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Initiatives Addressing Multiple Preventive Services

To generate creative approaches for fostering strong community-clinical partnerships, three interventions are offered to improve the delivery of multiple clinical preventive services for adults.

Two are evidence-based interventions that have been vetted in a variety of real-world settings:

SPARC  (Sickness Prevention Achieved through Regional Collaboration), a community-based collaboration in 4 states

WISEWOMAN  (Well-Integrated Screening and Evaluation for WOMen Across the Nation), sponsored by the Centers for Disease Control and Prevention (CDC) and implemented in 19 states and 2 tribal organizations

The third example, the Family Heart Study directed by Johns Hopkins University, has not yet been replicated outside the research setting but may foster future interest in similar community-based initiatives.

Key features of these initiatives:

  • Two or more preventive services are planned, offered and delivered as a “bundle” in accessible community sites.
  • Interventions are based on science, evidence-based practices and clinical guidelines.
  • Emphasis is placed on hard-to-reach populations or those less likely to use or have access to services in clinical settings.
  • The community at large and the populations to be served are engaged at all stages of planning and implementing.
  • Strong partnerships are formed between community organizations and clinical providers for vaccinations, screenings, risk reduction and lifestyle services and diagnostic and follow-up care.

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SPARC

(Sickness Prevention Achieved through Regional Collaboration)

The SPARC program builds partnerships with and between community organizations and healthcare providers to increase the delivery of multiple clinical preventive services, namely vaccinations and screenings.

Who is reached?

Over the past 12 years, SPARC and its many partners have touched the lives of tens of thousands of residents in four adjacent counties at the intersection of Massachusetts, Connecticut and New York.(1)  A recent expansion to nine counties in and around Atlanta (2) has already served over 4,000 men, women and children.

What multiple preventive services are offered?

SPARC promotes influenza and pneumococcal vaccinations, cancer screening (mammograms, pap tests and colorectal cancer), and cardiovascular screenings (including cholesterol and blood pressure) with follow-up as needed.

In what community settings?

Preventive services are offered at key locations where community residents can be reached easily, such as churches, beauty salons, barbershops, worksites, polling places, public schools, community centers, physician practices, low-income housing and flu shot clinics. The locations can be expanded depending upon the particular opportunities in each community served.(3)

As a nonprofit health organization, SPARC serves as a catalyst and a “bridge” by bringing community organizations and healthcare agencies together to:

  • Create local networks of healthcare and social service providers that take responsibility for population-wide access to and delivery of preventive services
  • Develop efficient programs by bundling services for one-stop delivery at multiple community sites
  • Coordinate outreach for preventive services across the entire community
  • Identify and reach out to groups most in need
  • Provide screening results as follow-up to participants’ healthcare providers
  • Provide guidance and training to local healthcare practitioners as appropriate
  • Monitor and continually enhance community-wide efforts.

Common agencies and organizations that partner with SPARC include state and local health departments, hospitals, mayors, community advocacy groups, faith-based organizations, visiting nurse and home health agencies, local election authorities, media, home-delivered meal programs, public housing authorities, schools, area agencies on aging, quality improvement organizations and businesses.  

With what outcomes?

SPARC’s initiatives have successfully increased the use of influenza vaccinations, pneumococcal vaccinations, hepatitis B vaccinations, tetanus booster and mammography.

  • In 1997, SPARC led a broad program to ensure the delivery of pneumococcal vaccinations (PPV) at all community flu shot clinics in two of its counties.  Using Medicare reimbursement data, SPARC doubled the annual PPV delivery in both counties.(4)
  • SPARC pioneered a mechanism to provide mammography appointments at flu shot clinics for women who were behind schedule for breast cancer screening. This simple innovation resulted in a doubling of mammography rates among women attending these flu shot clinics.(5)

What contributes to success?

The SPARC program is the glue that binds collaborating healthcare and other community services agencies, facilitates access to multiple preventive services, and tracks and provides guidance for community-wide efforts.  Some of the key attributes contributing to the success of this program include:

  • Assuming responsibility for needs that fall between the cracks of medicine and public health
  • Relying on the leadership of a “neutral convener” agency that does not deliver preventive services and therefore does not compete with local providers
  • Building on the in-depth knowledge of the community that local partners bring to the collaboration
  • Involving all local sectors, including healthcare, social and aging services, local government, nonprofit organizations and private sector participants
  • Bundling clinical preventive services together and linking them to a convenient community delivery platform
  • Evaluating the results of the intervention.(6)

Want to learn more?

If you are a community agency seeking to improve and protect the health of your residents, you are encouraged to consider developing a broad-based strategy to expand the delivery of critical preventive services utilizing the SPARC principles. To get started:

CDC has developed the SPARC Action Guide [PDF–2.6M] to assist communities in adopting the SPARC model. The Guide offers the opportunity to learn more about the core preventive services and SPARC's potential for improving the health of a community. It also outlines a step-by-step process that a community can undertake to embrace the SPARC approach while implementing a program that meets the community's own unique needs and priorities.

In 2006, the Atlanta Regional Commission initiated the SPARC model with technical assistance from CDC and SPARC President Douglas Shenson, MD, MPH. The Atlanta pilot is described in an article in CDC’s e-journal, Preventing Chronic Disease.

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WISEWOMAN

(Well-Integrated Screening and Evaluation for WOMen Across the Nation)

WISEWOMAN is a program that instills lasting, healthy lifestyle changes in women at risk for heart disease, stroke and other chronic diseases.

Who is reached?

Funded by CDC since 1995, WISEWOMAN serves low-income, underinsured or uninsured women aged 40 to 64. The 21 programs in 19 states and 2 tribal organizations have reached 84,000 women with risk factors for heart disease and stroke.  Between January 2000 and June 2008, participating women had the following risk factors: overweight or obese (74%); high blood cholesterol (40%); smoking (29%); high blood pressure (28%); or diabetes (23%).(7)  More than one-third are from racial and ethnic minority populations.

What multiple preventive services are offered?

A typical WISEWOMAN program:

  • Screens women for hypertension, cholesterol, and diabetes
  • Offers strategies for healthy nutrition and physical activity as well as smoking cessation
  • Works with women to set goals, develop support networks, and maintain heart-healthy strategies in their daily lives
  • Facilitates referrals for needed treatment and medication
  • Monitors and evaluates progress through regular follow-up visits.(8)

Women who participate in WISEWOMAN also receive breast and cervical cancer screening through the National Breast and Cervical Cancer Early Detection Program.

In what community settings?

Screening and counseling services are delivered primarily by local health departments, community health centers, clinics, hospitals, solo clinician practices and visiting nurses services.(9)  Interventions rely on one-on-one, face-to-face interaction supplemented by telephone follow-up, but more recent innovations include self-help, video, computer or Web-based delivery and group counseling.(9)

With what outcomes?

Thanks to WISEWOMAN, many women are now aware that they are at risk for cardiovascular disease. Between January 2000 and June 2008, WISEWOMAN has identified more than 7,674 new cases of high blood pressure, 7,928 new cases of high cholesterol and 1,140 new cases of diabetes.(7)  Furthermore:

  • Participants were more likely to continue to have regular health screenings(10)
  • Seven percent of the participants who smoked had stopped(10)
  • Blood pressures and cholesterol levels had been lowered(10)
  • Women were at much lower risk of chronic heart disease and cardiovascular disease (5.4% less for 10-year estimated chronic heart disease risk and 7.6% for five-year estimated cardiovascular disease risk).(10)

Best of all, these improvements in health and quality of life have been achieved at a reasonable cost of $4,400 per estimated year-of-life saved.(11)

What contributes to success?

High performing WISEWOMAN sites share many distinguishing features.(9)  A few of the more salient commonalities are their commitment to:

  • Form relationships with providers and community organizations and use multiple strategies to recruit women to the program
  • Apply behavior change theory, tailor interventions, use incentives and assure stable resource levels
  • Embrace the team approach and tailor plans to meet individual needs
  • Train staff
  • Establish multiple partnerships for referrals
  • Develop and use tracking systems to monitor changes in risk factors over time.

Want to learn more?

If you work in a state that does not currently have a WISEWOMAN program, consider:

  • Creating and implementing a WISEWOMAN “look-alike” program using the WISEWOMAN model and lessons learned
  • Exploring the potential of becoming a new WISEWOMAN program as CDC funding becomes available.

If you work in a clinic, health department or other community-based organization interested in linking with the WISEWOMAN program, consider:

  • Identifying eligible women in your community and referring them to participating sites
  • Exploring the potential to add your clinical preventive screening to an existing WISEWOMAN program and evaluate effectiveness
  • Promoting policy, environmental and system changes that support adoption and maintenance of heart-healthy behaviors among underserved populations in your area
  • Implementing evidence-based, low-cost lifestyle intervention programs accessible to help underserved populations in your area achieve and maintain their heart-healthy behaviors.

For general information, visit the WISEWOMAN Web site

For effective interventions and best practices, visit this program link.

For state/tribal program contacts, visit this link.  

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Johns Hopkins Family Heart Study

The Family Heart Study, directed by Johns Hopkins University, documented the merits of delivering multiple preventive services in a community setting to adults at high risk of cardiovascular disease.

Who was reached?

A total of 360 African Americans, 30 to 59 years of age, participated in the study. All had a sibling who had been hospitalized for coronary heart disease in one of 10 Baltimore hospitals and at least one additional cardiovascular risk factor other than family history.(12)

What prevention services were offered?

Participants were randomly assigned to one of two groups: the Enhanced Usual Care Intervention or the Community-based Care Intervention.(12-14)  Both groups received:

  • Physical exams and medical histories (initially, at one-year and at five-years) to determine blood pressure, body mass index, cholesterol, physical activity level and smoking status
  • Recommendations based on national guidelines and tailored to individual risk factors
  • Pharmacy charge service cards to authorize prescriptions free of charge at any pharmacy
  • Free entry to risk reduction seminars, diet and exercise programs and smoking cessation classes.

In what settings?

The Enhanced Usual Care Intervention was based in primary care physicians’ offices. Physicians received screening and measurement results, along with copies of the same risk-specific educational materials and recommendations for risk factor management sent to the participants. They then provided their usual standard of care, including office visits, education, pharmacotherapy and adherence monitoring. Pharmacy service cards and coupons for free local YMCA exercise programs were mailed to the physician, and the participants were instructed to ask for them.

The Community-based Care Intervention, designed by a community advisory panel, was implemented at a Family Heart Center—an apartment-based, non clinical site with free parking or easily reached by foot, bus or subway.(12) Services were delivered by nurse practitioners and community health workers, with oversight from primary care physicians.

During an average 30-minute visit, the nurse practitioner measured blood pressure, evaluated pharmacotherapy and monitored compliance.  Changes in pharmacotherapy were shared by mail with the participant’s primary care physician. In addition, community health workers provided dietary counseling, smoking cessation, exercise counseling, and culturally sensitive support to help fill and use prescriptions, shop for and prepare healthier foods, and access an exercise facility. They invited participants to join them at the local YMCA for two evening exercise sessions per week, or urged them to use the Family Heart Center’s exercise room. Periodic telephone calls afforded another method for offering additional encouragement and support and for monitoring progress.

With what outcomes?

After only one year, participants in the Community-based Care group had significantly lower cardiovascular disease risk than their Enhanced Usual Care counterparts.(13) The Community-based Care group:

  • Was twice as likely to achieve goal levels of low-density lipoprotein cholesterol and blood pressure than the Usual Care group, and significantly more effective at reducing risk of coronary heart disease
  • Decreased its smoking rate by 16.2% compared with a 7% reduction in the Usual Care group
  • Was twice as likely to receive a prescription card and use it to fill prescriptions and 13 times more likely to use the cholesterol-lowering medication
  • Had higher physical activity rates; 20% exercised at the YMCA compared with none in the Usual Care group.

Even more remarkable is that some of these outcomes were sustained for the next five years. Participants receiving Community-based Care were significantly more likely to sustain their one-year cholesterol levels throughout the five-year period, while those receiving Enhanced Usual Care were significantly much less likely to ever reach their goal levels for either cholesterol or blood pressure.(14)

Want to learn more?

For study methodology, results and additional questions:  Dr. Diane Becker, Division of General Internal Medicine, Johns Hopkins Medical Institutions at dbecker607@aol.com.

 

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Mobility

Mobility impairment leads to morbidity

Mobility in older adults, individuals’ ability to move around effectively and safely in their environment, is fundamental to health and well-being. Although there is no agreed upon definition of mobility, Satariano and colleagues provide the following description, “Mobility refers to movement in all of its forms, including transferring from a bed to a chair, walking for leisure and the completion of daily tasks, engaging in other activities associated with work and play, exercising, driving a car, and using other forms of passenger transport.”(15)

Among older adults, the consequences of chronic conditions and geriatric syndromes may be limitations in mobility (impaired mobility) that can lead to dependence in activities of daily living and other adverse outcomes.(16)

Impaired mobility is associated with a variety of adverse outcomes such as specific health conditions like depression, cardiovascular disease, cancer, and injuries secondary to falls and automobile crashes. Mobility impairment may cause reduced access to goods and services as well as limited contact with friends and relatives. These illnesses and injuries can lead to increased morbidity.(15)

Physical Activity and the Physical Environment

Previous efforts to improve mobility have focused on encouragement of physical activity such as walking. Social support interventions in community settings have focused on changing physical activity behavior through building, strengthening, and maintaining social networks that provide supportive relationships for behavior change. The Guide to Community Preventive Services (The Community Guide) is a reference point for finding information about evidence based programs and recommendations related to health interventions for behavior change. See the Expert Panel Recommendations section for specific recommendations.

Driving

In 2009, there were 33 million licensed drivers aged 65 years or older in the United States.(17)  Driving helps older adults stay mobile and independent; however the risk of being injured or killed in a motor vehicle crash increases with age. An average of 500 older adults are injured every day in motor vehicle crashes.(18) 
Older adults are at risk because:

  • Starting at age 75, fatal crash rates increase per mile traveled. This is largely due to increased susceptibility to injury and medical complications among older drivers rather than an increased tendency to get into crashes.
  • Age-related declines in vision and cognitive functioning (ability to reason and remember), as well as physical changes, may affect some older adults' driving abilities.(19)

There are a number of strategies that older adults can take several steps to stay safe on the road such as exercising regularly to increase strength and flexibility, having vision checked by an eye doctor at least once a year wearing corrective lenses or glasses as required, driving in good weather daylight, and navigation of the safest route with well-lit streets and intersections with left turn arrows. Communities also need to provide safer conditions or alternatives to driving.

Promoting Alternatives – Complete Streets

Complete streets are designed and operated to enable safe access for all users. The essential components of a complete street incorporate the following principles:

  • Complete streets include a vision involving all users including pedestrians, motorists, bicyclists and transit passengers of all ages and abilities.
  • A complete street can apply to new or retrofit road projects and includes the design, planning, operations and maintenance for the right of way. It encourages street connectivity and is adoptable by all agencies to cover all roads.
  • A complete street uses the latest and best design criteria and guidelines, will complement the context of the community, establish performance standards with measureable outcomes and steps to implement the related policies associated with integration.

The Future of Smart Growth… Improving the Quality of Life for All Generations

Smart Growth is characterized by development patterns that create attractive, distinctive, walkable communities that give people of varying age, wealth, and physical ability a range of safe, affordable, convenient choices in where they live and how they get around.

"Communities across the country are using creative strategies to develop in ways that preserve natural lands and critical environmental areas, protect water and air quality, and reuse already-developed land. They conserve resources by reinvesting in existing infrastructure and reclaiming historic buildings. By designing neighborhoods that have shops, offices, schools, churches, parks, and other amenities near homes, communities are giving their residents and visitors the option of walking, bicycling, taking public transportation, or driving as they go about their business. A range of different types of homes makes it possible for senior citizens to stay in their homes as they age, young people to afford their first home, and families at all stages in between to find a safe, attractive home they can afford. Through smart growth approaches that enhance neighborhoods and involve local residents in development decisions, these communities are creating vibrant places to live, work, and play. The high quality of life in these communities makes them economically competitive, creates business opportunities, and improves the local tax base." (20)

Looking Ahead – A National Mobility Action Plan

A national agenda to promote mobility among older adults identifying priorities and strategic actions to maintain and enhance mobility is underway thanks to efforts from the National Association for Chronic Disease Directors, the Healthy Aging Research Network (CDC-HAN), and the Centers for Disease Control and Prevention’s Healthy Aging Program. A framework is being developed that will identify priorities and strategic actions that have relevance to policy makers, funders, community planners, and organizations vested in the well-being of older adults and healthy communities, as well as researchers who work on mobility. The foundation for this work comes from the development of a CDC-HAN environmental audit tool [PDF 513] and protocol for assessing the walkability of streets and communities. It is expected to be available in January 2013.

The creation of the Centers for Disease Control and Prevention Healthy Aging Research Network’s Environmental and Policy Change (EPC) Clearinghouse has been integral in helping states work on collaborative efforts. The resources included in the Clearinghouse have been chosen for their relevance and usefulness to people working in the fields of aging and disability services, public health, planning, architecture, engineering, recreation, transportation, and healthcare. The EPC Clearinghouse provides resources, tools, and concrete strategies that support local efforts in environmental and policy change for healthy aging. Clearinghouse resources include toolkits, best practices, case studies, and process steps for engaging other stakeholders, guidelines for working with decision-makers at various levels of government, environmental and policy change information specific to older adults in the areas of walkability, livable communities, transportation, older pedestrians and drivers, improving access to healthy foods, universal design and rural community issues.

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References

 

SPARC

  1. Brodeur P. SPARC–Sickness Prevention Achieved through Regional Collaboration. In: Isaacs SL, Knickman JR., editors. To Improve Health and Health Care, Vol. X. The Robert Wood Johnson Anthology. San Francisco, CA: Jossey-Bass; 2006. p.145–167.
  2. Shenson D, Benson W, Harris AC. Expanding the delivery of clinical preventive services through community collaboration: The SPARC model. Preventing Chronic Disease (serial online) 2008;5(1):A20. Available at: www.cdc.gov/pcd/issues/2008/jan/07_0139.htm.
  3. Shenson D. Putting prevention in its place: The shift from clinic to community. Health Affairs 2006;25(4):1012–1015.
  4. Shenson D. Quinley J, DiMartino D, Stumpf P, Caldwall M, Lee T. Pneumococcal immunizations at flu clinics: The impact of community-wide outreach. Journal of Community Health 2001;26(3):191–201.
  5. Shenson D, Cassarino L, DiMartino D, Marantz P, Bolen J, Good B, Alderman M. Improving access to mammograms through community-based influenza clinics. A quasi-experimental study. American Journal of Preventive Medicine 2001;20(2):97–102.
  6. Robert Wood Johnson Foundation. National Vaccine Summit Recognizes SPARC for the Success of the Vote and Vax 2008 Program. Robert Wood Johnson Foundation Web site. Available at: www.rwjf.org/pr/product.jsp?id=40588.

WISEWOMAN

  1. Centers for Disease Control and Prevention. WISEWOMAN: Preventing Disease Among Women Most in Need. At a Glance 2009. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention Web site. Available at: www.cdc.gov/WISEWOMAN/.
  2. Will JC, Loo RK. The WISEWOMAN program: Reflection and forecast. Preventing Chronic Disease (serial online) 2008;5(2):A56. Available at: www.cdc.gov/pcd/issues/2008/apr/07_0209.htm.
  3. Besculides M, Zaveri H, Hanson C, Farris R, Gregory-Mercado K, Will J. Best practices in implementing lifestyle interventions in the WISEWOMAN program: Adaptable strategies for public health programs. American Journal of Health Promotion 2008;22(5):322–328.
  4. Centers for Disease Control and Prevention. WISEWOMAN – Well-Integrated Screening and Evaluation for Women Across the Nation. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention Web site. Available at: www.cdc.gov/WISEWOMAN/.
  5. Finkelstein EA, Khavjou O, Will JC. Cost effectiveness of WISEWOMAN, a program aimed at reducing heart disease risk among low-income women. Journal of Women’s Health 2006;15(4):379–389.

Johns Hopkins Family Heart Study

  1. Becker DM, Tuggle MB, Prentice MF. Building a gateway to promote cardiovascular health research in African-American communities: Lessons and findings from the field. American Journal of Medical Sciences 2001;322(5):288–293.
  2. Becker DM, Yanek LR, Johnson WR Jr, Garrett D, Moy TF, Reynolds SS, et al. Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease. Circulation 2005;111:1298–1304.
  3. Cene CW, Yanek LR, Moy TF, Levine DM, Becker LC, Becker DM. Sustainability of a multiple risk factor intervention on cardiovascular disease in high-risk African American families. Ethnicity & Disease 2008;18(2):169–175.

Mobility

  1. Satariano WA, Guralnik, JM, Jackson RJ, Marottoli RA, Phelan EA, Prohaska TR. Mobioity and aging: new directions for public health action. AM J Public Health. 2012; 102(8):1508–1515.
  2. Branch, L.G., Meng, H., Guralnik, J.M. (2012). Disability and functional status. In Prohaska T, Anderson LA, Binstock R. editors. Public Health for an Aging Society. Baltimore, Maryland: Johns Hopkins University Press.
  3. U.S. Department of Transportation, Federal Highway Administration. Highway Statistics 2009. USDOT Web site: http://www.fhwa.dot.gov/policyinformation/statistics/2009/dl22.cfm.
  4. U.S. Department of Transportation, Federal Highway Administration. Traffic Safety Facts 2008. USDOT Web site: http://www-nrd.nhtsa.dot.gov/Pubs/811161.PDF [PDF–185].
  5. Owsley C. Driver Capabilities in Transportation in an Aging Society: A Decade of Experience. Technical Papers and Reports from a Conference: Bethesda, MD; Nov. 7–9, 1999. Washington, DC, Transportation Research Board; 2004.
  6. U.S. Environmental Protection Agency. About Smart Growth. EPA Web site. http://www.epa.gov/smartgrowth/about_sg.htm#principles.

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