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A
Public Health Action Plan to Prevent Heart Disease and Stroke
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Section 2. A Comprehensive Public Health Strategy and the Five Essential
Components of the Plan: A Platform for Action
A
Framework for a Comprehensive Public Health Strategy
Developing a
comprehensive public health strategy requires considering the full scope of
a public health problem and the array of potential approaches to controlling
it. It also requires recognizing the present reality and having a vision of
the future that includes the most favorable conditions that can result from
effective public health action. Bringing these four elements together in one
action framework provides guidance and helps ensure that all relevant
aspects are addressed. The framework developed for the Action Plan provides
a useful point of reference for considering the recommendations and proposed
action steps (see figure 1).
This framework is
intended to represent the full scope of CVH in all its aspects, including
the progressive development of CVD and the corresponding opportunities for
CVH promotion and CVD prevention. It reflects the extensive research and
practical experience of the past 50 years and more, which have provided a
solid understanding of the causes of CVD and identified a wide range of
opportunities for intervention. The framework also indicates where
intervention approaches can be applied, through greatly expanded public
health efforts, to advance from the present reality toward the vision of the
future.
The Present Reality
The present reality of
the burden of heart disease and stroke, especially in the United States, was
documented in Section 1.1,2
Underlying this burden are the long–term development of atherosclerosis and
high blood pressure, conditions that are widely prevalent throughout our
society. The causes begin with unfavorable social and environmental
conditions that foster adverse behavioral patterns and result in a high
prevalence of major risk factors. Inadequate measures for preventing,
detecting, and controlling risk factors lead to first CVD events (e.g.,
heart attack, heart failure, stroke) from which many victims die suddenly,
while others survive with a high risk for recurrence and often with
disability. Many victims ultimately suffer fatal complications or
cardiovascular decompensation months or years after the initial event.
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A Vision of the Future
We envision a future when
the epidemic of heart disease and stroke has been arrested and reversed.
This future includes social and environmental conditions that are favorable
to health, a predominance of health-promoting behaviors, a low prevalence of
risk factors, fewer and less frequently fatal CVD events, rapid recovery of
full functional capacity for victims who survive, and good quality of life
thereafter until death from whatever cause. The critical question is, how do
we move from the present reality to this vision of the future?
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Intervention Approaches
The answer can be found
in the six–fold array of intervention approaches available today. First,
policy and environmental change addresses fundamental social and
environmental conditions that operate early in CVD development; this
approach can also influence later phases of the disease process (e.g., by
improving accessibility, use, and quality of health care).3
Second, behavioral change, especially population–wide, can reduce the
effects of adverse social and environmental conditions. It can also
reinforce the approaches that follow (e.g., by fostering community awareness
and support for heart disease and stroke prevention). The third
approach—detecting and controlling risk factors—has been a mainstay of CVD
prevention and is needed continually once risk factors are present, to
prevent both first and recurrent CVD events. (This approach comes too late
in the process to prevent the risk factors themselves.) The fourth approach
is emergency care and acute case management for those victims of first
events who survive long enough to receive intervention. This approach
continues to apply when survivors of previous acute CVD events experience
recurrent ones. The fifth approach is rehabilitation, which should be
applied following most acute events, and long–term management, which
continues throughout the remainder of a victim's life until the sixth
approach, end–of–life care, may be required.
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Healthy People 2010 Goals
The action framework
establishes a clear link between the proposed comprehensive public health
strategy and Healthy People 2010 goals.4 Together, the six
intervention approaches will help achieve the two overarching goals of
Healthy People 2010, as well as the specific goal for preventing heart
disease and stroke. The Healthy People 2010 Heart and Stroke Partnership
divided this goal into four separate goals based on the different
intervention approaches that would be needed to achieve them.
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Target Population
Each intervention
approach has the potential to affect millions of people in the United
States.1 The total U.S. population of 281 million people stands
to benefit from policy and environmental change and populationwide
behavioral change. The more than 100 million people with risk factors (e.g.,
high cholesterol, high blood pressure, smoking, obesity, diabetes) could
benefit from effective risk factor detection and control. In addition, the
hundreds of thousands of victims of first major CVD events each year can
gain from acute or long–term case management and, potentially, from
end–of–life care.
Interventions with the
greatest impact on the population as a whole are those applied in the
earliest phases of CVD development. To treat victims of heart disease,
stroke, or other cardiovascular conditions is clearly to intervene late in
the disease process. For those who die suddenly without warning, it is too
late to have any benefit. Today, only a few cents per person per year are
invested in the most far–reaching intervention approaches, whereas thousands
of dollars per person per year are spent in efforts to treat established
risk factors, rescue the victims of acute events, restore function and
reduce risk for recurrent events among survivors, and provide end–of–life
care. There is a need and opportunity to support a continuum of care, from
the whole population to the individual victims of CVD, but we as a nation
are not doing so. To attain our vision of the future and achieve the
applicable goals of Healthy People 2010, a change in the balance of
investment between early and late intervention is needed. A comprehensive
public health strategy to prevent heart disease and stroke must aim for
greatly increased application of the earliest intervention approaches, while
working toward assurance that appropriate services of high quality will be
accessible and used by all those who continue to need them. In the vision of
the future, that need will be substantially reduced.
Finally, the action
framework offers a clearer understanding of CVH promotion and CVD
prevention, as these terms are defined and used in the Action Plan
(see Section 1 and Appendix A). CVH promotion is intended to
prevent risk factors (goal 1) and includes policy and environmental change
and behavioral change, especially at the population level. CVD prevention
applies to subsequent phases of CVD development and includes primary and
secondary prevention. Primary prevention is intended to prevent first
clinical events by detecting and treating risk factors (goal 2), whereas
secondary prevention follows the first event and, for victims who survive,
seeks to restore full functional capacity and reduce the risk of recurrence
(goal 4). Goal 3, early detection and treatment of heart attacks and
strokes, is part of CVD prevention and falls between primary and secondary
prevention.
Next Section: The Three Core
Functions of Public Health
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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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