A Public Health Action Plan to Prevent Heart Disease and Stroke

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Appendix D: Development of A Public Health Action Plan to Prevent Heart Disease and Stroke

In 2001, CDC initiated development of A Public Health Action Plan to Prevent Heart Disease and Stroke. The concept of the plan and the process for its development were presented at the First National CDC Prevention Conference on Heart Disease and Stroke on August 24, 2001, in Atlanta. Valuable input was received, especially from the Cardiovascular Health Council of the Chronic Disease Directors (CDD), who identified representatives to join in the planning process. This appendix outlines this process and identifies the many partners who participated. 

Organization

The planning process for the Action Plan included several key partners, public health experts, and heart disease and stroke prevention specialists in the United States and abroad. These participants were asked to contribute in several ways, including as members of a Working Group, one of five Expert Panels, or a National Forum. The figure illustrates the organizational structure for the planning process, which included CDC Core Staff. 

Organizational Structure of the Action Plan Planning Process 

Note: Abbreviations used in the figure are identified in the text or the participants list.

For the Expert Panels, each of which was chaired by an extramural public health expert, 45 national and international experts contributed to formulation of the recommendations and proposed actions steps. For the Working Group, which also was chaired by an extramural public health expert, 20 national and international experts served. For the National Forum, which was presided over by the chair of the Working Group, 81 individuals representing 66 national and international organizations and agencies other than CDC participated. With technical support from CDC, these groups developed the substance of the plan. 

CDC Core Staff 
The CDC Core Staff was responsible for coordinating the overall planning process. This staff works for the Associate Director for Cardiovascular Health Policy and Research in the Office of the Director, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (OD/DACH/NCCDPHP/CDC). An outside contractor helped CDC with meeting arrangements and other logistical details. 

Expert Panels 
CDC convened five Expert Panels, each to address one of the five essential components of the Action Plan. The panels identified relevant concerns and problems, proposed solutions, and offered recommendations appropriate to their topics. The Working Group then reviewed these recommendations. The synthesized recommendations are presented in Section 3 of this plan. The corresponding action steps are presented in Section 4. 

The titles and topics for the five Expert Panels were as follows: 

• Panel A: Policy and Programs
  Taking action: Putting present knowledge to work. 
• Panel B: Capacity Development and Support 
  Strengthening capacity: Organization and structure of public health agencies and partnerships. 
• Panel C: Monitoring, Evaluation, and Communication 
  Evaluating impact: Monitoring the burden, measuring progress, and communicating urgency. 
• Panel D: Research in CVH Promotion and CVD Prevention 
  Advancing policy: Defining the issues and finding the needed solutions. 
• Panel E: Global Cardiovascular Health 
  Engaging in regional and global partnerships: Multiplying resources and capitalizing on shared experience. 

Each Expert Panel had 16–22 members, including the following: 

• Experts from outside CDC nominated from multiple sources and invited to participate on a particular panel based on the specific contribution they would make to the process. 
• Members nominated by the Cardiovascular Health Council, CDD, which is part of the Association of State and Territorial Health Officers (ASTHO). 
• The Cardiovascular Health Coordinating Committee (CVHCC), made up one or more representatives from each of the five NCCDPHP divisions that deal most directly with cardiovascular health: the Division of Adult and Community Health (DACH), the Division of Adolescent and School Health (DASH), the Division of Diabetes Translation (DDT), the Division of Nutrition and Physical Activity (DNPA), and the Office on Smoking and Health (OSH). 
• NCCDPHP's Associate Director for Cardiovascular Health Policy and Research and the CDC Core Staff.

Working Group 

The Working Group was responsible for initial critical review of the draft outline of the plan and the development process. Members also formulated the instructions for the Expert Panels, nominated members for the National Forum, and reviewed the final reports of the Expert Panels. In addition, they assessed the proposed implementation process and considered all input from the National Forum in preparing the final document. The 36–member Working Group included the following: 

• The chairs of the Working Group and each of the five Expert Panels. 
• Representatives from the Cardiovascular Health Council, CDD. 
• Representatives from the five NCCDPHP divisions that deal most directly with cardiovascular health. 
• Representatives from CDC's National Center for Environmental Health (NCEH) and National Center for Birth Defects and Developmental Disabilities (NCBDDD).
• Each partner working with CDC under a current memorandum of understanding (MOU) in the area of heart disease and stroke. These include one MOU with the American Heart Association (AHA) and American Stroke Association (ASA); the Centers for Medicare & Medicaid Services; the Office of Public Health and Science and the Office of Disease Prevention and Health Promotion, Department of Health and Human Services; and the National Heart, Lung, and Blood Institute and the National Institute of Neurological Disorders and Stroke, National Institutes of Health. CDC also has MOUs with the Ministry of Health and Welfare Canada and with the National Stroke Association. 
• Representatives from CDC's Prevention Research Center Program (PRCP). 
• Representatives from other national health professional organizations. 
• NCCDPHP's Associate Director for Cardiovascular Health Policy and Research and the CDC Core Staff. 

National Forum 
National Forum participants were responsible for reviewing the draft plan from the perspectives of a wide range of partners, constituencies, and other interested parties. They also were asked to assess priorities for the many proposed action steps and to consider the potential contributions of partners to implementing the plan. The National Forum comprised the following participants: 

• All members of the Working Group.
• Representatives from additional state and territorial organizations. 
• Additional new partners. 
• Additional representatives of the CVH research community. 
• Additional CDC staff members from other Centers, Institutes, and Offices (CIOs). 
• Other appointees as recommended during the planning process.

General Process and Format 

The CDC Core Staff was responsible for overall planning and for executing production of the plan, including preparation of working drafts of all materials and the final draft for publication. The CDC Core Staff established and maintained Internet communications about the process and interim products to make the material widely accessible and to encourage broad–based input. A contractor was responsible for logistical arrangements for all meetings.

The Working Group met first in December 2001 to provide input to the draft outline, draft implementation plan, and Expert Panel instructions and to recommend members for the National Forum. During its second meeting in late May 2002, members reviewed and discussed the reports of the five Expert Panels and the implementation plan. Based on this discussion, the CDC Core Staff prepared a draft of the plan for review by the National Forum. 

Each Expert Panel was convened for two meetings, the first during January–February 2002 and the second during March–May 2002. These meetings included preliminary discussions, interim work, and final discussions, which led to completed position papers for each panel that will be published separately. 

In preparation for the first meeting, panelists received selected background material and were asked to prepare a written statement on their topics. This material was compiled and distributed to all members of each panel before the meeting. During the first meeting, participants discussed their designated component of the plan and identified approximately five issues of foremost importance regarding that component. This discussion facilitated development of a set of premises, which each panel used as the basis for their recommendations. These premises are as follows:

Panel A: Policy and Programs

• Policy development for cardiovascular health (CVH) promotion and cardiovascular disease (CVD) prevention must proceed under a comprehensive framework that recognizes the full array of cardiovascular disorders (e.g., heart attack, heart failure, stroke, vascular dementia) and the need to establish strategic links with efforts to prevent other chronic conditions of public health concern (e.g., obesity, diabetes, pulmonary disease, cancer). 
• For maximum impact, community–wide interventions must address all appropriate settings, all opportunities throughout the life span, and the total U.S. population, with added emphasis on populations at high risk. 
• A comprehensive public health strategy must focus on preventing major risk factors and assuring services to detect and control them once they develop. This strategy must also support efforts to widely implement guidelines for early identification and treatment of acute CVD events and prevention of recurrent events. 
• The ideal program should be 1) national in scope, with state and local adaptation and implementation; 2) based on strategic partnerships, both innovative and established; 3) comprehensive with respect to CVD development and intervention approaches; and 4) responsive to community concerns.

Panel B: Capacity Development and Support 

• Preventing heart disease and stroke requires a robust and effective public health infrastructure. Recent events have underscored the need for improved public health infrastructure in the United States. The current public health infrastructure urgently needs to be transformed to allow initiation of programs that are large enough and have the necessary competencies to achieve the goals of the plan. Such competencies include technical as well as political capacity (i.e., to develop policies, partnerships, and a societal commitment to prevent heart disease and stroke). Both aspects are essential. Technical capacity does not assure its own implementation, and a societal commitment cannot succeed without technical capacity. 
• The public health capacities needed to prevent and manage CVD and other chronic diseases differ from those needed for communicable disease control. CVD presents special challenges because of its roots in societal conditions, its protracted duration of development, its varied manifestations, and the need for a continuum of intervention approaches (from CVH promotion through the full spectrum of primary and secondary CVD prevention). Thus, addressing chronic diseases such as CVD requires an infrastructure of technical expertise and policies different from traditional public health agency models. 
• The goals of this plan can best be met by recognizing the needed contributions of a diverse and culturally competent workforce. 
• Capacity should be developed specifically to eliminate racial, ethnic, and geographic disparities in heart disease and stroke, through development of resources and competencies that address the causes of these disparities.
• Capacity should be developed at multiple levels, including local (i.e., city, county), state, tribal, and national. Challenges and opportunities unique to each should be considered. All levels should engage communities where people live, work, learn, and play.
• These recommendations can be supported by the accumulated knowledge and experience in public health practice and prevention research, which is sometimes derived from randomized trials but more often depends on other types of evidence (like many public health decisions). 

Panel C: Monitoring, Evaluation, and Communication 

• Surveillance is needed at national, state, and especially local levels, with indicators established for community and individual measures. 
• A strong focus is needed on current and future uses of new data. 
• Publicly funded CVH programs must conduct process and outcome evaluations. Privately funded programs should be encouraged to do the same. 
• When planning surveillance and evaluation, three questions must be answered: What are the minimum data requirements? What additional data are highly desirable? What is the ideal scope of data collection? These answers are needed to develop appropriate interventions for CVD, to monitor the factors leading to CVD development, and to assess the impact of interventions on the population. These answers are also critical for setting priorities for data collection systems.

Panel D: Research in CVH Promotion and CVD Prevention 

• A research agenda for heart disease and stroke prevention must recognize the opportunities for research throughout the life span. Conditions that lead to CVD development (e.g., atherosclerosis, high blood pressure) can result from exposures during childhood, adolescence, or even gestation. Risk factor levels generally progress throughout adulthood. Many older adults remain at high risk for continued progression of atherosclerosis and high blood pressure or recurrence of heart attacks or strokes unless adequate preventive measures are taken. Thus, preventive measures are important in childhood and adolescence (or earlier) and throughout early, middle, and later adult years. 
• The concept of best practices is well established in public health and involves systematic review and assessment of available knowledge in accordance with accepted criteria. An appropriate review of the extensive knowledge and experience that already exists from public health practices in preventing heart disease and stroke would advance CVD best practices and help shape the prevention research agenda. 
• The distinction between policy, environmental, and individual approaches to addressing CVD should be recognized. All are appropriate, and each has elements especially suited to particular settings. 
• New prevention research will continually be needed to identify and evaluate current and proposed interventions, especially those related to policy and environment, which have rarely been investigated. Prevention effectiveness studies are needed to investigate interventions, addressing such aspects as the percentage of disease occurrence that can be prevented, costs and cost–effectiveness, feasibility (strengths/weaknesses/opportunities/threats), specific target populations, multiple levels (local, state, national), multiple settings (communities, work sites, schools, families), specific behaviors or health states studied as outcomes (e.g., smoking cessation, obesity), and effects of varied combinations of approaches (e.g., in a comprehensive model program). 
• Important determinants of cardiovascular risk, including social and environmental conditions, have been investigated much less than personal behaviors (e.g., dietary imbalance, physical inactivity, smoking). These determinants require prominent attention in the research agenda. 
• The infrastructure needed for such research includes multiple agencies and organizations at national, state, and local levels (including federal agencies, national voluntary organizations, and foundations). The roles of these and other potential partners in implementing the research agenda are an important aspect of implementing the plan.

Panel E: Global Cardiovascular Health 

• A public health strategy for CVH promotion and CVD prevention is guided by commitment to the social values of health as a human right, equity, solidarity, participation, and accountability.¹ 
• Cooperating on global CVD control and CVH promotion is imperative and urgent. Partners in this plan recognize the strategic need for strong U.S. involvement in global CVH issues.
• The basic needs of vast numbers of people continue to be unmet, and the resulting health challenges leave many people without hope. A more optimistic view recognizes and responds to the importance of a global context in addressing health and security. Better health—achieved through improvements in basic living conditions, income, education, and social services (including health care)—is a key element to achieving a better and safer world for everyone. Without these elements, better CVH cannot be fully achieved.
• With current knowledge and resources, a world that is substantially free from epidemic heart disease and stroke can be envisioned. Eliminating health inequalities and increasing the quality and years of healthy life are strategic goals for the global community in this century.
• To progress, we must maximize the use of all resources in our globalized, interconnected, and interdependent world. Despite the current picture of world affairs, our commitment to improving health conditions, especially CVH, offers the hope of a better future. 
• The first four components of this plan (taking action, strengthening capacity, evaluating impact, and advancing policy) can also apply to global CVH promotion. Global recommendations in these areas must 1) correspond to global needs; 2) correspond to capacities and resources of CDC and its partners; 3) contribute to advancing national CVH or enrich the plan itself; and 4) reflect the underlying values and correspond to the stated vision of the plan. 
• Based on the preceding criteria for global recommendations, CDC is assumed to be the primary agency to support their implementation, in conjunction with regional and global partners. The recommendations are directed accordingly. 

The second meeting of each panel focused on making specific recommendations for the Action Plan. Areas of consensus and difference were identified, and salient points were incorporated in a set of recommendations and corresponding action steps. The recommendations and action steps constituted the primary products of the Expert Panels. These were used to prepare the draft plan, after synthesis by the Working Group.

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Reference 

1. Advisory Board of the First International Conference on Women, Heart Disease and Stroke. The 2000 Victoria Declaration on Women, Heart Diseases and Stroke. Victoria, Canada: Advisory Board of the First International Conference on Women, Heart Disease and Stroke; May 8–10, 2000.

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Action Plan Participants

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Date last reviewed: 05/12/2006
Content source: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion