Perspectives in Disease Prevention and Health Promotion Prevention Policy Review Group Summary of Meeting -- March 27, 1986

A distinguished panel comprised of former Assistant Secretaries for Health and presidents of major national public health organizations was convened in March 1986 by the Public Health Service (PHS) to consider past, current, and future directions for PHS disease prevention and health promotion policies *. The panel was chaired by the Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion). Given federal health policy and initiatives as a reference, panel members were asked to assess approaches to preventing health problems facing the nation; to consider whether these problems deserved increased, continued, or lessened emphasis; to suggest ways in which existing resources could more effectively support disease prevention and health promotion measures; and to recommend a national approach to establishing health objectives for the year 2000.

Deliberations by the review panel yielded 10 critical themes for PHS prevention efforts through the remainder of the century. Rationales for inclusion of and direction for these individual themes are provided.

National Objectives. Refine and apply national objectives in disease prevention and health promotion. Rationale: The process of establishing and tracking measurable national objectives to be achieved by 1990 has not only helped to establish a national health agenda and identify explicit health priorities, but also has facilitated organized responses and has supported progress toward enhanced levels of health. The PHS should continue the leadership shown in the 1990 process and extend the effort to the year 2000. The objectives are important because they stimulate organized objective-setting at the state level and strengthen the interface between national, state, and local programs. The link between the objectives and "Model Standards: A Guide for Community Preventive Health Services" should be emphasized (1). Federal and state legislators as well as private and voluntary organizations should be involved in setting the health agenda. Setting objectives for the year 2000 should be a broad, grassroots effort that solicits extensive community-level involvement. The results should be widely publicized with a national conference.

Reimbursement. Facilitate broader reimbursement for preventive services delivered in clinical settings. Rationale: Given that physicians will continue to be the prominent deliverers of health care services, it is necessary to create incentives for physicians to deliver preventive services. The same can be said for other deliverers of clinically-based preventive services. Innovative approaches to financing preventive services, in the public and private sectors and for individuals and groups, need to be explored. Initiatives by private insurers for coverage of preventive services should be encouraged. Likewise, federal reimbursement programs should engage more directly in prevention, while taking account of the need for budget neutrality in tight fiscal times.

School Health. Foster a major national effort to enhance the quality and scope of school health programs. Rationale: It is clear that the health knowledge, attitudes, and practices developed during childhood become the basis for adult health practices and shape the prospects for health in later years. The school environment has significant impact on decisions of fundamental importance to life and health, such as the use of tobacco, alcohol, and drugs; sexual practices; and dietary and exercise habits. Where possible that environment ought to foster healthy practices. A major national study has recently confirmed that proper school health education efforts can change attitudes and behavior (2). Yet, survey evidence also indicates that school-based health initiatives are too few, too infrequent, and often misdirected (3). The PHS should work with state and local school leaders, teachers, and the U.S. Department of Education to foster health promotion and health education programs and sponsor demonstrations and pilot programs to apply and improve upon what is already known.

Marketing Strategies. Develop methods of effectively presenting health promotion information by using simple, clear messages with unifying and mutually reinforcing themes. Rationale: With more than half of all preventable deaths in the United States attributable to behavioral choices, an imperative for national health policy is the development of an effective means of motivating healthy choices related to smoking, alcohol and drug use, exercise, diet, safety, and the appropriate use of preventive services. The PHS should make full use of the potential of marketing techniques by developing media-oriented materials that bring together common themes and messages on health behavior, personal choice oppor- tunities for health, and actions that can improve health. Partnerships with private and voluntary organizations, states, and localities are critical to success.

Low Income Populations. Establish as a special priority a focus on the health promotion and disease prevention opportunities for low-income Americans. Rationale: While disease prevention and health promotion activities have already had a dramatic impact on the conditions of a substantial portion of our society, there is evidence that minorities are at higher risk for each of the major diseases and conditions confronting Americans. If minorities had the same life expectancy as whites, there would be 60,000 fewer deaths among minority Americans each year. Six causes of death account for more than 80% of the excess mortality in minority groups; they are cancer, cardiovascular diseases, infant mortality, cirrhosis, diabetes, and trauma. A substantial measure of these conditions can be prevented. The PHS and public health programs at the state and local levels bear special responsibility for leading in addressing the needs of these groups.

The Elderly. Establish as a special priority a focus on the health promotion and disease prevention opportunities for older Americans. Rationale: Over the course of this century, the share of the nation's population which is over age 65 will have increased from 4% in 1900 to 13% by the year 2000. The fact that more Americans reach older ages is largely attributable to successful disease prevention efforts. Yet improved health is possible even after age 65, and the health care system will be challenged to think of disease prevention along a much broader continuum than before. A person is never too old to benefit from appropriate exercise, cessation of smoking, or improved dietary habits; in addition, special measures are needed among the elderly to prevent injuries and problems from medications. The Healthy Older People Program of the PHS has taken an important step to extend prevention to older people (4,5). Such efforts need to be sustained, expanded, and augmented with a better-trained cadre of health professionals to deal with the problems of the elderly.

Capacity Building. Stimulate and support efforts, including training, to strengthen state and local capabilities in disease prevention and health promotion. Rationale: Capacity for carrying out effective disease prevention and health promotion programs at the state and local levels derives from organizing resources and accurate information around defined problems. The model standards for community preventive health services provide a standard by which localities can assess their health care system (1). Enhanced summarization, translation, and dissemination of current scientific information is necessary for more widespread implementation of effective state and local programs. The PHS can assist in this regard. Sponsoring continuing education workshops and training efforts can enhance the application of new intervention techniques in prevention.

Coalition Building. Support the development and strengthening of community-level coalitions for achieving disease prevention and health promotion. Rationale: The essential infrastructure for establishing effective long-term programs in disease prevention and health promotion is at the community level. To assure a commitment to such efforts, the support and involvement of community leaders must be recruited. Organized approaches to community-based disease prevention/health promotion will require significant coordination of resources and interests. The PHS should serve as a catalyst in these efforts, helping to put resources to use at the local level. The PHS should provide technical assistance and develop collaborative models for establishing local coalitions for health.

Economic Analyses. Undertake economic analyses that can support efforts to change reimbursement decisions and tax policies favorable to disease prevention and health promotion. Rationale: The use of tax policy and other economic means to create incentives for individuals, insti- tutions, insurers, and corporations to participate in health promotion and disease prevention efforts has not been explored widely enough. Healthy populations place less economic drain on a society's health budget and retain higher productivity potential. Promoting health through tax policy and economic incentives will require well-designed studies; significant collaboration between legislators and those who pay for health services; and a conviction that some reasonable risks should be taken, at least on a pilot basis. The PHS should develop approaches demonstrating how such incentives can be used to change health behaviors. The PHS should also develop analytic reviews of the relative merits of various interventions in improving the functional capacity of our society.

Transfer of Research Results. Foster the expeditious application of research findings -- particularly for applied research -- by strengthening mechanisms for systematically synthesizing, classifying, and translating research results in prevention. Rationale: It is research that has made possible the present achievements in health. Many more advances can be anticipated, and every day's delay in their application means lives lost unnecessarily. The PHS needs, therefore, not only to deepen its commitment to research in prevention, but to foster developing a means for speeding application of research results. Communication needs to be improved between the research community and practicing physicians, state and local public health officials, and officers of voluntary and professional organizations as well as with leaders in new avenues for disease prevention and health promotion, such as schools, worksites, and the media.

Reported by Office of Disease Prevention and Health Promotion, Public Health Service, DHHS.

Editorial Note

Editorial Note: The themes and points of deliberation arising out of this Prevention Policy Review Session represent the considered opinions of key leaders in the health field. They are personal opinions, but they form a critical portion of the public record on disease prevention/health promo- tion policy and will be relevant to continuing activities and deliberations around the 1990 Objectives for the Nation and ultimately the national health objectives established for the year 2000. Comments on the points arising out of this policy review session are welcome: Please send them to J. Michael McGinnis, M.D., Deputy Assistant Secretary for Health, Director, Office of Disease Prevention and Health Promotion, Switzer Building, Room 2132, 330 C Street, SW, Washington, DC 20201.

References

1. American Public Health Association. Association of State and Terri- torial Health Officials, National Association of County Health Officials, US Conference of Local Health Officers, CDC. Model standards: a guide for community preventive health services. Washington, DC: American Public Health Association,. 1985.

2. Connell DB, Turner RR, Mason EF. Summary of findings of school health education evaluation: health promotion effectiveness, implementation, and costs. J School Health 1985;55:316-21.

3. Basch CE. Research on the dissemination and implementation of health education in schools. J School Health 1984;54:57-66.

4. Gilbert SB, Wittenberg CK, Maloney SK. Health promotion for older Americans. Health Values 1986;10:38-46.

5. Jones PS. Healthy older people national campaign. Aging 1986;353:22-3.

Participating panel members. Former Assistant Secretaries for Health: Theodore Cooper, MD, PhD, Vice Chairman of the Board, Upjohn Company; Merlin K. DuVal, MD, President, American Healthcare Institute; Roger O. Egeberg, MD, Scholar, Institute of Medicine, National Academy of Sciences; Julius B. Richmond, MD, Director, Division of Health Policy Research and Education, Harvard University. Presidents of public health organizations: William Bridgers, MD, Dean, School of Public Health, University of Alabama/ Birmingham (Association of Schools of Public Health); Christopher M.G. Buttery, MD, MPH, State Health Commissioner, Virginia Department of Health (U.S. Conference of Local Health Officers); William H. Foege, MD, MPH, Executive Director, Carter Presidential Center at Emory University (American Public Health Association); Joel L. Nitzkin, MD, MPH, Director, Monroe County Department of Health, Rochester, New York (National Associ- ation of County Health Officials); Jay Noren, MD, Acting Vice Chancellor, University of Wisconsin (Association of Teachers of Preventive Medicine); Lloyd F. Novick, MD, MPH, Director, Center for Community Services, New York State Department of Health (Association of State and Territorial Health Officials); George E. Pickett, MD, Chairman, Department of Health Care Organization and Policy, Department of Public Health, University of Alabama/Birmingham (American College of Preventive Medicine).

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