Chapter One: Making the Case for Population-based Cardiovascular Health Interventions

Key Topics

• Defining Interventions for Public Health Policy and Environmental Change
• Examining the Role of State Heart Disease and Stroke Prevention Programs
• Using this Guide

Teaching children not to play with matches.  Discouraging teenagers from smoking.  Alerting college students to the hazards of binge drinking.  Directing adults to early–detection programs for cardiovascular disease, cancer, and diabetes.  Encouraging families to "buckle up," exercise, and eat five or more servings of fruits and vegetables each day for better health.  These disease prevention and health promotion strategies represent merely a handful of educational initiatives that are being advocated by our nation's public health practitioners.  The messages supporting these efforts are compelling, informative, and clear and the majority of interventions designed to promote them share a consistent approach — educate, enable, and encourage individuals to adopt healthy attitudes and behaviors.

Although promoting individual behavior change is essential to health promotion and prevention of chronic disease, public health authorities increasingly view use of this social marketing tactic alone as insufficient.  In the past decade, there has been growing interest in developing and implementing policy and environmental changes that can reduce the chronic disease risks of many people.¹

In 2001, the Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Directors of Health Promotion and Public Health Education published Policy and Environmental Change, New Directions for Public Health (The Blue Book).  This book was developed to assist decision makers in recognizing the value of designing and implementing policy and environmental interventions that can affect large segments of the population in tandem.  In the introduction, James S. Marks, M.D., M.P.H., then director of CDC's National Center for Chronic Disease Prevention and Health Promotion comments:

"The major public health problems of our time will not be solved merely by individual actions and health choices, but by individuals coming together to make our society one in which healthy choices are easy, fun, and popular.  Communities where policies and environments focus on the latter approach will be healthier and more satisfying places to live, work, and play."²

The initiative of the U.S. Department of Health and Human Services on Steps to a HealthierUS provides another example of support among decision makers for addressing prevention of heart disease and stroke through interventions for policy and environmental change.  This initiative affirms the role of public health in providing policy makers with research and data on cardiovascular health (CVH) and in educating policy makers across settings about the importance of supporting health through policy change.³

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Defining Interventions for Public Health Policy and Environmental Change

Public health policies include laws, regulations, and rules (both formal and informal) that are designed to have a positive effect on the health of a large number of people, or a "target population."  Laws and regulations that restrict smoking in public buildings and an organizational rule that provides time off during work hours for physical activity are examples of policy interventions focused on CVH.  Environmental interventions include changes to the economic, social, or physical environment.  CVH-related environmental interventions include incorporating walking paths and recreation areas into designs for development of new communities, making low-fat choices available in cafeterias, and removing ashtrays from meeting rooms.⁴  (See Public Health Policy and Environmental Change Interventions Flow Chart below.)

Source: Centers for Disease Control and Prevention

Noteworthy Achievements

In recent years, various policies (laws, regulations, and rules) have proven effective in reducing the risk and burden of numerous chronic diseases.  Similarly, a host of environmental interventions (changes to economic, social, or physical settings) have complemented and enhanced traditional public health efforts to reform individual behaviors.

For the past decade, one major focus of such efforts has been to reduce tobacco use, which creates a safer environment through policy changes.  These efforts have led to the nationwide limitation of smoking in public buildings and the restriction of minors' access to tobacco products.  CVH also has benefited from efforts to achieve policy and environmental change.  Other successful strategies for prevention of disease and injury through policy and environmental change  have centered on:

• Folic Acid Fortification — The Food and Drug Administration's January 1998 requirement for food manufacturers to enhance the level of folic acid in enriched grain products is helping to ensure that women of childbearing age receive recommended levels of folic acid to prevent birth defects.^5,6
   
• Lead Poisoning — Since the 1980s, the federally mandated ban on or reduction of lead in gasoline, drinking water, residential paint, and other consumer and industrial products has lowered the incidence of lead poisoning in children.⁷
   
• Motor Vehicle Safety — Engineering efforts to make vehicles and highways safer, laws requiring use of seat belts and child safety seats, and a Federal Motor Vehicle Safety Standard requiring automobile manufacturers to install automatic restraint systems (airbags or automatic seat belts) have contributed to large reductions in fatal and nonfatal motor vehicle injuries.^9,10
   
• Safer Workplaces — Extraordinary efforts by employees, unions, employers, government agencies, and scientists have provided safer working conditions for people with hazardous occupations, such as mining, manufacturing, construction, and transportation.  Since 1980, safer workplaces have reduced the rate of fatal occupational injuries by approximately 40 percent.¹¹
   
• Water Fluoridation — The fluoridation of community drinking water is a major factor responsible for the decline in tooth decay during the second half of the 20th century.¹²

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Building Upon a Strong Foundation

A great deal of activity in interventions for policy and environmental change is already under way.  A survey led by the Association of State and Territorial Directors of Health Promotion and Public Health Education, with support from CDC, concluded that interventions for policy and environmental change signify a major new area of effort for state and local health departments.  The survey, conducted in 1996–1999, was based on a review of interventions in chronic disease at state and local levels.  Findings of this survey and review included the following:

• The vast majority of "highly successful" state policy interventions focused on tobacco use, diabetes, cancer, physical activity, oral health, and nutrition.¹³
   
• Highly successful state interventions for environmental change mostly addressed nutrition, physical activity, local–level capacity building, tobacco use, diabetes, and cardiovascular disease (CVD).¹⁴
   
• The most effective interventions for local policy and environmental change addressed tobacco use, physical activity, and nutrition.¹⁵

Despite these successes, "many public health practitioners, including some key decision makers, do not intuitively understand what policy and environmental change interventions are, why they are important, and how to engage in them."¹⁶  Practical tools and information are needed to help public health professionals better understand and communicate the concept of policy and environmental change interventions.

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Role of State Heart Disease and Stroke Prevention Programs

A major role of State Heart Disease and Stroke Prevention Programs is to communicate the importance of strategies for policy and environmental change to policy makers, program decision makers, sources of funding, and other key stakeholders.  Great opportunities exist to inform and implement such interventions at the state and local levels.

The communication and marketing of policy and environmental change can help you, as a Program Director, to fulfill specific program components that support population–based interventions.  For example, by explaining the importance of this concept to your program partners, you can achieve their buy–in and support for promoting strategies for CVH policy and environmental change through media advocacy and other outreach activities.  In addition to establishing greater visibility for your State's Heart Disease and Stroke Prevention Program, this collective effort can help you to attract new program partners.  It can also enable you to identify and develop an inventory of successful strategies for policy and environmental change that can be incorporated into the plan for the State's Heart Disease and Stroke Prevention Program.

Appeal for Enhanced Communication Skills and Resources

A series of CDC–sponsored interviews with the directors of 15 State Heart Disease and Stroke Prevention Programs revealed that most programs are concentrating their prevention efforts on facilitating policy and environmental changes.¹⁷

Many State Heart Disease and Stroke Prevention Programs are targeting their communication efforts to policy makers, potential partners, and health care providers.  The majority of the State Program Directors interviewed expressed a desire for CDC to assist them in communicating to their partners, potential partners, and other stakeholders how their efforts to influence policy and environmental changes will help to improve public health in the state.  Many states emphasized a need for Program Directors to acquire basic communication and media skills to support this endeavor.

State Program Directors also said they could benefit from CDC guidance in their communication efforts to build partnerships.  Several directors cited a need for state and local offices to promote their activities aimed at policy and environmental change as part of a "national movement" and to facilitate the sharing of information across the three levels of government as a means to enhance their skills and credibility.

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Purpose of the Guide

This guide has been developed to enhance communication skills and to address state needs.  It provides you and your partners with comprehensive skill–building tools, information, and resources for conveying and marketing the concept of CVH policy and environmental change to policy makers, program decision makers, funding sources, and other key stakeholders.  Designed as a tactical instrument for planning, implementing, and evaluating communication strategies to facilitate policy and environmental change, this resource offers step–by–step guidance on the following tasks:

1. Tracking and influencing the policy development process;
2. Leveraging partnerships;
3. Developing a communication plan;
4. Framing a message, media advocacy, media relations, presentations and meetings, and materials to implement the plan;
5. Using other communication strategies to implement your plan; and
6. Conducting process and outcome evaluation.

The guide should be used in coordination with CDCynergy 2001 — Cardiovascular Health Edition, an interactive CD–ROM designed to help public health professionals plan CVH–related communication programs.  (A copy is included with the printed guide).  CDCynergy 2001 guides users through a sequence of questions on communication planning and offers examples related to CVH.  Together, this publication and CDCynergy 2001 provide you with powerful tools for planning and executing communication initiatives that can make a significant impact on CVH.  CDC's Heart Disease and Stroke Prevention Program periodically holds CDCynergy 2001 training workshops.  For more information about these workshops see the CDC Heart Disease and Stroke Prevention Web site at http://www.cdc.gov/dhdsp/.

Taking Action for Heart-healthy and Stroke-free States: A Communication Guide for Policy and Environmental Change can be a useful tool in your work to help create a heart–healthy and stroke–free nation.

A list of additional resources to help you learn more about communicating for policy and environmental change is provided in Chapter 7: Tools and Resources.

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Chapter References

1. Policy and Environmental Change: New Directions for Public Health. Association of State and Territorial Directors of Health Promotion and Public Health Education, U.S. Centers for Disease Control and Prevention. August 2001;13.
2. Ibid., ii.
3. U.S. Department of Health and Human Services. Steps to a HealthierUS: A Program Policy Perspective. A Public Health Action Plan to Prevent Heart Disease and Stroke [online]. 2003. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/dhdsp/library/Action_Plan/
4. Policy and Environmental Change: New Directions for Public Health. Association of State and Territorial Directors of Health Promotion and Public Health Education, U.S. Centers for Disease Control and Prevention. August 2001;15.
5. TDH Accent on Health. New folic acid requirement begins new year’s day (online). December 19, 1997. (cited 2003 December 1)
6. Centers for Disease Control and Prevention. National Council on Folic Acid: a coalition to promote the vitamin folic acid for the prevention of birth defects [online]. March 2002. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/ncbddd/folicacid/council.htm
7. U.S. Environmental Protection Agency. Lead in paint, dust, and soil [online]. 2002. [cited 2003 December 1]. Available from URL: http://www.epa.gov/lead
8. Centers for Disease Control and Prevention. Promising Practices in Chronic Disease Prevention and Control: A Public Health Framework for Action. Atlanta, GA: Department of Health and Human Services, 2003.
9. Centers for Disease Control and Prevention. Ten great public health achievements — United States, 1900-1999. MMWR [online]. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm
10. Dinh-Zarr TB, Sleet DA. Reviews of evidence regarding interventions to increase the use of safety belts. American Journal of Preventive Medicine. 2001;21:50.
11. Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: improvements in workplace safety. MMWR, 1999;48:461-469.
12. Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: fluoridation of drinking water to prevent dental caries. MMWR, [online]. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm
13. Policy and Environmental Change: New Directions for Public Health. Association of State and Territorial Directors of Health Promotion and Public Health Education, U.S. Centers for Disease Control and Prevention. August 2001;43.
14. Ibid., 44.
15. Ibid., 46.
16. Ibid., 59.
17. Thompson L, Shaham L. Preliminary Report on State Interviews for Heart Attack Signs and Symptoms Project [unpublished]. Washington, DC: Ogilvy Public Relations Worldwide. 2002.

 
*Links to non–Federal organizations are provided solely as a service to our users. Links do not constitute an endorsement of any organization by CDC or the Federal Government, and none should be inferred. The CDC is not responsible for the content of the individual organization Web pages found at this link.
 

Date last reviewed: 08/29/2008
Content source: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion