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A
Public Health Action Plan to Prevent Heart Disease and Stroke
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Section 3. Recommendations: A Call to Action
Recommendations for the Five Essential Components of the Plan
To help the public health
community implement the Action Plan, specific recommendations were
developed by five Expert Panels. These panels addressed the five essential
components of the plan—taking action, strengthening capacity, evaluating
impact, advancing policy, and engaging in regional and global partnerships.
Their work was synthesized by a Working Group into 22 recommendations, which
are presented here according to the Expert Panel that produced them.
Taking Action: Putting Present Knowledge to Work
- Initiate policy
development in CVH promotion and CVD prevention at national, state, and
local levels to assure effective public health action against heart
disease and stroke. In addition, evaluate policies in non–health sectors
(e.g., education, agriculture, transportation, community planning) for
their potential impact on health, especially with respect to CVD.
As described in Section 1, interventions that address
policy and environmental change can have population–wide impact. Such
changes represent the coming era of chronic disease prevention and health
promotion.1 The greatest potential for sustained,
population–wide health behavior change lies in policy decisions in
communities and organizations that support heart–healthy behaviors and in
interventions that favor CVH promotion and CVD prevention.
- Act now to
implement the most promising public health programs and practices for
achieving the four goals for preventing heart disease and stroke, as
distinguished by the Healthy People 2010 Heart and Stroke Partnership
based on the different intervention approaches that apply. These goals are
prevention of risk factors, detection and treatment of risk factors, early
identification and treatment of heart attacks and strokes, and prevention
of recurrent cardiovascular events. Public health agencies and their
partners must provide continuous leadership to identify and recommend new
and effective interventions that are based on advances in program
evaluation and prevention research and a growing inventory of "best
practices."
To rigorously evaluate
policies and programs, new evaluation concepts and methods must
continuously be developed. Because input to this development may arise
from many sources (e.g., other agencies and organizations, academia,
participating communities), establishing leadership responsibility for
this function will be advantageous. Taking action based on current
knowledge presupposes a well–founded inventory of programs and practices
and assessment of their potential effectiveness. Such an inventory is
required in relation to the four Healthy People 2010 Heart and Stroke
Partnership goals (which are based on the one Healthy People 2010
goal for preventing heart disease and stroke2). Selected
programs and practices must also be implemented on a sufficient scale to
permit meaningful evaluation of their impact.
- Address all
opportunities for prevention to achieve the full potential of preventive
strategies. Such opportunities include major settings (schools, work
sites, health care settings, communities, and families), all age groups
(from conception through the life span), and whole populations,
particularly priority populations (based on race/ethnicity, sex,
disability, economic condition, or place of residence).
Only a comprehensive
approach can most effectively control the progressive development of risk
factors and disease outcomes. In this approach, multiple programs must
often be coordinated if all major risk factors are to be addressed in all
settings for all population groups. CVH leadership includes assuring that
all risk factors are adequately addressed through the available resources
and stakeholder groups and that requisite preventive and clinical programs
and services of acceptable quality are accessible and used by those who
need them.
- Emphasize promotion
of desirable social and environmental conditions and favorable behavioral
patterns in order to prevent the major CVD risk factors and assure the
fullest attainable accessibility and use of quality health services for
people with risk factors or who develop subclinical or overt CVD. These
actions are integral to a comprehensive public health strategy for CVH
promotion and CVD prevention.
Only a comprehensive
strategy can effectively address the Healthy People 2010 goal for
preventing heart disease and stroke (see Recommendation 2). Such a
strategy for CVH promotion must emphasize the earliest aspects of CVD risk
development that jeopardize the health of the entire population (e.g.,
influences on behavior related to diet; physical activity; and tobacco,
alcohol, and drug use) (see Section 2).
This is the most neglected area of intervention, and it provides the
greatest opportunities both to promote CVH and prevent the later
consequences (e.g., risk factors, clinical events). Public health
officials and their partners in the health care delivery system and other
areas also must assure to the fullest extent possible that clinical
guidelines and treatment recommendations for addressing risk factors when
they are present (i.e., primary prevention) and CVD events and conditions
once they have occurred (i.e., secondary prevention) are implemented
effectively across all population groups.
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Strengthening Capacity: Transfroming the
Organization and Structure of Public Health Agencies and Partnerships
- Maintain or
establish definable entities with responsibility and accountability for
CVH programs within federal, state, and local public health agencies,
including laboratory components.
As a preventable
disease that profoundly affects mortality, disability, and health care
costs in the United States, CVD warrants visibility and attention as a
major public health problem. The large and growing level of disparity
among certain racial and ethnic populations adds urgency to this need.
Establishing the visibility of CVH in all public health agencies will
contribute to the needed recognition of this area of responsibility.
- Create a training
system to develop and maintain appropriately trained public health
workforces at national, state, and local levels. These workforces should
have all necessary competencies to bring about policy change and implement
programs to improve CVH promotion and decrease the CVD burden, including
laboratory requirements.
The necessary
competencies go beyond traditional public health knowledge to encompass
practical skills such as developing and maintaining partnerships and
coalitions, defining and identifying the burden and status of chronic
diseases, and knowing how to incorporate sound business practices. Few
academic training opportunities to learn these essential skills exist in
currently available curricula, including master of public health programs.
New workers require on–the–job training or other informal means to acquire
these skills. Several training options are proposed in Section 4 to meet
the needs of local, state, and national public health workers.
- Develop and
disseminate model performance standards and core competencies in CVD
prevention and CVH promotion for national, state, and local public health
agencies, including their laboratories.
Rather than mandating
specific personnel and other resources for CVD prevention programs,
setting performance standards and competencies that public health agencies
can meet through flexibility with their own personnel and resources may be
more successful.
- Provide ongoing
access to technical assistance and consultation to state and local health
agencies and partners for CVD prevention.
Although health
agencies and organizations can develop personnel capacities through
episodic training, continuous availability of technical support through
consultation and information sharing can enhance the effectiveness of
staff with sufficient previous training. Resources are needed to assure
the availability of such support.
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Evaluating Impact: Monitoring the Burden, Measuring
Progress, and Communicating Urgency
- Expand and
standardize population–wide evaluation and surveillance data sources and
activities to assure adequate assessment of CVD indicators and change in
the nation's CVD burden. Examples include mortality, incidence,
prevalence, disability, selected biomarkers, risk factors and risk
behaviors, economic burden, community and environmental characteristics,
current policies and programs, and sociodemographic factors (e.g., age,
race/ethnicity, sex, and ZIP code).
Existing data sources
do not adequately support current populationwide surveillance and
evaluation priorities. Strengthening and enhancing these data sources will
contribute better information for monitoring and improving CVH in the
United States.
- Establish a network
of data systems for evaluation of policy and program interventions that
can track the progress of evolving best practices and signal the need for
changes in policies and programs over time. This network would support the
full development, collection, and analysis of the data needed to examine
program effectiveness.
The scientific basis
for public health policy and programs in heart disease and stroke
prevention must be continually strengthened. A prerequisite for achieving
this recommendation is to build data systems that can evaluate health
burdens, health practice experiences, and the possible opportunities for
new policy and program development.
- Develop the public
health infrastructure, build personnel competencies, and enhance
communication systems so that federal, state, and local public health
agencies can communicate surveillance and evaluation results in a timely
and effective manner.
Communicating health
information is essential to assuring the timely application of proven
interventions for the greatest public health benefit. Strengthening the
capacity of public health systems to collect and use information will
stimulate policy development and lead to more effective programs and a
greater ability to measure their impact.
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Advancing Policy: Defining the Issues and Finding
the Needed Solutions
- Conduct and
facilitate research by means of collaboration among interested parties to
identify new policy, environmental, and sociocultural priorities for CVH
promotion. Once the priorities are identified, determine the best methods
for translating, disseminating, and sustaining them. Fund research to
identify barriers and effective interventions in order to translate
science into practice and thereby improve access to and use of quality
health care and improve outcomes for patients with or at risk for CVD.
Conduct economics research, including cost–effectiveness studies and
comprehensive economic models that assess the return on investment for CVH
promotion as well as primary and secondary CVD prevention.
The importance of
policy, environmental, and sociocultural determinants of risk factors and
CVD has only been recognized recently and requires intensified
investigation. Innovative approaches are needed to advance CVH promotion
policy. For example, research is needed to assess community–wide
interventions aimed at maintaining and restoring low blood cholesterol
levels and low blood pressure, which help prevent atherosclerosis and high
blood pressure. To quickly and effectively translate science into practice
and improve health outcomes, researchers must identify barriers and
implement interventions that prove successful. As the U.S. population ages
over the coming decades, the economic aspects of CVD health care (e.g.,
managing risk factors, events, disabilities, and long–term dependency)
will become an even greater problem. Prevention effectiveness research
must provide current and projected estimates of the cost to prevent and
treat each CVD risk factor and outcome, singly and in integrated
multifactor approaches, and determine the cost–effectiveness of current
interventions.
- Design, plan,
implement, and evaluate a comprehensive intervention for children and
youth in school, family, and community settings. This intervention must
address dietary imbalances, physical inactivity, tobacco use, and other
determinants in order to prevent development of risk factors and
progression of atherosclerosis and high blood pressure.
The need to focus on
prevention early in life is compelling. First, very early experience (even
in utero or during early postnatal life)3 may contribute to
risk for adult CVD and determine vulnerability to later effects from
factors such as weight gain or low income. Second, many health behaviors
are established in childhood and youth, when they are more susceptible to
change. Third, biological CVD risk factors such as blood cholesterol level
and blood pressure and behavioral risk factors such as tobacco use track
from childhood into adult life, and family history of CVD predicts CVD
risk factors in children and adolescents. Fourth, preclinical CVD in the
form of atherosclerosis is already present in youth, and its extent and
severity are increased by the presence of these risk factors. Fifth,
emerging evidence on biomarkers of risk may point to specific groups
especially likely to benefit from intervention. The evidence outlined here
indicates that critical, early periods exist when CVD risk can be detected
and treated, and research is needed to define these periods more precisely
and to demonstrate the impact of population–wide interventions.
- Conduct and
facilitate research on improvements in surveillance methods and data
collection and management methods for policy development, environmental
change, performance monitoring, identification of key indicators, and
capacity development. Address population subgroups in various settings
(schools, work sites, health care, communities) at local, state, and
national levels. Additionally, assess the impact of new technologies and
regulations on surveillance systems and the potential benefit of
alternative methods.
Existing surveillance
systems do not collect sufficient data in many of these areas. Thus, the
ability to make evidence–based improvements in policy and capacity
development is limited. Declining survey response rates and increased cell
phone use, caller identification technologies, and privacy protections
impede collection of data representative of many target populations.
Because future innovations could produce communication methods more useful
for data collection, methodological research must continue to adapt.
- Conduct and support
research to determine the most effective marketing messages and
educational campaigns to create demand for heart–healthy options, change
behavior, and prevent heart disease and stroke for specific target groups
and settings. Create and evaluate economically viable CVD prevention
ventures (e.g., in food production, manufacturing, marketing).
The need for more
effective communication about the potential for effective CVH promotion
and CVD prevention is widely acknowledged. Research on this topic can
contribute substantially to the impact of marketing and public education
about heart disease and stroke and increase the return on investment.
Strengthening the market for heart–healthy commercial ventures is
essential. For example, change in the nation's dietary patterns may
require extensive change in food production, processing, marketing, and
consumption. Research collaborations that bring interested parties
together should achieve a major—if gradual—transition in which public
interest and demand for healthy options continue to provide a sustainable
economic market for the food industry.
- Initiate and
strengthen training grants and other approaches, such as training
workshops and supervised research opportunities, to build the competencies
needed to implement the CVD prevention research agenda.
Current training
programs in prevention research are too few and too small to develop the
large cadre of skilled researchers needed to conduct the program
effectiveness research and other investigations recommended in this plan.
Training grants in other areas have proven that this approach can work.
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Engaging in Regional and Global Partnerships:
Multiplying Resources and Capitalizing on Shared Experience
- Engage with
regional and global partners to mobilize resources in CVH promotion and
CVD prevention, develop and implement global CVH policies, and establish
or strengthen liaison with the partners identified in these
recommendations.
Global partnerships
should be strengthened to develop CVH policy and programs that will
advance both U.S. and global agendas for enhancing CVH. These efforts can
build on existing partnerships, thereby increasing the net investment of
effort and resources, and draw on the strengths of the public health
community.
- Address
inequalities in CVH among developed and developing countries, rich and
poor people within countries, and men and women of all ages. Work with
national and global partners to assess the impact of globalization and
trade policies on global CVH.
Inequalities strongly
influence CVH nationally and globally, and eliminating them is a cardinal
goal of public health interventions aimed at promoting CVH. Globalization
affects many aspects of health among people in the United States and
worldwide. Current information on how globalization, including trade
policies and practices, affects CVH is inadequate. Better information is
needed to determine how the positive forces of globalization can be
harnessed to benefit CVH nationally and globally.
- Develop a strategy
to promote use of the media to support CVH globally.
Media channels are
powerful health promotion tools that are underused in CVH promotion and
CVD prevention. In fact, their messages sometimes serve countervailing
interests. Partnership with the global media can help mobilize the use of
these capacities to promote CVH.
- Strengthen global
capacity to develop, implement, and evaluate policy and program
interventions to prevent and control heart disease and stroke. Involve all
relevant parties—governmental and nongovernmental, public and private, and
traditional and nontraditional partners—in a systematic and strategic
approach.
Improvements in a
country's ability to develop or expand its activities in policy and
program interventions can best be made if the organizations with
experience in this area contribute their expertise. Thus, public health
agencies in the United States and their partners can play a significant
role in supporting global efforts to prevent and control heart disease and
stroke. In addition, partnerships limited only to organizations and
agencies within the health sector will be less effective, especially
globally, because effective interventions must be multidimensional.
Further, the potential for expanding resources and commitments to
preventive policies and programs increases as participation grows.
- Strengthen the
global focus of public health agencies in the United States and their
partners on CVH and increase their participation in partnerships intended
to a) develop and implement standards for adequate monitoring of health,
social, and economic indicators and b) develop the ability to effectively
disseminate and translate information into policy and action.
A set of standard
elements that could or should be collected in a monitoring system is
needed. Through technical assistance, public health agencies in the United
States and their partners could contribute to this development.
- Promote and support
research on implementing and evaluating CVH policy interventions in
diverse settings where different social and economic development and
health transition experiences offer contrasting conditions for testing new
intervention approaches.
Current research on
policy interventions and their impact on CVH promotion and CVD prevention,
nationally and globally, is insufficient to provide adequate assurance of
their effectiveness. Policy research tools should be developed, and
emerging policy interventions that could be useful to the United States
and its global partners should be identified and evaluated continually.
Next Section: References
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Contents
Date last reviewed:
05/12/2006
Content source: Division for Heart Disease and Stroke
Prevention,
National Center for Chronic Disease Prevention and
Health Promotion |
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