Special Issue, November 2005
COMMUNITY CASE STUDY
Statewide Community-based Health Promotion: A North Carolina Model to Build Local
Capacity for Chronic Disease Prevention
Marcus Plescia, MD, MPH, Suzanna Young, RD, MPH, Rosemary L. Ritzman, PhD,
Suggested citation for this article: Plescia M, Young S, Ritzman RL.
Statewide community-based health promotion: a North Carolina model to build
local capacity for chronic disease prevention. Prev Chronic Dis [serial
online] 2005 Nov [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2005/
Public health faces major challenges to building state and local
infrastructure with the capacity to address the underlying causes of chronic
disease. We describe a structured statewide approach to providing technical
assistance for local communities to support and develop health promotion
Over the last two decades, the North Carolina Statewide Health Promotion
program has supported local approaches to the prevention and control of
chronic disease. In 1999, a major change in the program required local health
departments to focus on policy-change and environmental-change strategies for
addressing three major risk factors: physical inactivity, poor diet, and
State program consultants provided technical assistance and training
opportunities to local programs on effective policy-change and
environmental-change strategies and interventions, based on needs defined by a
statewide monitoring and evaluation system.
The percentage of health departments in North Carolina with interventions addressing
at least one of three targeted risk factors in 2004 approached 100%; in 2001,
this percentage was 62%. Additionally, between 2001 and 2004, the number of health departments reporting policy or
environmental outcomes related to these risk factors almost doubled.
Requiring local programs to implement policy-change and
environmental-change interventions that address the three major behavioral
risk factors provides an organized framework for accountability. An
established reporting system guides technical assistance efforts and monitors
their effectiveness based on standardized objectives that address the full
scope of the socioecologic model.
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Public health and medical care systems throughout the United States
struggle to address the increasing burden of chronic disease at the national,
state, and local levels. Preventable chronic disease conditions represent the
nation’s leading causes of death and account for 75% of all health care
costs (1). Analyses of risk factors for chronic diseases clearly indicate that
physical inactivity, poor diet, and tobacco use are the underlying causes of
the majority of all deaths each year (2,3). Although chronic diseases have
surpassed infectious diseases as the main cause of death and disability in the
United States during the last 50 years, local and state public health efforts
continue to focus on infectious disease control (4).
A socioecologic approach to community health recognizes that health
behaviors are multifaceted and are part of a larger social system of behaviors
and social influences. Changes in health behaviors require supportive changes
within the following five levels of influence: intrapersonal factors,
interpersonal processes and groups, institutional factors, community factors,
and public policy (5). Policy changes include changes to laws, regulations,
and both formal and informal rules and practice standards. These policy
changes lead most often to further changes in the physical and social
environment that provide new or enhanced support for positive health
behaviors. Programs that target supportive changes at the community,
institutional, and policy levels are now encouraged by the public health
community as highly effective evidence-based approaches (6). An example of how
a community health promotion program would target these intervention levels to
promote physical activity might include 1) advocating for county subdivision
ordinances and land-use plans to require sidewalks; 2) working with local
businesses to provide on-site exercise opportunities for employees; and 3)
using a variety of media-based prompts to encourage use of available resources.
Public health faces a major challenge to building state and local
infrastructure with the capacity to address the primary risk factors for
chronic disease. Despite awareness of the benefits of a more comprehensive
approach to community health promotion, implementing policy and environmental
change is a difficult process, and there are few reports of states that have
made this transition at the community level (7). Strong comprehensive
approaches have been made in some state tobacco control programs; much of this
success appears to be based on significant resources made available from
Master Tobacco Settlement Agreement revenues and on an increasingly well-developed
evidence base describing effective policy and environmental interventions for
tobacco control (8).
In this paper, we describe a structured statewide approach to providing
technical assistance for local communities to support and develop health
promotion capacity. This approach is focused on policy-level and
environmental-level community-based interventions and includes an evaluation
system to monitor progress and guide technical assistance for local
communities. This program in North Carolina is oriented toward county health
departments, but applications of this model can be adapted for use in a more
regionalized public health system.
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The county is the main unit of local government in North Carolina. In 2003,
individual county populations ranged from 4226 to 750,221 residents (9). North
Carolina has a strong local system of autonomous county health departments
that provide the core infrastructure of the state’s public health system. Each
health department is administered by a health director who is hired and
supervised by a local board of health. The state provides pass-through and
contracted funding to local health departments from a range of state and
federal sources. The state is currently working to design and institute an
accreditation system that would help standardize the scope and quality of
services provided by local health departments.
In 1985, a North Carolina Legislative Research Study Commission was
authorized to study “innovative approaches to finance health promotion and
disease prevention efforts in the state.” In 1986, the commission’s study
committee recommended that the legislature create a statewide program to
provide resources to local health departments to develop and implement
community-based health promotion interventions. To support this effort, called the
North Carolina Statewide
Health Promotion Program, an annual appropriation of $750,000 was provided in 1987 by
the state legislature in addition to a Preventive Health and Health Services
(PHHS) Block Grant of $459,461.
The North Carolina Statewide Health Promotion Program provides funding to
85 local health departments and districts to support increased physical
activity, healthy eating, and tobacco cessation. During the last two decades, the North Carolina Statewide Health Promotion
Program has supported local approaches to the prevention and control of
chronic disease in every community across the state. During the initial period
of the program, the state provided limited oversight and little program
guidance or technical assistance. Health departments used the funds primarily
to support adult chronic disease screening and treatment services and patient
education programs for high-risk clients. These services were
also supported by separate state allocations of Adult Health, Hypertension,
and Health Promotion funds (including federal PHHS Block Grants). Annual reports
the state documented the number of clients screened and the services provided
for each funding source.
In 1999, based on increasing evidence of the effectiveness of
community-based policy and organizational approaches to health behavior
change, the state reorganized the Statewide Health Promotion Program and
changed the program's focus. All state appropriations and federal PHHS Block Grant
funding for adult health and primary care services were combined. Local health
departments continued to receive a baseline appropriation (approximately
$21,000 annually). Based on their prior allocations for adult health funds and hypertension
funds, 75 counties were funded above this baseline level.
All health departments were required to prepare 3-year strategic plans to
transition toward programs focused on policy and organizational changes to
increase physical activity, improve eating habits, and reduce tobacco use.
During the transition period, all local health departments were required to
use their baseline funding and at least 75% of any above-baseline funds for
policy-change and environmental-change strategies. Local programs were also
required to participate in a comprehensive monitoring system. These new
requirements were implemented as part of the contractual agreement between the
state and local health departments that allows individual programs to
stipulate performance requirements as addenda to the state’s consolidated
contract. During the 2004–2005 fiscal year, the program provided $2.7 million to local
health departments from PHHS Block Grant funds. State appropriations comprised an
additional $1 million.
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Three regional program consultants provide technical assistance and
training to each county on community-based prevention programs and monitor each local program’s progress
annually. Local health
departments designate a health promotion coordinator to serve as the primary
liaison to the state program. The local health promotion coordinator is
responsible for submitting an annual community action and budget plan that specifies policy-change and environmental-change
objectives that address at least one of the targeted risk factors. The action
steps in each plan must include the names and roles of community partners.
Community action and budget plans are reviewed annually by regional program consultants
for approval. Contracts require local health departments to create
and maintain local partnerships, work collaboratively with community
coalitions to plan and implement health promotion activities, submit plans and
reports electronically, and attend regional meetings and approved training
programs at least twice yearly.
The North Carolina Statewide Health Promotion Program uses the Progress
Check system to document and monitor local activities and outcomes. Progress
Check is based on a structured framework developed to evaluate community
efforts to prevent cardiovascular disease (10). Local staff members document
activities linked to their annual community action plan objectives using an
application based on Microsoft Access (Microsoft Corp, Redmond, Wash). Twelve categories are used to describe events; these categories are grouped
into three main areas: 1) groundwork, which includes assessment, partnering,
planning products, and training; 2) actions, which includes policy-change and
environmental-change advocacy, services provided, capacity building, and
actions related to working on a regional level to implement programs; and 3)
accomplishments, which includes media coverage, resources generated, policy-change
outcomes, and environmental-change outcomes.
Local staff members describe a significant activity event and categorize
the event based on one or more of the 12 areas described above. The policy and
environmental activities reported through the Progress Check system allow
regional consultants to monitor each county’s progress toward completing its
annual action and budget plan and determine the need for technical assistance
and training to improve local strategies for change. Progress Check data are exported to state staff for tracking and analysis of progress within
individual programs and across the state. Data can be combined across multiple
categorical programs (e.g., state diabetes and cardiovascular disease
programs), and local programs have the capacity to generate an automated
report of their activities.
A program evaluator maintains the Progress Check evaluation system and
provides training to local programs. Regional program consultants review local
reports to validate entries and identify needs for technical assistance and
Activities reported by local programs are related to the county’s
community action plan and may include events that indicate that objectives
were met, partially met, or exceeded. Fortuitous outcomes not connected to
original objectives can also be captured by the system.
Table 1 summarizes
Progress Check data fields for risk factors, age, race and ethnicity, setting,
funding source, and collaborating agencies.
An example of a reported policy-change and environmental-change outcome was
a county health department’s partnership with the county school system to
implement the Take 10! program. This program integrated daily physical
activity opportunities within the academic curriculum for 763 elementary
school-aged children in four schools (11). The project coordinator reported
event descriptions of the major change activities. The final school-policy
changes to implement the Take 10! program and create an additional 26,423
10-minute exercise opportunities for students were reported as environmental
and policy outcomes. These activities and outcomes were categorized by risk
factor (physical activity), target audience (students in kindergarten through
fifth grade), partners (North Carolina Department of Public Instruction,
individual school staff), and funding source (Statewide Health Promotion
Program and county funds). Additional long-term objectives for the
intervention include increased numbers of students with measurements within
the recommended body mass index category.
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Data collected during program year 2000–2001 were used as a
baseline to assess the effectiveness of the transition of local programs to
community-based programs by 2003–2004. The reporting system used
during 2000–2001 was a simple paper reporting system that did not include
all of the information that the Progress Check system captures. Despite
limitations of the early reporting system, variables common to both systems
demonstrate that the Statewide Health Promotion Program clearly influenced
local health promotion activity in three priority areas: targeted risk
factors, high-risk populations, and policy and environmental change.
Table 2 compares the number of
health departments reporting policy-change or
environmental-change outcomes during program years 2001–2002 and 2003–2004.
The percentage of health departments in North Carolina with interventions addressing at
least one of three targeted risk factors during 2003–2004 approached 100%,
with almost three quarters reporting activities addressing all three risk
factors at the policy-change or environmental-change level or both. These data
contrast dramatically with baseline data collected during 2000–2001, indicating that about 40% of
health departments addressed physical activity, 32%
addressed nutrition risk factors, 56% addressed tobacco use, and only 20%
addressed all three. There was a similar increase during the 3-year period in
the number of health departments reporting policy or environmental outcomes
related to these risk factors. For 2001–2002, 62% of local programs reported
policy-change or environmental-change outcomes. For 2003–2004, 93% reported
policy-change or environmental-change outcomes. During the same period,
outreach to targeted minority populations increased from 18% to 74%.
Implementation of programs in community, school, faith, and worksite settings
Examples of specific outcomes documented by local programs during the 2003–2004
program year include the following:
- 40 school districts in North Carolina established 100% smoke-free
campuses (an increase from only 15 of 115 school districts in North
Carolina before 2003–2004).
- 41 county school systems in North Carolina implemented healthy meal and
snack options for schoolchildren.
- 14 counties in North Carolina increased walking and bike-riding trails
by more than 41 miles in their communities.
- 36 counties in North Carolina partnered with work sites to implement
policies and facilities that support employees in increasing their
physical activity levels and access to healthy eating options.
Although state and federal funding for the Statewide Health Promotion
Program is limited — approximately one dollar per North Carolina
resident is allocated — local health departments and their community partners
have used these funds to leverage additional local funding. During the state
fiscal year 2003–2004, more than $5 million in local and private resources
were generated from the $3.7 million state allocation to local programs.
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Increased capacity must be developed at the federal, state, and local
levels to affect the rates of chronic disease in the United States. Noncategorical funding for state and local health promotion efforts, however,
has received recent criticism and faces significant budget reductions because
of concerns that such resources are not used in a standardized or
evidence-based way. Our experience in establishing a statewide health
promotion program addresses these concerns. Requiring local programs to
implement policy-change and environmental-change interventions that address
the three major behavioral risk factors provides an organized framework for
accountability. The reporting system we established allows state staff members
to monitor the effectiveness of local programs in achieving their objectives,
provides a basis for tailoring technical assistance to a county’s specific
needs, and creates a mechanism for performance-based allocations of limited
health promotion resources.
A comprehensive reporting system makes it possible to document statewide
policy and environmental changes addressing chronic disease prevention. These
data, however, have some limitations. Because the program framework allows
local health departments to write county-specific objectives that might
include a variety of outcomes, it is difficult to summarize statewide changes
in a particular area of interest, such as policies on school nutrition or
community opportunities for physical activity. The outcomes documented in the
Progress Check system are useful for assessing process changes. They do not address
overall indices of community change within a particular county or at the state
level. The impact on local objectives is also difficult to assess and compare
among counties because their definitions of policy-change and
environmental-change outcomes can range from minimal to significant.
Several lessons were learned from the development of this statewide
approach to health promotion. Funding was initially provided to local health
departments without consistent central guidance and oversight. Local agencies
allocated resources based on their agency’s priorities and funding needs;
they resisted the introduction of specific performance expectations. Many
local program coordinators have professional backgrounds in working with
individuals; they struggled with the change in program guidelines. The
initiation of a structured approach to program accountability has provided a
basis for instituting performance-based funding allocations. The state can now
use Progress Check and program monitoring to decrease local allocations based
on poor performance and reallocate resources to counties with high performance
levels. Funding has been reduced to some noncompliant health departments. For
example, when recent state and federal program funding reductions occurred,
the Statewide Health Promotion Program used performance measures to implement
cuts rather than reduce all counties equally as it had done in the past. There
are limits to this approach, however, because of the politics of state government.
Attempts are underway in North Carolina to institute a local health department
accreditation system with additional provisions for performance-based funding.
This would provide better mechanisms for enforcing program guidelines and
would allow the development of links between local plans and statewide
Introducing new technology and reporting requirements for local programs
also required planning at the state level to ensure that training and
technical assistance for local programs was accessible at the time the changes
occurred. Initially, many local health promotion staff had limited computer
skills and felt intimidated by the reporting system. Individual training,
ongoing technical consultation, and reassurance from the consultants were
necessary to resolve these issues. Providing local programs the capacity to
generate their own reports proved to be one of the most critical factors in
increasing local acceptance of the monitoring system and improving the quality
and consistency of data reported to the state. Local programs could also use
the summary data to prepare reports to local government agencies and develop grant
proposals for additional resources.
Requiring local health departments to transition health promotion funding
to community-based interventions rather than clinical services could raise
concerns that screening and adult health services may not be available in
these communities. In North Carolina, the transition of health promotion funds
to community-based programs was part of a trend by many local health
departments to discontinue primary care services. Communicable disease
services and other essential public health services remain, but adult health,
home health, and in many locations, prenatal and child health services have
been transferred to local hospitals and community health centers. This
transfer has allowed health departments to focus limited resources on
community-based public health programs and services.
Health promotion interventions are often most effective when implemented at
the community level. The North Carolina Statewide Health Promotion Program is
a structured model for evidence-based approaches and the development of local
capacity for health promotion practice that can be used by other states.
Although North Carolina has been successful in obtaining federal categorical
funding for chronic disease programs, the Statewide Health Promotion Program
is funded by federal block grant funds (PHHS Block Grants) and moderate levels of state
funding. The program could be adopted by other states using similar resources.
The Progress Check monitoring system is adaptable; technical assistance is
provided by a limited number of staff. Other states could face similar
challenges in developing local acceptance of a more structured framework and
commitment to consistent standards. States with a more regionalized,
district-oriented infrastructure or a well-developed system of local
accreditation would be particularly well prepared to institute this system.
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Corresponding Author: Marcus Plescia, MD, MPH, Chief, North Carolina
Division of Public Health, Chronic Disease and Injury
Section, 1915 Mail Service Center, Raleigh,
NC 27699. Telephone: 919-715-0125. E-mail: Marcus.firstname.lastname@example.org.
The author is also affiliated with the University of North Carolina Department
of Family Medicine, Chapel Hill, NC.
Author Affiliations: Suzanna Young, RD, MPH, Rosemary L. Ritzman, PhD, MSN, North Carolina Division of Public Health, Raleigh, NC.
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