include a primary care entity (often as part of a larger organized delivery
system), a public health entity, and the community. Often, other stakeholders are involved at the local
level as well. For this report, the committee conceived of a primary care entity as any entity whose main
purpose is the delivery of primary care, but the report also considers larger organized systems that
contain entities with this purpose. These could include a solo practice, a group practice, primary care
providers affiliated with a health care system, primary care providers affiliated with a university system,
a HRSA-supported health center, or other community health centers. The committee was more selective
in its choice of public health partners. While many entities provide public health services (including
academic health centers and community-based organizations), health departments are legally
responsible for provision of the essential public health services. Given that the committee’s statement
of task explicitly mentions local health departments, the report emphasizes them over other entities in
integration efforts. Finally, community participation, which could be facilitated through advisory boards,
surveys, or community assessments undertaken by health departments, is critical to any integration
efforts at the local level.
In addition to primary care and public health entities, other groups working at the community level are
striving for population health improvements. These may include business groups, community-based
organizations, public–private partnerships, academic health centers, faith-based groups, or other
community-level entities. These groups can play many roles. For example, they may act as neutral
conveners, able to link primary care and public health in a balanced way. They may also provide shared
resources, such as community health workers, IT support staff, or case managers—resources that
neither primary care nor public health may be able to support, but that could be beneficial in linking the
two. Thus for the purposes of this report, linkages created at the community level must consist of a
primary care partner, a public health partner (preferably a health department), and the community
itself. However, other stakeholders working in the community may and often should be involved as well.
Actions
How the above partners integrate will differ depending on which partners are involved, the level at
which the integration is occurring, and the local situation. At a minimum, each partner should be
committed to a shared goal of improved population health and be willing and able to contribute to
achieving that goal. The contribution may range from ideas and planning assistance, to financial or
human resources, to goods or a physical space, but ideally will include a shared vision for an ongoing
and sustainable relationship and a continual dialogue that goes beyond a single project. The
contributions of each partner may not always be equal. And the action need not always be challenging;
taking on easy tasks to start is as valid as tackling more complex problems. It is the shared recognition
that success is not possible without each of the partners that is key.
Degree
As stated above, integration can have different meanings for different people. To some, it has a negative
connotation, implying that one entity is subsumed by another, stronger entity. To others, integration
has a positive connotation, suggesting a seamless flow between two entities. The committee recognized
that integration occurs along a continuum (see Figure 1-2). At one end of this continuum is isolation,
with primary care and public health entities working completely separately. At the other end is merger,
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with primary care and public health entities working completely separately. At the other end is merger,
with one combined entity replacing the formerly separate entities. By using the term “integration,” the
committee is not advocating for a complete merger, nor does it see the benefit of isolation. Rather, the
committee believes there are degrees of integration—ranging from mutual awareness, to cooperation,
to collaboration, to partnership—that can be used to achieve better health. With mutual awareness,
primary care and public health are informed about each other and each other’s activities. Cooperation
denotes some sharing of resources, such as space, data, or personnel. Collaboration is more intense and
involves joint planning and execution, with both entities
working together to coordinate at multiple points to carry out a combined effort. Partnership implies
integration on a programmatic level, with two entities working so closely together that there is no
separation from the end user’s perspective; there are, in fact, two parties, but their degree of
integration is so great that the effect is nearly seamless. The discussion of integration in this report
encompasses all of these degrees. Each community is different, and not all will be able to achieve true
partnership. In some communities, achieving mutual awareness will be a significant step forward.
However, it is useful to be aware of this continuum and strive for greater integration when possible.
Degrees of integration. FIGURE 1-2
From <https://www.nap.edu/read/13381/chapter/3#29>
BENEFITS AND CHALLENGES OF INTEGRATION
Primary care and public health have complementary functions and a common goal of ensuring a
healthier population. However, they presently operate largely independently with distinct governance
and funding streams, and each approaches this goal differently. Table 1-1, based on a table that
highlights the differences between medicine and public health (Fineberg, 2011), provides an overview of
these different perspectives.
While their perspectives and approaches may differ, in many ways primary care and public health align
neatly. By working together, primary care and public health can each achieve their own goals and
simultaneously have a greater impact on the health of populations than either of them would have
working independently. For example, public health’s ties to community resources can provide support in
areas of patient care that are typically difficult for primary care to handle on its own, such as prevention,
health promotion, and the management of chronic disease. A primary care practitioner caring for
significant numbers of people with asthma can work with local public health agencies to identify
geographic areas in the community where poor housing stock or environmental risks can be addressed
through combined action with other local stakeholders to remove or reduce asthma risks and ultimately
decrease unnecessary use and expense in the health care system. And the incorporation of data from
frontline health care providers into public health systems can enable more accurate and timely
assessments of health issues, such as infectious disease outbreaks or diseases related to environmental
exposures, as well as chronic disease trends in communities that might suggest areas for public health
interventions.
These examples illustrate why primary care and public health should and how they could integrate. The
evidence base supporting integration is not robust. Few studies have specifically examined integration
and gauged its impact on health or process outcomes. In Chapter 2, some examples of integration
taking place in local communities around the United States are presented; cases in which improved
outcomes have been reported are highlighted.
Perspectives of Medicine and Public Health TABLE 1-1
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Perspectives of Medicine and Public Health TABLE 1-1
Medicine
Primary focus on individual
Personal service ethic,
conditioned by awareness of
social responsibilities
Emphasis on diagnosis and
treatment, care for the whole
patient
Medical paradigm places
predominant emphasis on
medical care
Well-established profession with
sharp public image
Biologic sciences central,
stimulated by needs of patients;
move between laboratory and
bedside
Clinical sciences an essential
part of professional training
Rooted mainly in the private
sector
Public Health
Primary focus on population
Public service ethic, tempered by concerns
for the individual
Emphasis on prevention, health promotion
for the whole community
Public health paradigm employs a spectrum
of interventions aimed at the environment,
human behavior and lifestyle, and medical
care
Multiple professional identities with diffuse
public image
Biologic sciences central, stimulated by
major threats to health of populations; move
between laboratory and field
Clinical sciences peripheral to professional
training
Rooted mainly in the public sector
SOURCE: Based on Fineberg, 2011.
It has long been asserted that public health and primary care should be viewed as “two interacting and
mutually supportive components” of a health system designed to improve the health of populations
(Welton et al., 1997, p. 262). There is vast potential for alignment between the two sectors. Each has
knowledge, resources, and skills that can be used to assist the other in carrying out its roles. To quote
the 1996 IOM report Primary Care: America’s Health in a New Era, “the population-based functions of
public health and the primary care services delivered to individuals are complementary functions, and
strengthening the relationship should be the focus of action in both arenas” (pp. 131-132).
Benefits of Integration
As mentioned above, there have been few formal analyses of the efficacy of primary care and public
health integration. However, evidence indicates that some advantages can be realized through
integration.
A recent literature review of primary care and public health collaborations conducted in Canada found
that these efforts resulted in improved
health outcomes, improved workforce outcomes, and benefits at the patient and population levels
(Martin-Misener et al., 2009), but that these examples are not widespread. Lasker and the Committee
on Medicine and Public Health (1997) conducted a review of more than 400 instances of medicine and
public health collaboration and noted a number of benefits that arose from such endeavors. Specifically,
the authors found that collaboration benefited clinicians by providing population-based information
relevant to their practices, enhancing their capacity to address behaviors and the underlying causes of
illness, and generating better quality assurance standards and performance measures. Public health
entities received support for their role in carrying out population-based strategies, including the
collection of individual-level data for surveillance purposes, the dissemination of health education and
key health promotion messages, and cooperation for the assurance of quality medical care for all
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key health promotion messages, and cooperation for the assurance of quality medical care for all
members of a community.
Beyond the benefits to providers and public health entities, it stands to reason that society gains from
integration as well. Integration can improve the efficiencies and harness the capabilities of primary care
and public health and their respective workforces to focus on common problems. By joining forces,
primary care and public health are better able to meet the nation’s goal of improved population health.
Unfortunately, however, integration is no easy task.
Challenges of Integration
Aligning primary care and public health to work together and with other partners in pursuit of the
shared goal of improved population health is challenging. A number of trends reinforce the fragmented
nature of the current health system, including a history of segregation between primary care and public
health, a lack of financial resources and incentives, and an inflexible regulatory system (Baker et al.,
2005; IOM, 1988, 2002, 2003, 2011b).
In the early 20th century, despite years spent as related and overlapping areas (Brandt and Gardner,
2000; Duffy, 1979), public health began to establish itself as a profession independent of medicine. This
fissure can be traced to a number of factors, most notably the decision to create public health schools
separate from medical schools and the rise of the biomedical model.
In 1915, the Welch-Rose Report, authored by William Welch and Wycliffe Rose of the Johns Hopkins
School of Medicine, described a research-focused approach to public health education. Based on this
report, the Rockefeller Foundation, with which Welch was affiliated, began to focus its philanthropic
efforts on public health, and in 1916, the Johns Hopkins School of Hygiene and Public Health was
established with financial support
from the foundation. By 1947, 10 schools of public health had been established, separating public health
education from the more narrowly focused and uniform medical curriculum. As public health
professionals and educators argued for more independence from medicine in universities and
government, public health became viewed by medical professionals as an economic competitor that was
largely encroaching on matters believed to be best resolved through the care and treatment provided by
medical professionals to individual patients (Brandt and Gardner, 2000).
In addition to this separation, the biomedical model of disease emerged from a greater understanding of
germ theory and bacteriology. This model conceived of disease as something separate from any social
causes. As the objective biomedical model gained prominence, a natural consequence was the
uncoupling of medical care from public health, which was viewed as being marred by politics and social
matters. This view led to a decline in spending on and attention to public health relative to medical care
that persists today (Brandt and Gardner, 2000).
After decades of separation, both primary care and public health have hard-won identities,
achievements, and cultures that they prize. Revising these identities and adapting to each other’s
cultures in order to integrate their efforts can be experienced as a loss. Both sectors tend to view
themselves as neglected and underappreciated. Both primary care and public health are fragmented
within themselves, sometimes struggling to coordinate and align efforts internally, much less with each
other. Both have dedicated advocacy groups that stake out territory and defend it against
encroachment by alternative interests.
This historical divide is further cemented by a lack of financial investment in both primary care and
public health. In this environment, the creation of financial incentives and supporting linkages between
primary care and public health is not easy to accomplish or sustain. Payment structures within the
delivery system reward disease treatment rather than prevention, pay for volume rather than value, and
incentivize specialty care and procedural interventions over primary care. Moreover, primary care and
public health both receive a relatively small proportion of the expenditures devoted to health in the
United States (as discussed in more detail in Chapter 4). Frequently, they find themselves competing
with each other for resources insufficient for either, much less both. Primary care and public health at
their best result in nonevents, often at moments distant in time, for individuals and populations, making
success somewhat invisible to others. This invisibility often hinders both sectors from attracting funders
willing to invest in improvement efforts.
Furthermore, both primary care and public health operate under inflexible regulatory policies and
funding restrictions that may preclude or hamper shared action. Neither is accountable to the other,
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funding restrictions that may preclude or hamper shared action. Neither is accountable to the other,
and there is no
shared space where primary care and public health come together routinely and automatically to
identify problems and opportunities, plan together, coordinate their work, and undertake joint efforts.
In terms of informatics and data collection, primary care and public health often lack interoperable
information systems both within the delivery system and between the delivery and public health
systems. This internal fragmentation and external siloing often means that even when entities are
willing to integrate, they lack the infrastructure to do so.
These challenges notwithstanding, the committee believes that the potential benefits of greater
integration of primary care and public health are sufficiently promising to merit action now, taking these
challenges into account. The call to better integrate primary care and public health is not new. The
National Commission on Community Health Services, in a report known as “The Folsom Report” (1966),
raised this issue half a century ago by calling for a more comprehensive model of health including both
primary care and public health elements; Kerr White’s Healing the Schismrevisited this idea in 1991
(White, 1991). While examples of long-term, successful models of integration are not abundant, there
appears to be an interest in communities in bringing primary care and public health together to improve
population health (see Box 1-3 and Chapter 2). However, the sustainability and scalability of models of
integration have been lacking. The key task now is to focus on the challenge of sustainable
implementation of community-based models of primary care and public health integration. Critical
elements for this task are providing sustained resources and incentives for these models and supporting
the infrastructure necessary to weave together the diverse stakeholders across multiple sectors that
must participate in their implementation.
Previous examples of integration of primary care and public health can be found both in the United
States and abroad.
From <https://www.nap.edu/read/13381/chapter/3#34>
BOX 1-3
Interest in Collaboration
A willingness to collaborate is evident among diverse health disciplines. In 2011, the National Committee
on Vital and Health Statistics focused on communities as learning health systems and explored a
convenience sample of contemporary examples of local efforts in multiple states to use data to identify
and monitor local health needs and problems. Many examples were readily identified and studied in
sufficient detail to conclude that, even without formal programs and sufficient infrastructure, these
efforts were successful and demonstrated widespread interest in collaboration among community
leaders, clinicians, public health departments at various political levels, and academicians to identify
local health and health care concerns and new, collaborative ways of responding to them (HHS, 2011a).
Efforts in the United States
Some prior initiatives have focused on bridging the gap between primary care and public health and the
community. For example, efforts have been made in some areas within the United States to adopt COPC
models. COPC has been defined as a continual process by which primary health care teams provide care
to a defined community on the basis of its assessed health needs through the integration in practice of
primary care and public health (IOM, 1984). It is a dynamic, interdisciplinary model for planning,
implementing, and evaluating primary care, health promotion, and disease prevention in the community
that generally has appealed to practitioners working in underresourced areas with limited access to
health care services. The application of COPC in the United States has not been widespread. A recent
systematic review found that most articles about COPC did not adhere strictly to the model as originally
described (Thomas, 2008). Even with modified models, however, a number of COPC initiatives have
been found to generate notable improvements in the delivery of primary care (Merzel and D’Afflitti,
2003; Pickens et al., 2002). COPC models have been implemented internationally as well, with some
success (Epstein et al., 2002; Iliffe and Lenihan, 2003).
In 1994 the American Medical Association and the American Public Health Association created the
Medicine and Public Health Initiative. This effort began with a task force that met for 2 years and
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Medicine and Public Health Initiative. This effort began with a task force that met for 2 years and
outlined shared agendas in several areas. The task force developed seven major recommendations for
collaboration between primary care and public health: (1) engaging the community, (2) changing the
education process, (3) creating joint research efforts, (4) devising a shared view of health and illness, (5)
working together in health care provision, (6) jointly developing health care assessment measures, and
(7) translating initiative ideas into action (Beitsch et al., 2005, p. 150). Other activities of note included a
national congress in 1996, the development of a grant program funded by the Robert Wood Johnson
Foundation (Cooperative Actions for Health Program, 2001), and a monograph of examples of
collaboration (Lasker and the Committee on Medicine and Public Health, 1997).While the initiative was
successful in promoting and showcasing efforts at the local level, commitment at the state and national
levels ultimately faltered (Beitsch et al., 2005).
Since the Medicine and Public Health Initiative, other, more limited efforts to catalogue and analyze
integration initiatives on the ground have
been undertaken in the United States. These include a review of public–private partnerships that
brought together service delivery networks and coalitions of stakeholders focused on public health and
community planning (Bazzoli, 1997), an examination of how organizational characteristics and market
conditions contribute to collaborations between either community hospitals or community health
centers and public health agencies (Halverson et al., 2000), and the American Medical Association’s
analysis of effective clinical partnerships between primary care practices and public health agencies
(Sloane et al., 2009). While these initiatives point to an enduring interest in integration, they were not
part of a sustained effort to promote integration, and none alleviated a steady and persistent relative
neglect of both primary care and public health.
International Efforts
There has been some international recognition of the need to coordinate primary care and public health
efforts. In 2003, at a primary care strategic planning meeting held to assess the status of health
improvement since the Declaration of Alma Ata (WHO, 1978), the World Health Organization noted that
“the emphasis placed on community participation and intersectoral collaboration is especially
appropriate now, when so many health issues … cannot be effectively addressed by health systems
working in isolation” (WHO, 2003, p. 16). The ensuing report on that meeting recommended the
strengthening of public health functions in primary health care settings. Likewise, a number of countries
have made efforts to implement the integration of primary care and public health. A restructuring of the
National Health Service in England placed public health professionals in Primary Care Trusts in an
attempt to change the way primary care operates (The NHS Confederation, 2004). In 2000, New Zealand
announced changes to its health care system that established District Health Boards with responsibility
for both primary care and public health (New Zealand Ministry of Health, 2000). Attempts to reform
public health currently are under way in Canada, where a 2005 workshop called for the Public Health
Agency of Canada to develop stronger collaboration between primary care and public health (Rachlis,
2009). In addition, McMaster University in Ontario initiated a research program to explore the potential
for collaboration between primary care and public health and the extent to which such collaborative
partnerships currently exist (StrengthenPHC, 2011).
STUDY PURPOSE AND APPROACH
This study originated in a joint request from HRSA and CDC. With the passage of the ACA, these two
agencies, further described in Appendix A,
have a unique opportunity to ensure that the provisions they are charged with implementing line up in a
way that promotes population health and contributes to an enhanced health system with increased
access, improved quality, and reduced costs. These agencies asked the IOM to convene the Committee
on Integrating Primary Care and Public Health, whose 17 members include experts in primary health
care, state and local public health, service integration, health disparities, HIT, health care finance, health
care policy, public health law, workforce education and training, organization management, and child
health. Biographical sketches of the committee members are presented in Appendix D.
In clarifying the committee’s charge at its first meeting, the sponsors reiterated their interest in
receiving practical, actionable recommendations that could assist both agencies in establishing linkages
with each other and with other relevant agencies. Box 1-4 presents the committee’s statement of task.
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with each other and with other relevant agencies. Box 1-4 presents the committee’s statement of task.
Funding for the study was provided by HRSA, CDC, and the United Health Foundation.
In conducting the study, the committee held six open and two closed meetings. The open meetings were
held in Washington, DC, and Irvine, California, and included 34 presentations. Four of the open meetings
were focused on HRSA and CDC and their work in the areas of maternal and child health, cardiovascular
disease prevention, and colorectal cancer screening. The agendas for the open meetings can be found
in Appendix C. Members of the general public made comments at the open meetings and submitted
documents to the committee. The committee also reviewed the published literature, held discussions
with HRSA and CDC, and commissioned papers on relevant topics. Finally, a number of consultants
assisted the committee; they are listed at the front of the report.
While cardiovascular disease prevention was identified as a required area for the study, the committee’s
statement of task (Box 1-4) included selecting one or two additional areas. The committee selected
maternal and child health (further refined to focus on maternal, infant, and early childhood home
visiting) and colorectal cancer screening to complement cardiovascular disease prevention. These three
areas flow across the life course and include elements of mental and behavioral health, while also
reflecting many of the issues related to health disparities.
BOX 1-4
Statement of Task
The Health Resources and Services Administration (HRSA) and the Centers for Disease Control and
Prevention (CDC) have requested that the Institute of Medicine convene a committee of experts to
examine ways to better integrate public health and primary care to assure healthy communities. The
committee’s work would ultimately result in an evidence-based, integrated model and other
recommendations that would help achieve successful linkages between public health and primary care.
As part of its work, the committee will address the following questions:
1. What does the evidence report as the best methods to improve population health and/or reduce
health disparities through integrating or connecting public health and primary care?
A. What are the models and factors that promote and sustain effective integration and connection
between public health and primary care?
B. What are the gaps in evidence?
2. What are the best examples of effective public health and primary care integration and connection
that address:
A. Demonstrated, shared accountability for population health improvement
B. Optimizing the integration of the public health and primary care workforce
C. Collaborative governance, financing, and care coordination models including optimizing
reimbursement to health departments for clinical and case management (particularly STDs and TB
models)
D. Effective use of health information technology (explore the possible role of health departments as
data hubs)
a. This should include non-patient specific reporting of notifiable conditions and health department
notification of primary care providers regarding key community health challenges
b. This should include patient specific information on
i. TB, HIV, HBV perinatal immunization—coordination of care and follow-up to improve outcomes
ii. Primary care systems and public health departments as potential hubs (neutral brokers for the
community)
iii. Sentinel surveillance systems (e.g., autism, birth defects)
c. This should include recommendations on the barriers and steps to make significant progress on
exchanging electronic health record generated information
E. Promotion of integration for the goal of achieving high quality primary care and public health
3. How can HRSA and CDC use Affordable Care Act provisions (e.g., community transformation grants,
prevention strategy, quality strategy, community health center expansion, National Health Services
Corps, and other workforce programs) to promote integration of public health and primary care?
4. How can HRSA-supported primary care systems (e.g., Federally Qualified Health Centers, Rural
Health Clinics, Ryan White Clinics) and state and local public health departments effectively integrate
and coordinate to improve cardiovascular disease prevention (which would include obesity, tobacco
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and coordinate to improve cardiovascular disease prevention (which would include obesity, tobacco
use, aspirin use, blood pressure and cholesterol management)
A. One to two additional topics based on Committee input that address issues relevant to health
disparities or specific populations
a. These should be chosen from among immunization, TB control, STD control, asthma management,
falls prevention, behavioral health, SBIRT (screening, brief intervention, and referral to treatment),
cancer screening, diabetes mellitus prevention and care, and family planning
5. Within each care area, the committee should address potential actions, needs, or barriers regarding:
A. Science
B. Finance
C. Governance
D. Health information technology
E. Delivery system and practice
F. Policy
G. Workforce education and training
6. What actions should CDC and HRSA take to promote these changes?
The committee should engage relevant stakeholders and perform a comprehensive literature review
that includes international experiences, to identify promising practices and gaps in integrating public
health and primary care.
From <https://www.nap.edu/read/13381/chapter/3#39>
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