In the 25th in a series of assessments
of Healthy People 2010, Senior Executive Advisor
to the Assistant Secretary for Health Larry Fields chaired
a focus area Progress Review on Educational and Community-Based
Programs. Dr. Fields noted that even when best practices
in the field of health care and prevention are well defined
and widely accepted, their translation into practical
application can be problematic. In this regard, programs
that are mediated by educational and community-based
settings can be said to serve at the front lines of health
promotion and disease prevention efforts. Among the more
effective health promotion programs are those that implement
comprehensive plans with multiple intervention strategies
in the fields of education, policy, and the environment
within various settings, such as schools, worksites,
healthcare facilities, and the community. In conducting
the review, Dr. Fields 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). Also participating were representatives of other
U.S. Department of Health and Human Services (HHS) offices
and agencies.
The complete text for the Educational and Community-Based
Programs focus area of Healthy People 2010 is
available at www.healthypeople.gov/document/html/volume1/07ed.htm.
The meeting agenda, tabulated data for all focus area
objectives, charts, and other materials used in the Progress
Review can be found at www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa07-ecbp.htm.
Data Trends
Edward Sondik, Director of the CDC National Center for
Health Statistics (NCHS), provided an overview of progress
achieved in meeting the targets of selected objectives
in the Educational and Community-Based Programs (ECBPs)
focus area. Dr. Sondik characterized this focus area
as providing the foundation for many others, but one
that is challenged by the difficulty of collecting data
to assess progress. Of the objectives in the focus area
that have had updates to the baseline in the past 6 years,
data show progress toward the target for two, a mixed
picture for a third, and a worsening trend for a fourth.
Objective 7-2 seeks to increase the proportion of middle,
junior high, and senior high schools that require courses
on health education in nine areas—unintentional
injury; violence; suicide; tobacco use and addiction;
alcohol and other drug use; unintended pregnancy, HIV/AIDS,
and sexually transmitted infections; unhealthy dietary
patterns; inadequate physical activity; and environmental
health. The only significant change with respect to any
one of these topics has occurred among schools requiring
courses in violence prevention—an increase from
58 percent of schools in 1994 to 73 percent in 2000 (target,
80 percent). The proportion of schools that have a ratio
of at least 1 school nurse to 750 students increased
from 32 percent in 1994 to 57 percent in 2000 among middle
and junior high schools and, over the same period, from
26 percent to 44 percent among senior high schools. The
target is 50 percent (Obj. 7-4a, b, c). In 2000, 53 percent
of elementary schools had at least 1 school nurse to
every 750 students. The target is 60 percent (Obj. 7-4d).
Between 1994 and 1998, the proportion of employees (age
adjusted, aged 18 years and older) who participated in
employer-sponsored health promotion activities decreased
from 67 percent to 59 percent. In 1998, race and ethnicity,
gender, and educational attainment were not significantly
associated with employee participation in employer-sponsored
health promotion programs. The target is 75 percent (Obj.
7-6).
Of a total of 419 local health jurisdictions responding
to a 2004 survey, more than 250 jurisdictions reported
that their community health promotion programs addressed
17 to 28 of the Healthy People 2010 focus areas
(Obj. 7-10). The largest proportion (c. 90 percent) of
responding agencies involved at least three community
sectors to define health problems, resources, perceptions,
and priorities for action. Almost 80 percent involved
at least three community sectors to develop targeted
and measurable objectives for outcomes, risk factors,
public awareness, services, and protection. Just over
60 percent reported involving at least three community
sectors to monitor and evaluate processes to measure
objectives. The community sectors referenced here include
government, business, education, the faith community,
health care, media, voluntary agencies, and the public.
Data from 1996–1997 were used to establish the
baseline for Objective 7-11 to increase the proportion
of local health departments that have established culturally
appropriate and linguistically competent community health
promotion and disease prevention programs. Culturally
appropriate and linguistically competent programs are
programs that are adapted to address the cultural differences
and special language needs of racial and ethnic minorities
in a population. Of the focus areas covered by the survey,
health departments reported the highest proportion of
culturally appropriate and linguistically competent programs
for immunization and infectious diseases (48 percent),
maternal and infant health (47 percent), HIV (45 percent),
family planning (42 percent), and sexually transmitted
infections (41 percent). Health departments reported
fewer culturally appropriate and linguistically competent
programs for environmental health (22 percent), mental
health (18 percent), occupational safety and health (13
percent), and physical activity and fitness (21 percent).
The target is 50 percent of local health departments.
In 1998, 12 percent of older adults (age adjusted, aged
65 years and older) participated in community health
promotion activities, such as an exercise class or a
presentation on health topics. Older adults with at least
some college education participated at a rate (20 percent)
that was twice that of high school graduates (10 percent)
and almost 4 times the rate of those who had not completed
high school (6 percent). The target is 90 percent (Obj.
7-12).
Key Challenges and Current Strategies
In the presentations that followed the data overview,
the principal themes were introduced by representatives
of the two co-lead agencies—Barbara Bowman, Acting
Associate Director for Science of CDC’s National
Center for Chronic Disease Prevention and Health Promotion,
and Dennis Williams, HRSA’s Deputy Administrator.
These agency representatives and other participants in
the review identified a number of barriers to achieving
the objectives and discussed activities under way to
meet these challenges, including the following:
-
In support of the President’s HealthierUS
initiative, HHS and the Departments of Education
and Agriculture created the collaborative Healthier
Children and Youth Memorandum of Understanding
to strengthen and promote the education and health
of U.S. school-aged children and youth.
-
In fiscal year 2003, HHS provided $15 million through
a cooperative agreement to support 23 communities
to help them establish innovative community-based
programs targeting the six chronic diseases and conditions
that are the focus of the HHS Steps to a HealthierUS
initiative launched in that year.
In April 2004, the President established the
position of National Coordinator for Health Information
Technology (HIT), whose office is located in HHS. In
pursuit of the President’s overall goal of having
electronic medical records for all Americans within 10
years, the HIT initiative embraces the strategy of unifying
public health surveillance infrastructures and streamlining
health status monitoring to achieve compatible data systems
nationwide. Wide-ranging adoption of advances in telehealth
technology and other aspects of HIT is expected to increase
healthcare consumers’ empowerment, retard the rise
in the cost of health care, and reduce the prevailing
disparity in health status between rural and urban populations.
-
The CDC-based initiative REACH 2010 (Racial and
Ethnic Approaches to Community Health) is a collaborative
Federal initiative that, since its inception 5 years
ago, has focused on key health areas identified in
Healthy People 2010 with the aim of eliminating
disparities in health status experienced by racial
and ethnic populations. The summer 2004 special issue
of Ethnicity and Disease examines the intervention/prevention
strategies implemented by 15 of the 42 communities
that participate in REACH 2010, all of which address
one or more of the following priority areas: cardiovascular
disease, diabetes, infant mortality, breast and cervical
cancer screening and management, HIV/AIDS, and child
and adult immunizations.
-
CDC’s School Health Index is an online self-assessment
and planning tool that can be tailored to an individual
school’s needs through a series of three steps
for improving the effectiveness of health and safety
policies and programs.
-
Electronic recordkeeping in some community health
centers now employs technology that enables clients
at the end of their individual sessions to receive
a computer-generated list of preventive activities
to pursue in the course of a self-managed program.
-
With support from CDC, the Guide to Community
Preventive Services provides recommendations
based on systematic reviews of population-based interventions
that have been found to be effective in changing
risk behaviors, addressing environmental challenges,
and reducing the burden of disease, injury, and impairment.
With the aid of the Guide, published articles
on various health topics can be accessed by users,
including public health professionals, healthcare
service providers and purchasers, law and policymakers,
and community-based organizations.
Approaches for Consideration
Participants in the review made the following suggestions
for steps to enable further progress toward achievement
of the objectives for the ECBPs focus area:
-
Seek to fill gaps in research on health disparities,
particularly in the areas of dissemination and diffusion
of effective programs, new technologies, relationships
between settings, and approaches to disadvantaged
and special populations.
-
Take advantage of economies of scale by building
networks of community health centers to include the
smaller centers that would otherwise be unable to
afford to implement state-of-the-art recordkeeping
practices.
-
Disseminate to community health centers and other
facilities the lessons learned and best practices
deriving from the experience of the Department of
Veterans Affairs, which has been highly successful
in the diabetes and pre-diabetes prevention and treatment
programs offered at its hospitals and clinics and
in the application of telehealth technology, especially
in rural areas.
-
Make greater use of micro-grant programs, which
can have a ripple effect in bringing salutary changes
in the community that far exceed the minimal outlay
of funds they entail.
Promote commonality and synergy among efforts
in the fields of ECBPs, health communication, and health
literacy, which deal with many of the same issues and
face some similar challenges, such as data collection.
Endeavor to share savings in healthcare costs
that arise from technological advances so that healthcare
payors will benefit directly and have incentives to adopt
more efficient and innovative approaches in their reimbursement
role.
Seek ways to better characterize the reach,
coverage, and influence of ECBPs by geographic region
to identify features of the most successful programs
that could be emulated more widely with enhanced public
support.
Contacts for information about Healthy
People 2010 focus area 10Educational
and Community-Based Programs:
- Office of Disease Prevention and Health Promotion
(coordinator of the Progress Reviews)—Ellis Davis
(liaison to the focus area 7 workgroup), edavis@osophs.dhhs.gov
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Cristina V. Beato, M.D.
Acting Assistant Secretary for Health
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