In the 28th session of the second series of assessments of
Healthy People 2010, Deputy Assistant Secretary for Health (Science
and Medicine) Anand Parekh chaired a Progress Review on Educational and
Community-Based Programs. He was assisted by staff of the co-lead Agencies for
this Healthy People 2010 focus area, the Health Resources and Services
Administration (HRSA) and the Centers for Disease Control and Prevention (CDC)
of the U.S. Department of Health and Human Services (HHS). Dr. Parekh stressed
the importance to the Nations collective health status of education and
other social determinants that are addressed by many of the focus area
objectives, usually in one of the great variety of non-clinical settings in
which people spend their lives.
The complete November 2000 text for the Educational and
Community-Based Programs focus area of Healthy People 2010 is
available online at
www.healthypeople.gov/document/html/volume1/07ed.htm.
Revisions to the focus area chapter that were made at the January 2005
Midcourse Review are available at
www.healthypeople.gov/data/midcourse/html/focusareas/fa07toc.htm.
For comparison with the current state of the focus area, the report on the
first-round Progress Review (held on December 15, 2004) is archived at
www.healthypeople.gov/data/2010prog/focus07/2004fa07.htm.
The meeting agenda, tabulated data for all focus area objectives, charts, and
other materials used in the Progress Review can be found at a companion site
maintained by the CDC National Center for Health Statistics (NCHS):
www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa07-ecbp2.htm.
That site has a link to wonder.cdc.gov/data2010,
which provides access to detailed definitions for the objectives in all 28
Healthy People 2010 focus areas and periodic updates to their
data.
Data Trends
Richard Klein, Chief of the NCHS Health Promotion Statistics
Branch, presented an overview of data related to the Educational and
Community-Based Programs focus area. He noted that ones education level
is a powerful predictor of physical and mental health and longevity. Schools
can play a critical role in providing information, tools, and practical
strategies to help students adopt healthy lifestyles. Of the focus area
objectives and subobjectives that were retained after the 2005 Healthy
People 2010 Midcourse Review, one has met its target, six are improving,
one is getting worse, nine show little or no change, and four have baseline
data only. Mr. Klein then provided a more detailed examination of objectives
the focus area workgroup selected to highlight at the Progress Review:
(Obj. 7-1): In 2006, 88 percent of persons
aged 18 to 24 years had completed high school, compared with 85 percent in
1998. By racial and ethnic group for whom data were available, the proportions
of people in this age group in 2006 who had completed high school were as
follows: non-Hispanic Asians and Pacific Islanders, 96 percent; non-Hispanic
whites, 93 percent; persons of two or more races, 90 percent; non-Hispanic
blacks, 85 percent; and Hispanics, 71 percent (a significant improvement from
63 percent in 1998). The target for all population groups is 90 percent.
Among some population groups, the likelihood of high school
completion is strongly influenced by the recency of immigration. In 2006, 57.7
percent of Hispanics born outside, but resident in, the United States had
completed high school, compared with 81.9 percent of first-generation
Hispanics, and 83.5 percent of Hispanics who were at least of the second
generation. Self-assessed health status appears to improve with the level of
education achieved. In 2007, only 38.2 percent of persons with less than high
school education reported themselves to be in excellent or very good health,
compared with 52.5 percent of high school graduates, 59.9 percent of persons
who had some college education, and 73.9 percent of college graduates. In
contrast, 28.2 percent of persons with less than high school education reported
themselves to be in fair or poor health, compared with 16.3 percent of high
school graduates, 13.2 percent of persons who had some college education, and
only 6.2 percent of college graduates. Also, the occurrence of negative mood is
associated inversely with the level of education achieved. In 2007, 3.7 percent
of persons with less than high school education reported feelings of
hopelessness in the preceding month, compared with 2.8 percent of high school
graduates, 1.7 percent of persons who had some college education, and only 0.7
percent of college graduates. The feeling during the preceding month that
everything required an effort occurred among 7.1 percent of persons with less
than high school education, 5.9 percent of high school graduates, 5.0 percent
of persons who had some college education, and only 2.2 percent of college
graduates.
(Obj. 7-2a-i): In 2006, the proportions of
middle, junior high, and senior high schools that provided school health
education on specific topics were as follows: all priority areas, 44 percent
(33 percent in 1994)target, 83 percent; unintentional injury, 80 percent
(66 percent in 1994)target, 90 percent; violence, 77 percent (58 percent
in 1994)target, 80 percent; suicide, 63 percent (58 percent in
1994)target, 80 percent; tobacco use and addiction, 87 percent (86
percent in 1994)target, 95 percent; alcohol and other drug use, 87
percent (90 percent in 1994)target, 95 percent; unintended pregnancy,
HIV/AIDS, and STD infection, 67 percent (65 percent in 1994)target, 90
percent; unhealthy dietary patterns, 84 percent (the same in 1994)target,
95 percent; and inadequate physical activity, 79 percent (78 percent in
1994)target, 90 percent.
(Obj. 7-4a-d): In 2006, the proportions of
schools that had at least one nurse for every 750 or more students were as
follows: all middle, junior high, and senior high schools, 45 percent (28
percent in 1994)target, 50 percent; senior high schools, 38 percent (26
percent in 1994)target, 50 percent; middle and junior high schools, 50
percent (32 percent in 1994)the target of 50 percent was met; and
elementary schools, 45 percent (42 percent in 2000)target, 48
percent.
(Obj. 7-10): In 2007, 97 percent of the
States and U.S. Territories included local health service areas or
jurisdictions that had established community health promotion programs
addressing two or more Healthy People 2010 focus areas. Also, the
Kickapoo Native American tribe had received block grant funding for a program
on substance abuse and the Santee Sioux tribe had funding for a program on
accessing health care.
Key Challenges and Current Strategies
Kurt Greenlund, Associate Director for Science in the
Division of Adult and Community Health of the CDC National Center for Chronic
Disease Prevention and Health Promotion, and Lyman Van Nostrand, Director of
the HRSA Office of Planning and Evaluation, made presentations on the principal
themes of the Progress Review. Their statements, the discussion that ensued,
and Progress Review briefing materials prepared by an interagency workgroup
identified a number of barriers to achieving the objectives, as well as
activities under way to meet these challenges, including the following:
Barriers
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According to the U.S. Department of Commerce, high
school dropouts are more likely to be unemployed and, when they are employed,
earn less than those who completed high school.
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A continuing problem facing efforts to address
educational and community-based program needs is assuring at all levels the
competency of the workforce required for evaluating, communicating, and
translating health promotion programs.
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In many areas of concern, dissemination mechanisms for
delivering evidence-based programs are inadequate, in terms of not only the
number of health promotion programs but also in the amount of exposure to these
programs.
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Increasing budget pressures at the Federal, State, and
local levels limit the amount of resources available for school health
education and for school nursing staff.
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Too often, community health promotion strategies lack
the firm basis in evidence of their results that would allow them to be
replicated in other settings.
-
Additionally, communities often have lacked the
appropriate tools and resources to translate effectively evidence-based
programs into community practice that suits local needs.
-
Surveys that are the sources of data by which objectives
can be tracked are sometimes conducted only once when funding is available for
a relatively short period (for example, the survey supporting the objective for
worksite health promotion) and not repeated again in a timely enough fashion to
make updating possible during the decade.
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It is increasingly difficult to measure progress for
some objectives in the focus area. Some data sources used to establish measures
were not continued or ceased collecting the data needed to support
tracking.
Activities and Outcomes
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CDCs Racial and Ethnic Approaches to Community
Health Across the United States (REACH U.S.) program has produced
improvements in health and reductions in health disparities in communities that
face serious community health problems. REACH U.S. provides training, technical
assistance, and support to community coalitions that design, implement,
evaluate, and disseminate community-driven strategies to eliminate health
disparities in key health areas. In fiscal year 2007, CDC launched Centers for
Excellence in the Elimination of Health Disparities to disseminate innovative
strategies developed in REACH U.S. communities to train and mentor new
communities. CDC has a Web site at www.cdc.gov.
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HRSA's Area Health Education Centers (AHEC) program
offers cooperative agreements to accredited schools of medicine and nursing to
encourage the establishment and maintenance of community-based training
programs in off-campus rural and underserved areas. The AHEC program provides
other community-based training for health professions students and practicing
healthcare providers and exposes students in grades 9 to12 to health career
activities. Other program activities include the mentoring of students in
medically underserved and unserved communities from kindergarten through grade
12. Between fiscal year 2003 and fiscal year 2006, a total of 203,253 high
school students received AHEC health career training of more than 20 hours.
HRSA has a Web site at www.hrsa.gov.
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CDC has published a series of guidelines documents that
identify the school health program strategies most likely to be effective in
promoting healthy behaviors among young people. Based on extensive reviews of
research literature, the guidelines were developed by CDC in collaboration with
other Federal Agencies, State agencies, universities, voluntary organizations,
and professional organizations. Included in the series are guidelines for
programs to prevent unintentional injury and violence, promote lifelong healthy
eating, promote lifelong physical activity among young people, and prevent
tobacco use and addiction.
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In 2004, HRSA developed the Take a Stand. Lend a
Hand. Stop Bullying Now! national public awareness and prevention
campaign directed at young people aged 9 to 13 years. The campaign's message to
kids is: You can play a key role in stopping bullying at schools and in other
social environments. The campaign Web site www.stopbullyingnow.hrsa.gov
receives up to 20,000 visitors in an average week. Since the campaign began,
HRSA has distributed more than 20,000 resource kits to parents, educators, and
other adults interested in bullying prevention.
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One resource designed to facilitate disease prevention
and health promotion planning in colleges and universities is Healthy
Campus 2010: Making It Happen. The manual helps local health workers
assess campus and community health needs in their area.
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CDCs Steps program implements prevention
and health promotion activities to address chronic diseases and related risk
behaviors. The program has moved into a new phase that will spread effective
local strategies to bring change in communities across the Nation on an ongoing
basis. The growing successes of Steps communities are being
continuously translated into Action Guides, mentorship networks, tools for
community change, and Action Institutes which will provide structured guidance,
support, training, and state-of-the-art models for replication in hundreds of
communities in all regions of the country.
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To assist schools in the implementation of quality
health programs, CDC recently developed the Physical Education Curriculum
Analysis Tool (PECAT) at
www.cdc.gov/healthyyouth/pecat/index.htm.
PECAT provides guidance that allows local school districts to meet local needs
and interests and increase the likelihood of improving students
knowledge, skills, and health behaviors.
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The National Center on School-Based Health Care
(NCSBHC), which receives funding from HRSA, provides up-to-date, evidence-based
information, resources, and technical assistance to school-based and
school-linked health clinics to improve and enhance their service capabilities
and quality of care. NCSBHC interacts with approximately 1,700
school-based/linked health clinics in the United States, as well as with
schools and communities interested in developing this model of health
care.
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CDC's Health Education Curriculum Analysis Tool (HECAT)
at www.cdc.gov/healthyyouth/hecat/index.htm
can help school districts, schools, and others conduct a clear, complete, and
consistent analysis of health education curricula based on the National Health
Education Standards and CDCs Characteristics of Effective Health
Education Curricula. With the HECAT results in hand, schools are better able to
select or develop appropriate and effective health education curricula and
improve the delivery of health education. The HECAT can be customized to meet
local community needs and conform to the curriculum requirements of the State
or school district.
-
A resource designed to increase disease prevention and
health promotion activities in the workplace is Healthy Workforce 2010: An
Essential Health Promotion Sourcebook for Employers, Large and Small,
prepared by the Partnership for Prevention (www.prevent.org
). This publication
educates employers on how health promotion helps businesses function more
effectively and efficiently. In addition, it provides strategies for developing
and maintaining worksite health promotion programs and activities.
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To provide guidance for designing and implementing
policy and environmental change interventions that affect large segments of the
population, the Directors of Health Promotion and Education (DHPE), with
support from CDC, has developed Policy and Environmental Change: New
Directions for Public Health. Another DHPE report, State Health
Promotion Capacity, describes the perceived health promotion capacities of
those carrying out programs in State health agencies, priority needs for
professional development, and actions that might be undertaken to strengthen
health promotion activities and programs conducted by State and local public
health agencies.
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CDC's Guide to Community Preventive Services
(www.thecommunityguide.org
) provides evidence-based
recommendations for programs and policies to promote population health in 16
principal subject areas. Users of the guide include public health
professionals, legislators and policymakers, community-based organizations,
providers of healthcare services, researchers, and employers and other
purchasers of healthcare services.
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HRSA developed a Web-based health communications
training tool designed to improve interaction between healthcare providers and
their patients. The training aid helps toward achieving Objective 7-11
(Increase the proportion of local health departments that have established
culturally appropriate and linguistically competent health promotion and
disease prevention programs). This Unified Health Communication Tool addresses
health literacy, cultural competency and limited English proficiency in a
five-part, self-paced interactive training format available at www.hrsa.gov/healthliteracy/training.htm.
The last module in the series allows participants to apply information learned
in previous modules to test their ability to communicate effectively with
patients.
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The second version of Community Health Status Indicators
(CHSI) is now in the final stages of preparation by a consortium that includes
HRSA, CDC, other HHS Agencies, associations of public health professionals, and
partners in the private sector. (See www.communityhealth.hhs.gov.)
CHSI II will provide an overview of key health indicators for local communities
and is intended to encourage dialogue about actions that can be taken to
improve a communitys health. With more than 200 measures for each of the
3,141 U.S. counties, community profiles can be displayed on maps or downloaded
in brochure format. The CHSI mapping capability will allow users to compare
their own county visually with similar, as well as adjacent counties.
What Needs To Be Done
Participants in the Progress Review made the following
suggestions for public health professionals and policymakers to consider as
steps to enable further progress toward achieving the objectives for
Educational and Community-Based Programs:
-
Ensure that the interests and expertise of active and
potential Federal Healthy People partners, such as the HHS Administration on
Children and Families and the U.S. Department of Education, are reflected in
any iteration of the Healthy People initiative, specifically in any
continuation in whatever form of objectives in focus area 7 of Healthy
People 2010.
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Strive to instill a sense of ownership in and advocacy
for the subjects of focus area 7 in Federal staff, State partners, and citizens
groups whose interests are most closely allied to and affected by Educational
and Community-Based Programs.
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Seek to profit by the experience of other Healthy
People 2010 focus areas in planning for the transition of focus area 7
content into the milieu of Healthy People 2020.
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Examine all sides of the issue of whether to continue
focus area 7 in much the same form in which it currently exists or to pursue an
alternative strategy, such as amalgamation with other focus areas.
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Explore alternatives for increasing rates of response to
public surveys and assess whether data can be collected from other national
data sources not currently used for this focus area.
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Seek to expand community intervention strategies among
young children, for whom such strategies are often more effective in the long
run.
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Consider a process for Healthy People 2020 that can
accommodate a changing field, such as community health and educational
programs, in which there have been substantial positive developments that may
not be reflected in the objectives developed several years earlier.
Contacts for information about Healthy
People 2010 Focus Area 7Educational and Community-Based
Programs:
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[Signed February 3, 2009] Steven K. Galson,
M.D., M.P.H. RADM, U.S. Public Health Service Acting Assistant
Secretary for Health
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