 Achieving a Heart-Healthy and
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Public Health Opportunities
Health Promotion and Primary and Secondary Prevention Health promotion targets the general population. This strategy enables people to gain control over the behaviors and conditions that affect their health status. Educational campaigns to increase public awareness of the signs and symptoms of heart attack and stroke, policy changes to ensure universal 9-1-1 coverage, and policy and environmental changes that support heart-healthy behaviors in the general population are examples of health promotion strategies. Primary prevention targets people who are at increased risk for a first CVD event because they have one or more CVD risk factors. Guidelines from the American Heart Association (AHA) and other national organizations advocate for primary prevention of CVD by addressing the risk factors of high blood pressure, high cholesterol, tobacco use, poor nutrition, physical inactivity, overweight and obesity, and diabetes. Secondary prevention targets populations with established CVD to prevent recurrent events. These strategies include ensuring compliance with guidelines on the use of aspirin, beta-blockers, ACE inhibitors, anticoagulants, and other antiplatelet agents. In addition, reducing risk factors through lifestyle changes such as losing weight and quitting smoking is an important strategy for secondary as well as primary prevention. Although other classification systems may include tertiary prevention, our program groups this prevention level with secondary prevention. Essential Strategies: The Socioecological Approach
Research and experience indicate that health is connected to both the physical and social environment. Individual behaviors are supported and reinforced in numerous ways by legislation, regulations, organizational policies, social norms, and environments. For this reason, a comprehensive and integrated approach to promoting CVH and addressing CVD requires not only education and increased awareness, but also a major emphasis on environmental and policy change at multiple levels of society. Changes in policy and the social and physical environment are necessary to foster and maintain individual-level behavior change; for example, restricting young people’s access to tobacco products will reduce the likelihood that they will use tobacco.6 Approaches should address policy and environmental change in multiple settings (e.g., health care sites, work sites, schools, communities) to reach people throughout their lives with a variety of messages and interventions. The primary roles of state heart disease and stroke prevention programs are to provide public and professional education and training and to facilitate policy and environmental changes. In addition, state heart disease and stroke prevention programs should work with partners to ensure that they provide appropriate interventions for behavior change among individuals. Policy and environmental approaches are part of three core functions of public health: assessment, policy development, and assurance. According to a 2001 Institute of Medicine report, “An understanding of the social factors influencing behavior is growing and should be considered in programs and policies for public health. Many social, economic, political, and cultural factors are associated with health and disease for which changes in individual health behaviors alone are not likely to result in improved health and quality of life...The law can change the informational, physical, social, or economic environment to facilitate healthier behavior.” 7 The report states that “program planners and policy makers need to consider modifying social and societal conditions to enable healthy behavior. Use of population-based policy and environmental strategies shifts public health from a direct service role to one that focuses on guidance, agenda setting, and coordination of CVH improvement efforts.” 7 The socioecological approach is the basis for the logic model for heart disease and stroke prevention programs shown in Figure 1. The model depicts relationships between actions (e.g., links between environmental and policy changes and individual-level behavior change) that are necessary to reduce rates of CVD. Because logic models are often cyclical, an outcome from one activity can provide information that then feeds back into a previous activity. Activities involve building capacity, conducting surveillance, and developing/establishing interventions. These activities influence changes that lead to short-term outcomes such as the development of a CVH plan, new strategies for system-level changes, and more effective implementation of interventions. These activities and outcomes result in changes in policy and environmental supports, changes in people’s behavior, and eventually improvements in their health. Figure 1. Logic Model for Heart Disease and Stroke Prevention Programs
The program logic model describes the program and is a tool to guide program evaluation. By identifying the steps necessary to reach intended outcomes, the logic model indicates where emphasis should be placed in evaluating the process and outcomes of the program. Interventions
Programs should emphasize interventions and in various settings (e.g., health care sites, work sites, schools, community) in which policy or environmental changes can produce substantial health benefits. However, they should focus their efforts at the highest level possible; for example, activities should focus on business coalitions and unions rather than individual work sites and on managed care organizations and state medical associations rather than on individual health care settings or physicians. Population-based approaches can be disseminated through various settings and groups. Policy and environmental changes and education should be used to make each setting more supportive of heart-healthy choices and ensure that it provides appropriate CVH promotion and CVD prevention and control services. Settings in which policy and environmental changes might be instituted include the following:
In addition, the media can be used to increase public awareness of the importance of CVH, the risk factors for CVD, and the need for policy and environmental changes. The media can also be instrumental in educating the public about the signs and symptoms of heart attack and stroke and when to call 9-1-1. Key partners for implementing these activities should include the American Heart Association (AHA), state quality improvement organizations (QIOs), and private health care providers and hospitals. The state heart disease and stroke prevention program should partner with its QIO to monitor secondary prevention practices (e.g., aspirin and drug therapy, physical activity regimens, and hypertension and lipid management) and to help improve compliance with secondary prevention guidelines. In collaboration with partners, it should also promote professional education and policy changes that support efforts to implement the guidelines on primary and secondary prevention. Providing blood pressure and cholesterol screenings is not appropriate for the state heart disease and stroke prevention program itself. However, the state program should encourage partners to provide these services and ensure that health care staff are trained in accurately measuring blood pressure and in applying quality assurance standards. Interventions should be coordinated with internal and external partners to ensure that health messages, policies, and environmental measures are consistent, effective, synergistic, and not redundant. Further research is needed on how to best implement intervention strategies in different settings and with different populations. For further discussion of effective interventions to address heart disease and stroke, please refer to related chapters in this document, including those on tobacco, school health, nutrition, physical activity, and diabetes. State Examples:
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