North Carolina`s Prevention Action Plan: A Collaborative Approach to Improving Health
Pam Silberman, JD, DrPH President & CEO North Carolina Institute of Medicine Elizabeth Walker, MSPH Project Coordinator Cecil G. Sheps Center for Health Services Research University of North Carolina at Chapel Hill

North Carolina is ranked number 37 in the 2009 America`s Health RankingsTM, a position it has held for several years. This low ranking reflects poor indicators in a variety of public health measures, including obesity, smoking, child poverty and infant mortality. Concern among several foundations and state organizations about North Carolina`s poor indicators on measures of access to care, healthy lifestyle and health outcomes measures resulted in the establishment of the multi-stakeholder North Carolina Institute of Medicine Prevention Task Force.

The Task Force`s `Prevention Action Plan,` published in October 2009, establishes evidence-based strategies and interventions for improving the health of North Carolinians and lays the groundwork for implementing and tracking the results of these interventions.

The Action Plan relies on activities by many stakeholders - including individuals, health care providers, insurers, employers, schools, communities, industries, and other institutions - to establish and ensure the long-term health of North Carolina. The process of developing the Action Plan was similarly collaborative.

The Task Force was organized by the North Carolina Institute of Medicine, a quasi-state agency, in collaboration with the state Division of Public Health, at the request of four health foundations: the Blue Cross and Blue Shield of North Carolina Foundation, The Duke Endowment, The North Carolina Health and Wellness Trust Fund, and Kate B. Reynolds Charitable Trust. The process to secure funding for a Prevention Task Force began in 2007, with the Task Force meeting 14 times between April 2008 and August 2009.

The Task Force membership represented a cross section of health stakeholders in the state. The Task Force was chaired by Leah Devlin, DDS, MPH, former State Health Director; Jeffrey Engel, MD, State Health Director, Division of Public Health, North Carolina Department of Health and Human Services; William Roper, MD, MPH, CEO, University of North Carolina (UNC) Health Care System and Dean, UNC School of Medicine; Robert Seligson, MA, MBA, Executive Vice President and CEO, North Carolina Medical Society; and included 45 additional members from across health, insurance, education, business, community, and policy organizations in the state.

The task force used a four step process to develop its Action Plan:

• Identify the diseases and health conditions that had the greatest impact on death and disability.
• Identify the underlying preventable risk factors which contribute to the leading causes of death and disability.

  These factors are:

  1. Tobacco use
  2. Diet and physical inactivity, leading to overweight or obesity
  3. Risky sexual behaviors
  4. Alcohol and drug use or abuse
  5. Emotional and psychological factors
  6. Intentional and unintentional injuries
  7. Bacterial and infectious agents
  8. Exposure to chemicals and environmental pollutants
  9. Racial and ethnic disparities
  10. Socioeconomic factors

Identify evidence-based strategies that can prevent or reduce the risk factors. The Task Force identified evidence-based, best, or promising practices that can reduce risk behaviors and lead to better health outcomes. Budget constraints make it particularly important to limit new funding to evidence-based strategies, or when unavailable, best or promising practices.

Identify multi-level interventions based on a `socio-ecological` model of prevention. A person`s decision to engage in risky health behaviors is influenced by other factors, including the opinions of family and friends, clinical advice, community and environment, and public policies. Thus, the Task Force attempted to identify multifaceted strategies that would support healthy lives on many different levels of the socio-ecological model including the individual, interpersonal, clinical care, community and environment, and public policy levels.

The Action Plan outlines a series of recommendations corresponding with each of the ten preventable risk factors.
For example, the Task Force made four recommendations to address the risk factor of tobacco use: fund and implement a comprehensive tobacco control program; increase North Carolina tobacco taxes; expand smoke-free policies in North Carolina; and expand access to cessation services, counseling, and medications for smokers who want to quit.
The Action Plan also makes specific recommendations for different stakeholders to address the risk factor. For tobacco use, these include:

• Individual/Family - Be tobacco free
• Clinical - Offer comprehensive cessation services
• Schools - Actively enforce tobacco free school laws
• Worksites - Institute worksite wellness program; create smoke-free worksites; offer coverage for tobacco cessation services
• Insurers - Pay for smoking cessation services and medications
• Community - Expand smoke-free policies to public places; support social marketing campaigns
• Public Policies - Expand smoke-free policies to all workplaces and public places; increase the tobacco tax; fund comprehensive tobacco prevention program

Implementation of multifaceted evidence-based strategies such as those recommended in the Action Plan has already been successful in cutting rates of youth smoking in North Carolina. These strategies have included a combination of a social marketing campaign aimed at youth, 100% tobacco free schools and hospitals, North Carolina`s smoking cessation telephone hotline, and increased tobacco taxes.

Between 1995 and 2003, the adult smoking rate hovered at about 25%. Since implementing this multifaceted evidence-based strategy, the adult smoking rate decreased from24.8% (2003) to 20.9% (2008). Similarly, the youth smoking rate has declined. From 2003 to 2007, the high school use rate has declined from 27.3% to 19.0%, while the middle school use rate dropped from 9.3% to 4.5%.

The final Action Plan was released in October 2009 and is available at www.nciom.org, along with supporting materials. An interim report, published in March 2009, was used as support for public health measures passed by the North Carolina state legislature during its most recent session, including an increase in tobacco and alcohol taxes, a move towards comprehensive sex education, and more emphasis on substance abuse prevention.

The Prevention Task Force`s Action Plan provides the basis for a broader campaign to improve health in North Carolina. Several state institutions and offices are proposing to develop a statewide campaign to make North Carolina the healthiest state in the nation by 2020. North Carolina`s campaign is inspired in part by the success of Washington`s campaign to become the healthiest state in the nation. Washington`s program included a combination of policy work, programs, grantmaking, direct services, and media outreach. The state`s overall health ranking in America`s Health RankingsTM has improved from 15th in 2004, when the program was launched, to 11 in 2009.

The next step in North Carolina is the development of the `Healthy North Carolina 2020` goals and objectives, 10-year targets for promoting health modeled after the federal Health and Human Services `Healthy People 2020` initiative. The development of the 2020 objectives will build directly on the work of the Prevention Task Force and will allow measurement of progress towards meeting the Task Force`s goals.

One of the limitations of North Carolina's 2010 health objectives, developed in 2000, was that they did not serve as the central focus of a coordinated campaign to improve population health. Further, there was little follow-up in the intervening years to determine how much progress the state was making in meeting the 2010 objectives. In contrast, the Prevention Action Plan and the Healthy North Carolina 2020 objectives will be used to prioritize the work of state and local public health agencies and many of their partners in prevention efforts. The Division of Public Health has been fully engaged in the development of the Prevention Action Plan and will continue as a partner to develop the Healthy North Carolina 2020 objectives. In addition, the Division of Public Health will incorporate as many of the objectives as possible into the existing state data system and produce annual reports measuring progress towards the goals of improving population health at the state and (where possible) county levels. The Division of Public Health will also help develop an ongoing public and private partnership of state officials, academics and funders to identify resources that can be redirected to implement the evidence-based prevention strategies outlined in the Action Plan.

The most practical approach to address poor health outcomes and negative health behaviors is to prevent them from occurring in the first place. However, health care spending is drastically skewed toward paying for therapeutic procedures to manage or treat acute and chronic health problems, and not toward prevention. We need to reorient our health system, as well as our overall society, towards a prevention focus. This represents a fundamental paradigm shift involving all members of our society. Each of us has a personal responsibility to be active stewards of our own health, but health care providers, employers, schools, communities, businesses, and other institutions also play a critical role in ensuring the long-term health of our state. We must all invest in prevention before the burden on individuals, their families, employers, and the broader community becomes too great. North Carolina`s prevention activities will draw on the capabilities of all levels of the community in order to improve the health and well-being of North Carolinians in both the short and long-term.

Dr. Leah Devlin served as one of the co-chairs for the Task Force from the inception of the work until she retired as State Health Director. At that time, Dr. Jeffrey Engel became one of the co-chairs. Dr. Devlin remained as a member of the Task Force.
Tobacco Prevention and Control Branch, Division of Public Health, North Carolina Department of Health and Human Services. Youth Tobacco Survey. 2003-2007. http://www.tobaccopreventionandcontrol.ncdhhs.gov. Published September 2, 2009. Accessed September 21, 2009. North Carolina State Center for Health Statistics. Behavioral Risk Factor Surveillance System. 2000-2008. http://www.schs.state.nc.us/SCHS/data/brfss.cfm. Published June 22, 2009. Accessed September 21, 2009.