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Infrastructure To Support Heart Disease and Stroke Prevention Programs
Program Management and Administration
A strong system of management, staff, and support are necessary to effectively address CVH. A heart disease and stroke prevention program in a health department should have staff who are able to
- Provide leadership for overall program development, program coordination,
and implementation.
- Use a variety of data to assess the burden of CVD, CVD-related disability, and risk factors, and interpret data for program planning.
- Frame public health issues for policy makers and apply policy and environmental strategies to improve CVH.
- Develop and maintain partnerships.
- Carry out health communications, health education, training, advocacy, and
media activities.
- Provide appropriate support to community-based intervention programs in a variety of settings and work with diverse populations.
- Develop and analyze health policy.
- Provide policy and administrative support for CVH program activities.
- Ensure that programs are implemented with integrity and evaluated for effectiveness.
Qualified personnel at the state, regional, and local levels are critical to implementing and managing a comprehensive heart disease and stroke prevention program.
State agency management should encourage collaboration between the state heart disease and stroke prevention program and related programs such as coordinated school health, diabetes, tobacco control, physical activity, and nutrition.
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Surveillance and Evaluation
The burden of CVD should be well defined. To assess that burden, the health department needs capacity in the areas of chronic disease epidemiology, statistics, surveillance, data analysis, and the application of data in program planning and priority setting. Staff should be able to use data to support allocating resources to CVH prevention.
Staff should have access to data systems such as vital statistics, the Behavioral Risk Factor Surveillance System (BRFSS), the Youth Risk Behavior Survey, hospital discharge data, HEDIS, Medicaid and Medicare data, and other data sources that are useful for defining the burden of CVD in the state. In addition, heart disease and stroke prevention program staff should be able to use data from geographic information systems to document the distribution of CVD, delineate disparities, and specify the needs of priority populations. (Geographical data by state and county are available on CDC’s Heart Disease and Stroke Prevention Program Web site: www.cdc.gov/cvh.)
The BRFSS modules on hypertension awareness, cholesterol awareness, cardiovascular disease, and heart attack and stroke signs and symptoms should be part of the state BRFSS survey; optional modules and state-added questions should be used to help the state program track trends in CVD and related risk factors. The state BRFSS sample size should be large enough to gather statistically adequate responses for priority populations, including racial and ethnic groups. States should consider surveillance questions as a means for gathering community- and regional-level data for targeted interventions.
Communication strategies should be based on state and local data so that partners and the public understand CVD’s relevance to, and impact on, both their personal health and the health of the people in their communities. A published document defining the burden of CVD in the state should communicate data in ways that are appropriate for different audiences, including community groups, state leaders, and decision makers. It should describe the burden of CVD (primarily heart disease and stroke) and related risk factors and conditions (e.g., high blood pressure, high cholesterol, tobacco use, physical inactivity, poor nutrition, diabetes). The document should describe the geographic and demographic distribution of CVD, highlighting disparities in CVD burden based on geography, sex, socioeconomic status, and race and ethnicity. It should also identify trends in CVD, including changes in numbers of deaths, average age at onset of disease, and average age at death.
This burden document should be used as a tool to increase public awareness
of CVD as a public health priority, to mobilize partners to address
CVD in a comprehensive manner, and to support the commitment of
resources to promoting CVH. Data can be presented to staff, partners,
community groups, policy makers, and decision makers to enhance
their understanding of how to use data for program planning. The
data should provide a basis for developing the CVH state plan and
for identifying priority populations and strategies.
Program evaluation is essential for planning pro-grams and building the scientific capacity of state health departments. Heart disease and stroke prevention program staff should have a good understanding of methodologies to evaluate process and outcome and should develop and implement an evaluation plan. Heart disease and stroke prevention programs should be able to validate and demonstrate the existence of “core capacities,” which include committed partnerships; surveillance, assessment, and evaluation functions; the ability to document the burden of CVD; the ability to develop a comprehensive CVH state plan; training and technical assistance capabilities; and the ability to identify or devise population-based intervention strategies that are culturally competent and address priority populations. Without this basic infrastructure in place, CVH activities may be scattered and lack focus and thus have a limited impact on the cardiovascular health of state residents.
State Examples:
- The Mississippi CVH Program collaborated with its AHA state affiliate to produce the 2000 Mississippi State of the Heart Report and the 2000 Mississippi Stroke Report. These documents contain data on CVD-related illness, death, and risk factors. Data include county-specific mortality rates depicted in county maps, which have a visual impact for local legislators. Strategies to reduce risk behaviors also are listed in the reports. The reports have been shared with members of the Mississippi Chronic Illness Coalition to increase their awareness of the burden of these diseases, provided to legislative study committees to enhance their understanding of the need for policy and environmental supports to reduce CVD, and used by public health staff to guide program planning.
Program contact: Wanda Magers, Cardiovascular Health Program, Mississippi State Department of Health.
- The West Virginia CVH Program produced a burden report in 2001 that includes data on mortality rates, behavioral risk factors, cost, and access to medical care. The report also describes CVH program goals and activities to eliminate health disparities. In March 2002, this report was placed on the West Virginia Department of Health and Human Resources, Bureau of Public Health Web site, where West Virginia risk factor data could be compared with national risk factor data. The report was used to establish the CVH Program’s priorities, track changes in data trends, and help the state coalitions implement strategies to achieve CVH goals.
Program contact: Amy Carte, Cardiovascular Health Program, West Virginia Bureau for Public Health.
- The Oregon CVH Program compared the prevalence of major CVD risk factors,
including hypertension and high cholesterol levels, among Medicaid-eligible
residents with their prevalence among the general population and
evaluated associations between these risk factors and Medicaid
claims for CVD hospitalization. It found that CVD risk factors
are more common among Oregon’s Medicaid populations than
among the general population and are associated with CVD hospitalizations
among the former group. The CVH Program is using this information
to identify priority populations and to help set program priorities.
Program contact: Laura Chenet Leonard, Cardiovascular Health Program, Oregon Department of Human Services.
- The New York Healthy Heart Program has developed a reporting system to monitor policy and environmental changes occurring in work sites so that it can evaluate the outcomes of its work site interventions. It is evaluating the Heart Check tool to determine whether the number of questions for the work site assessment can be reduced, thereby increasing ease of use. Pre- and post-Heart Check scores have increased an average of 75%, with improvements in nutrition, physical activity, and administrative support.
Program contact: Margaret O. Casey, Healthy Heart Program, New York State Department of Health.
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Partnerships
The multifaceted nature of opportunities for promoting CVH and preventing CVD requires the cooperation and collaboration of many partners in public and private sectors. A key task for partners is to develop a comprehensive CVH state plan and ensure that it is implemented. The involvement of partners should promote the coordination of activities to avoid duplication of effort and to share responsibility for improving CVH. The state heart disease and stroke prevention program should secure the involvement of diverse partners and provide leadership.
The heart disease and stroke prevention program should partner internally with health department programs that address the following:
- CVD-related risk factors, such as high blood pressure, high cholesterol, tobacco use, physical inactivity, and poor nutrition.
- Related areas, such as diabetes and school health.
- Data (e.g., vital statistics, the state’s BRFSS).
The heart disease and stroke prevention program should also form external partnerships with the following types of organizations:
- State agencies that address CVD risk factors, such as the departments of education, public safety, and emergency medical services.
- Organizations whose missions are associated with promoting heart health and reducing heart disease and stroke, such as the AHA.
- Other professional and voluntary organizations interested in improving health and quality of life and eliminating disparities in CVD burden, such as quality improvement organizations, minority health organizations, health care organizations, media, community-based organizations, academic institutions, and businesses.
In addition, the health department should collaborate with academic institutions and Prevention Research Centers (see www.cdc.gov/prc) to conduct research to improve programs and policies for CVH promotion and CVD prevention; to translate knowledge from social, behavioral, and medical sciences into sound public health practice; and to ensure that program interventions and evaluations are well grounded in science.
State Examples:
- The Virginia CVH Program coordinates strategic partnerships through
the Healthy Pathways Coalition. The coalition is charged with
comprehensively addressing primary and secondary prevention of
CVD and promoting CVH. Partners represent private and governmental
state-level organizations, including those representing priority
populations. The CVH Program has developed a logic model that
clarifies relationships among partners, sectors, and program activities.
The logic model is being used to guide the coalition’s strategic
planning and will be in the resulting Call to Action document.
Program contact: Jody Stones, Cardiovascular Health Program, Virginia Department of Health.
- The Utah CVH Program’s key state partners form
the Alliance for Cardiovascular Health in Utah. The alliance comprises
more than 140 organizations representing government, private businesses,
health care organizations, and nonprofit agencies. The alliance
has developed a 3-year CVH plan (Uniting Partners for a Legacy
of Health), which is designed to coordinate efforts among organizations
and identify key strategies, with an emphasis on policy and environmental
supports.
Program contact: Joan Ware, Cardiovascular Health Program, Utah Department of Health.
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Strategic Plans
Heart disease and stroke prevention programs need a comprehensive plan that identifies their priorities and focuses the efforts of their many partners. The heart disease and stroke prevention program and its diverse partners should develop and regularly update this plan, which should present strategic objectives that require leadership, ownership, coordination, and commitment of resources by both public- and private-sector partners. It should be a heart disease and stroke prevention program plan and not a health department plan. The strategic objectives should include population-specific strategies that address the needs of priority populations and should emphasize policy and environmental approaches, systems changes, and educational interventions that increase support for heart-healthy choices and provide a context for more effective CVD prevention.
The CVH plan should be based on data, including the burden of CVD in the state
and the results of an assessment of policies and legislation that
influence heart health. It should also be based on an assessment
of regulations, policies, and environmental barriers in work sites,
health care settings, schools, and communities. The results of such
an assessment will help program planners identify systems change
interventions that may be needed to achieve the objectives of the
CVH plan.
The CVH plan may be a stand-alone plan or an identifiable section within another state plan, such as a larger chronic disease plan. In either case, it should provide guidance for a comprehensive state heart disease and stroke program. The CVH plan may be packaged in a variety of formats (e.g., executive summary, monograph, visual presentation) for different audiences (e.g., decision makers, public health planners, the health care community, minority health organizations, the general public).
Although developing and updating a comprehensive CVH plan requires a major commitment of time and staff, such a plan can play a critical role in attaining the heart disease and stroke objectives.
State Examples:
- The North Carolina Plan to Prevent Heart Disease and Stroke 1999–2003
provides a comprehensive vision that builds upon existing services
and promotes new strategies for preventing CVD. The plan is based
on the socioecological prevention model, which has been proven
effective for creating environmental and policy change in multiple
levels of society. The plan guides state and local interventions
by providing strategies for prevent-ing CVD risk factors, managing
CVD, raising public awareness, and developing supportive policies.
The plan’s strategies are designed to be implemented in collaboration
with partners from private and governmental sectors. It will be
up-dated in 2003.
Program contact: Libby Puckett, Cardiovascular Health Program, North Carolina Division of Public Health/DHHS.
- The Alabama Cardiovascular State Health Plan contains
recommendations for changing policies, health systems, community
settings, and environmental factors that influence CVH. The plan
is designed to help policy makers, public health personnel, health
care providers, schools, communities, and voluntary organizations
develop coordinated approaches to CVD prevention. The plan is
organized around three major goals: increasing awareness of CVD
and how various sectors (e.g., health care providers and payers,
schools, communities) can promote CVH; minimizing CVD risk factors
through supportive environments; and promoting the use of recommended
treatment guidelines by health care providers and facilitating
state residents’ access to and use of early detection and
treatment options for CVD.
Program contact: Janice Cook, Cardiovascular Health Program, Alabama Department of Public Health.
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Policies
To identify priority policy areas for intervention, the state heart disease and stroke prevention program should assess existing policy and environmental supports. The assessment should also identify elements of the physical and social environments that can be modified to improve CVH-related behaviors.
The assessment should address the needs of priority populations and should focus on health promotion and primary and secondary prevention of CVD and related risk factors, including high cholesterol, high blood pressure, tobacco use, physical inactivity, and poor nutrition. The assessment should identify policies at the state level that could affect
communities, such as state legislation that may affect CVH-related policies in schools or agency policies that may affect the implementation of nationally accredited guidelines for primary and secondary prevention of CVD in health care settings.
Although the assessment should initially identify state-level policies and environmental supports, additional assessments should eventually be conducted to identify policies in health care sites, work sites, schools, and communities. As a planning tool, the assessment does not need to be performed statewide for each setting, but the geographical area selected should be justified and should help the state meet the objectives of its CVH plan.
State Examples:
- The Oklahoma Cardiovascular Health Program assessed policies
guiding stroke response and care and is working with local health
departments and hospitals to develop stroke protocols. The protocols
will guide emergency medical personnel and other hospital personnel
in providing comprehensive, appropriate care for stroke patients
from the initial call for emergency services through rehabilitation.
The CVH Program is collaborating with the AHA Oklahoma affiliate;
Oklahoma Foundation for Medical Quality; Oklahoma Hospital Association;
and local hospital physicians, stroke coordinators, and emergency
medical service units. Although modified to meet Oklahoma’s
needs, the protocols are based on those developed by the AHA and
the National Stroke Association.
Program contact: Adeline Yerkes, Chief, Chronic Disease Service, Oklahoma State Department of Health.
- The Healthy Maine Partnership is a collaborative effort of the Maine Cardiovascular Health Program, the Community Health Program, Partnership for a Tobacco-Free Maine, and the Coordinated School Health Program. The Healthy Maine Partnership is working with 31 local communities and 54 school administrative units to assess local and school policies supporting cardiovascular health, such as tobacco-use policies in public places and nutrition guidelines in schools. The Maine Cardiovascular Health Program will use the assessment results to identify supportive policies and key partners for future policy development.
Program contact: Debra Wigand, Maine Cardiovascular Health Program, Department of Human Services.
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Health Communications
Heart disease and stroke prevention programs and their partners should have the capacity to effectively plan, implement, and evaluate communications and education strategies that support policy and environmental changes for CVH. Recognizing the need for a tool that incorporates the most effective communication models and strategies for change, CDC has developed a tailored edition of CDCynergy for CVH. The CVH edition has the same features and format as CDCynergy 2001 Basic but includes CVH case examples and resources. In addition to providing training on specific communications topics such as media and policy advocacy and product development, the tool will help users strategically convey information in ways that advance the overall program goal of making states heart healthy and stroke free.
Communications plans created by heart disease and stroke prevention programs
using CDCynergy 2001 should be based on data from state surveys
and burden documents, CVH state plans, and policy inventories. The
communications plan should involve partners and their communications
resources and should consider multiple and innovative channels to
convey key messages, including conferences, workshops, and seminars
for select audiences; media outreach; and personal contact with
policy and decision makers in health care, workplace, school, and
community settings.
State Examples:
- The West Virginia CVH Program’s partnership with St. Mary’s
Hospital, Genesis Hospital System, led to the development of a
social marketing campaign to educate residents of Lincoln County
about the symptoms of heart attacks. CDCynergy was used to plan
the campaign, and data from BRFSS, household surveys, Prizm national
consumer surveys, and hospitals were used to select the target
county and develop media messages. Four radio spots and print
ads were developed, and a pretest telephone survey was conducted
in February 2001. The media campaign was launched in May 2001.
It promoted awareness of the symptoms of a heart attack, the importance
of immediate medical care, and healthy choices for daily living.
The posttest telephone survey was conducted in December 2001 and
showed an increased public interest (from 68% in the pretest to
84% in the posttest) in learning more about heart attack and stroke
symptoms. Approximately 40% of those surveyed noticed the public
service announcements (PSAs) regarding heart attack and stroke.
Perceptions regarding stroke and heart attack symptoms closely
mirror the results of the pretest survey. Further review of the
evaluation results is planned.
Program contact: Amy Carte, Cardiovascular Health Program, West Virginia Bureau for Public Health.
- The Georgia CVH Program has four main components in its communications plan: media advocacy, public relations, advertising, and social marketing. Its major social marketing campaign, “Take Charge of Your Health,” is coordinated through the Georgia Coalition for Physical Activity and Nutrition (GPAN). The campaign goal is to communicate three simple messages: Take Action (walk, dance, play), Take 5-A-Day (fruits and vegetables), and Take Down Fat (choices, portions, and preparation). Media for conveying these three messages statewide include billboards, radio PSAs, and educational programs in schools for youth and in community settings for all age groups. Campaign evaluation and communications training for GPAN members and district chronic disease coordinators are under way.
Program contact: Pamela Wilson, Cardiovascular Health Program, Division of Public Health, Georgia Department of Human Resources.
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Professional Development, Training, and Technical Assistance
Heart disease and stroke prevention programs should identify ways to meet the training needs of their staff, partners, and others. Training and technical assistance should be provided to help state and local health department staff and partners acquire the skills needed to support the development and implementation of the CVH plan. This training may include areas such as population-based interventions, policy and environmental strategies, cardiovascular diseases and related risk factors, primary and secondary prevention strategies, health communications, cultural competency, epidemiology and use of data in program planning, media relations, strategic planning, program management, and evaluation. The program might also provide technical assistance on implementing programs in health care sites, work sites, schools, and communities.
CVH-related training needs should be assessed to ensure that ongoing training and skill building are available for health department staff, their CVH partners, health care and human service providers, and priority populations. States also might assist or collaborate with partners (e.g., AHA, managed care organizations, academic institutions) to provide professional and public education. Programs need to look for imaginative ways to provide training and skill building, including the use of technology and Web-casting. Programs should encourage staff to participate in national and regional training programs and conferences and then disseminate what they learn statewide.
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Supporting Evidence and Consensus Documents
In the 1980s, large community demonstration projects that tested multiple intervention approaches for improving CVH were conducted in Finland and the United States. Many of the core capacities needed for state heart disease and stroke prevention programs are based on lessons learned from these projects.9
Results from these community projects suggested that states can play critical roles in activities such as strategic planning, working with other stakeholders, ensuring that projects are data-driven, supporting community participation, and providing guidance for quality assurance and intervention approaches. Project evaluators found that “interventions that simultaneously target the community environment as well as organizations, groups, and individuals tend to influence the public’s health far more than interventions at any one of these levels alone.”9
Results from these projects also indicated that policy and environmental interventions were often more effective than direct behavior-change strategies. Social marketing techniques were used to create awareness of CVH issues and to create demand for services, access to primary and secondary prevention, and support for public policy and environmental change.
In addition to the lessons learned from these studies, programs also should use the following resources when developing their own comprehensive state heart disease and stroke prevention programs:
- Preventing Death and Disability from Cardiovascular Diseases: A State-Based Plan for Action. CVD Plan Steering Committee, Association of State and Territorial Health Officials, 1994.
- Publications of the Advisory Board of the International Heart Health Conferences, including The Victoria Declaration on Heart Health (1992), The Catalonia Declaration—Investing in Heart Health (1996), Worldwide Efforts to Improve Heart Health: A Follow-Up to the Catalonia Declaration—Selected Program Descriptions (1997), and The Singapore Declaration: Forging the Will for Heart Health in the Next Millennium (1998).
- Evaluating Community Efforts to Prevent Cardiovascular Diseases: Community Changes. Department of Health and Human Services, CDC, 1995.
- North Carolina Plan to Prevent Heart Disease and Stroke 1999–2003. North Carolina Heart Disease and Stroke Prevention Task Force, 1999.
- Policy as intervention: environmental and policy approaches to the prevention of cardiovascular disease. Am J Public Health 1995;85:1207-11.
- Community heart health programs: components, rationale, and strategies for effective interventions. J Public Health Policy 1993;14(4):463-79.
- Three articles in Health Education Quarterly in 1995 (volume 22, number 4): “Environmental and policy approaches to cardiovascular disease prevention through nutrition: opportunities for state and local action;” “Environmental and policy approaches to cardiovascular disease prevention through physical activity: issues and opportunities;” and “Environmental and policy interventions to control tobacco use and prevent cardiovascular disease."
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