Special Issue, November 2005
At the Cutting Edge or the Center of the Storm? Innovation in Public
Health Through Health Promotion and Education in State Health Departments
Randy Schwartz, MSPH
Suggested citation for this article: Schwartz R. At the cutting edge
or the center of the storm? Innovation in public health through health
promotion and education in state health departments. Prev Chronic Dis [serial
online] 2005 Nov [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2005/
Health promotion and education components of state health agencies are at
the center of the application of modern public health practice. Two reports on
the future of public health, issued 15 years apart, detailed the changing
nature and systemic problems of public health in the late 20th
century (1) and identified the challenges in improving the public’s health as
we head into the 21st century (2). State health agencies — in
collaboration with federal partners, community organizations, and health care
systems — clearly play a critical role in ensuring the public’s health. In
response to these contemporary public health issues, the health promotion and
education components of state health agencies have rapidly evolved, gaining
the capacity to address newly recognized public health problems and become key
players in ensuring that community and public health problems are addressed
through cutting-edge public health strategies. These strategies include
community mobilization, coalition building, and community-based interventions;
integration of policy advocacy and media advocacy into comprehensive
interventions; collaborations with academic institutions and other partners to
advance the translation of research into practice; and the adoption of the
social–ecological approach to public health interventions, in which the
interplay of multiple interventions at multiple levels of society combine to
provide the impact necessary to address deep problems.
This issue of Preventing Chronic Disease highlights several
innovative health promotion and education initiatives conducted by state
health agencies, showing not only the breadth of public health issues
addressed by these agencies but also the scope of complex strategic issues
undertaken by the leadership of these organizations.
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In the early 1980s, the health promotion and education
units at state health agencies were small, often one-person programs, if present at all. With funding
from the Health Education–Risk Reduction program, the growth of these
enterprises began in earnest. Support from the Centers for Disease
Control and Prevention’s (CDC’s) Center for Health Promotion and Education and
the National Heart, Lung, and Blood Institute’s (NHLBI’s) National High Blood
Pressure Education Program helped to build the capacity of the staff and
provide program support for health promotion and education infrastructure. The
Healthy People Objectives for the Nation (3) were embraced and became part of
public health planning both nationally and in many states. Subsequent funding,
including the Preventive Health and Health Services Block Grant, and various
initiatives, such as cancer prevention and control, tobacco
control, and injury prevention, contributed to both the capacity of the
organization and the improvement of the public’s health.
With the emergence of HIV/AIDS as a serious public health problem, public
health education and school health became recognized as key components of an
overall strategy that, when combined with disease prevention and control methods such as
epidemiology, testing, and counseling, would strengthen an existing overall
public health strategy. Development of public health programs
in numerous areas such as environmental health and immunizations
reinforced the integration of health promotion and education into
comprehensive public health interventions. Professional organizations such as SOPHE (The Society for Public Health Education) and the Directors of Health
Promotion and Education (DHPE), formerly the Association of State and
Territorial Directors of Health Promotion and Public Health Education (ASTDHPPHE),
contributed to the development of the professional staff and advocated for
national- and state-level health promotion public policies and funding for
health promotion programs.
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Challenges in Leadership Development and
Strategic Priorities for Health Promotion
The health promotion and education leadership, staff, and programs
initiated by state health agencies have synthesized and integrated the best of
modern public health practice. In collaboration with the CDC, other federal
agencies, and professional organizations, they have taken the best approaches
available and worked with communities to implement them through state-level
systems and public policies. Brief descriptions of the strategies used follow.
Community mobilization and coalition building
Health promotion and education units have been pivotal in implementing key
aspects of modern public health practice through community mobilization and
with community participation, recognizing the capacity, politics,
and culture of each community. Broad-based community health improvement initiatives, such as
Colorado’s privately run
Healthy Communities, have recognized community-based coalition approaches
as effective strategies for public health practice. Such coalition-based
approaches are implemented by or in partnership with state health agency
health promotion units. In many states, collaboration was enhanced by the work
of the Turning Point initiative, funded by The Robert Wood Johnson Foundation and W.K.
Kellogg Foundation (4), with its mission of strengthening the public health
infrastructure and enhancing public health policy through community
Policy and media advocacy as essential elements of public health
Fueled by work on tobacco prevention and control, health promotion and
education intervention planning and delivery embraced the integration of
policy advocacy and media advocacy as critical components of comprehensive
community health improvement initiatives. The
ASSIST program, funded by the National Cancer Institute, used standards that included both policy and media
advocacy as essential to comprehensive tobacco-control program delivery (5).
More recently, the CDC developed standards for comprehensive
tobacco-control program delivery, recognizing the work of the ASSIST program
and notable tobacco prevention and control programs in California and
Massachusetts. Paradoxically, state health promotion
programs that build the capacity of state and community stakeholders in policy and
media advocacy should be prepared when these same trained advocates use their
new skills to advocate to or even speak out against state
Collaboration with academic partners to accelerate the translation of
research and evidence-based public health into practice
This issue of collaboration has received increasing attention over the past several years.
The health promotion unit plays an invaluable role as a “linking agent” in the
diffusion process (6). Links have been formed with CDC-funded Prevention
Research Centers (PRCs) (7,8), Health Resources Services Administration-funded
Public Health Training Centers, and other academic partners. State
health promotion programs and staff must assume responsibility for enhancing
practice and building capacity for the use of evidence-based practice by both
program staff and constituents in community-based health organizations.
Recently introduced tools such as The Guide to Community Preventive Services
(9) and Cancer Control PLANET Web site (10) make this strategic imperative a
more practical reality. Although some practitioners may, at times, seek to be
told what to do or how to develop and implement an intervention through a
“cookbook” approach, the skilled practitioner must integrate elements and
skills of using a diagnostic approach, combined with best practices (11).
Because of their varied backgrounds and experiences in the public health
workforce (12), state health promotion leaders must step forward to develop the capacity and quality of
not only health department staff skills but also the skills of community
health workers practicing in community-based health organizations, local
health departments, and other agencies of all sizes throughout the state.
Again, in conjunction with academic partners and professional organizations
such as local SOPHE chapters, health promotion workforce development remains
both a need and a challenge.
A remaining challenge: evaluation capacity building
Many of the interventions and applications of modern public health
practices need to be measured for impact and outcome. State health promotion
and education leaders can help address this challenge by incorporating
evaluation into the agency at all levels but ensuring that the evaluation
strategies are appropriate for the level of practice and staffing. Not all
practitioners need to be evaluators, but all programs need monitoring and
evaluation. The CDC Framework for Program Evaluation in Public Health (13) has
been a valuable model to promote such integration. State health promotion
leaders and the CDC, in conjunction with academic partners and professional
organizations, must develop ways to more effectively build the evaluation
capacity of staff and programs at all levels.
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I have had the privilege of being a participant in the growth of health
promotion and education in state health agencies as director of the Division
of Community and Family Health at the state health agency in Maine for almost
two decades prior to working at the American Cancer Society. The world of
public health changed dramatically during that time, and health promotion
practice rapidly evolved to meet such challenges. Partnership with and support
by federal agencies, especially the CDC, and professional organizations,
especially ASTDHPPE/DHPE and SOPHE, were essential to the division’s
continued quality and innovation with one goal in mind — improving the
public’s health. The collection of articles in this issue provides a glimpse
into some of those innovative initiatives. These articles and others published
in such journals as Health Promotion Practice help continually to
advance the use of innovative and promising practices in real-world settings.
The savvy practitioner can take the best of these examples and continue to
evolve new and innovative approaches to their application in a variety of
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Corresponding Author: Randy Schwartz, MSPH, Editor, Health
Promotion Practice, Sr VP for Cancer Control, American Cancer Society, New
England Division, 30 Speen St, Framingham, MA 01701. Telephone: 508-270-4660.
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- Institute of Medicine. The future of public health. Washington (DC):
National Academies Press; 1988.
- Institute of Medicine. The future of the public’s health in the 21st
century. Washington (DC): National Academies Press; 2003.
- U.S. Department of Health and Human Services, Public Health Service.
Promoting health preventing disease: objectives for the nation.
Washington (DC): U.S. Department of Health and Human Services; 1980.
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- Stillman FA, Hartman AM, Graubard BI, Gilpin EA, Murray DM, Gibson JT.
Evaluation of the American Stop Smoking Intervention Study (ASSIST): a
report of outcomes. J Natl Cancer Inst
- Schwartz R, Smith C, Speers MA, Dusenbury LJ, Bright F, Hedlund S,
building and resource needs of state
health agencies to implement community-based cardiovascular disease
programs. J Public Health Policy 1993;14(4):480-94.
- Institute of Medicine. Linking research and practice: a review of CDC’s
program of centers for research and demonstration of health promotion and
disease prevention. Washington (DC): National Academy Press; 1997.
- Franks AL, Brownson RC, Bryant C, Brown KM, Hooker SP, Pluto DM, et al.
Prevention research centers: contributions to updating the public health
workforce through training. Prev Chronic Dis [serial online] 2005 Apr.
- Zasa S, Briss P, Harris KW.
The guide to community preventive services. What works to promote health?
New York (NY): Oxford University Press; 2004.
- Cancer Control PLANET [Internet]. Atlanta (GA): Centers for Disease
Control and Prevention. Available from: URL: http://cancercontrolplanet.cancer.gov/.
- Schwartz R, Capwell E. Advancing the link between health promotion
researchers and practitioners: a commentary. Health Education
Research, Theory and Practice 1995;10(3):i-vi.
- Gebbie KM, Rosenstock L, Hernandez LM. Who will keep the public
healthy? Educating public health professionals for the 21st
century. Washington (DC): National Academies Press; 2003
- Centers for Disease Control and Prevention. Framework for program
evaluation in public health. MMWR 1999;48(No. RR-11).
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