Expert answer:SA Unit 1 Introductions
Answer & Explanation:*** I forgot to send you this one since the beginning, I need it ASAP. Sorry and thanks!!Topic 1: IntroductionsRead:Fielding, J. E., Teutsch, S., & Koh, H. (2012).HealthReformHealthyPeopleInitiative.pdf American Journal of Public Health, 102(1), 30–33.1. Answer these questions.What is your personal definition of health promotion?How do you view role of government in health promotion?How do you view the nurse’s role in health promotion?at least 250 words and 3 in-text citations/references. Thanks!
healthreformhealthypeopleinitiative.pdf
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COMMENTARIES
Health Reform and Healthy People Initiative
The passage of the
Affordable Care Act builds
on and strengthens the
foundation for prevention
and wellness that Healthy
People—the nation’s health
promotion and disease prevention aspirations for
a healthier nation—established. The Affordable Care
Act reaffirms the themes of
Healthy People by promoting population-based prevention and sets the stage
for Healthy People 2020.
The heart of Healthy People 2010 lies in its leading
health indicators, reflecting
high-priority health issues
for the nation. National progress requires broad application of the ecological health
model.
We reviewed the status of
each Healthy People 2010
indicator and noted how the
Affordable Care Act drives
future positive health outcomes using the ecological
model of health as a prism
for viewing health improvement. (Am J Public Health.
2 0 1 2 ; 102:30–33. doi:10.
2105/AJPH.2011.300312)
Jonathan E. Fielding, MD, MPH, Steven Teutsch, MD, MPH, and Howard Koh, MD, MPH
THE PASSAGE OF THE
Affordable Care Act (ACA), the
historic health reform legislation
signed into law in 2010, promotes
access to care and strengthens
consumer protections. But by supporting the integration of clinical
medicine with population-based
prevention, the ACA also builds on
and strengthens the foundation for
prevention and wellness established by Healthy People, the nation’s health promotion and disease
prevention aspirations for a healthier nation.1—3
Healthy People sets goals for
a robust and efficient health care
system, facilitates healthy behaviors, and strives for healthy communities, families, homes, and
worksites.4 Moreover, it concretely applies the ecological
model of health (Figure 1), placing
the individual biology of disease
within the context of the entire life
course as well as the social and
physical environments where
people live, work, learn, and play.
In this way, Healthy People captures the critical and modifiable
determinants of health that most
affect length and quality of life.
The heart of Healthy People 2010
(HP2010) lies in its leading health
indicators––reflecting high-priority
health issues for the nation. National progress on each indicator
requires broad application of the
ecological model of health.
HOW AFFORDABLE CARE
ACT ALIGNS WITH
HEALTHY PEOPLE
The ACA reaffirms the themes
of Healthy People by promoting
population-based prevention in
several ways. First, as of September
30 | Commentaries | Peer Reviewed | Fielding et al.
2010, all new group plans and
insurance policies must cover, at
no cost to patients, effective clinical preventive services recommended by the US Preventive
Services Task Force, the Advisory
Committee on Immunization Practices, and the Health Resources and
Services Administration. Second,
the ACA creates a National Prevention, Health Promotion, and Public
Health Council that will help formulate a National Prevention Strategy. The strategy will recognize and
incorporate the ecological model of
health that underscores the importance of various health influences
such as access to healthy foods,
prevention of violence, access to
quality education, and employment.
Third, the ACA establishes
a Prevention and Public Health
Fund that will provide $15 billion
in new funding over the next 10
years to expand and sustain the
necessary infrastructure to prevent
disease; detect it early; and, in
concert with other provisions in the
ACA, manage conditions before
they become severe. Finally, the
ACA authorizes investment in
a host of other programs, including
the National Health Service Corps
and community health centers that
will strengthen the public health
infrastructure for the future.
In these ways, the ACA also sets
the stage for Healthy People 2020
(HP2020), released in December
2010, which sets the national
health objectives for the decade5
and the new HP2020 goals. These
include creating social and physical environments that promote
good health as well as promoting
quality of life, healthy development,
health equity, and healthy behaviors across life stages. The new
iteration builds on the evolving
evidence base of public health
provided by the Guide to Community Preventive Services,6 its
companion Clinical Guide,7 and
related activities. Taken together,
these offer a systematic framework for assessing the effectiveness of population health initiatives and clinical services. The
evidence base is also bolstered by
the emergence of health impact
assessment and forecasting as
tools to provide the best available
information on effectiveness and
magnitude of impact.8—10
We reviewed the status of each
HP2010 indicator as of 200811
(the HP2020 leading health indicators were released October 31,
2011) and noted how the ACA
drives future positive health outcomes using the ecological model
of health as a prism for viewing
health improvement.
Physical Activity
In recent decades, Americans
have reduced physical activity in
their daily lives, increasing the
risk of cardiovascular disease and
some cancers. Healthy People data
show that the proportion of people
older than 18 years who engage in
moderate (30 minutes/day moderate intensity) or vigorous ( > 20
minutes at least three times/week of
vigorous intensity) physical activity
has remained stagnant for the past
decade. In 2008 it was 32%, far
below the HP2010 goal of 50%.
The Guide to Community Preventive Services recommends
making physical activity the easy
choice by reengineering our communities with accessible parks and
recreation; encouraging the social
norm of walking, bicycling, and
American Journal of Public Health | January 2012, Vol 102, No. 1
COMMENTARIES
Services Administration; in this
effort, multisectoral partners will
engage states and local communities in linking public health and
primary care to prevent and treat
obesity in children and families.
Tobacco Use
Source. Reproduced from the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase
I report recommendations for the framework and format of Healthy People 2020; 2008 (http://healthypeople.gov/hp2020/advisory/PhaseI/
PhaseI.pdf).
FIGURE 1—Ecological model of determinants of health from Healthy People 2020, 2008.
climbing stairs where these activities can reasonably substitute for
driving and riding elevators or
escalators; and placing greater
emphasis on mass transit and
mixed residential and commercial
development12 to encourage
greater spatial integration of places where people live, work, and
shop. The ACA-authorized Community Transformation Grants
will build on community-based
prevention grants funded by the
Recovery Act to enable multisectoral ways to promote physical
activity and other health outcomes
through a ‘‘health in all policies’’
approach, including education,
planning, and transportation.
Overweight and Obesity
With one third of adults obese,
the initial HP2010 objective of
15% remains a distant target.
Among the important strategies
for reversing the trend are policies
to improve (1) access to healthy
foods in schools, worksites, and
communities; (2) more responsible
marketing of processed foods high
in fat, salt, and sugar, especially to
children; and (3) educational initiatives that complement efforts to
increase physical activity.13—15
The ACA supports reducing
overweight and obesity in several
ways. For example, the Food and
Drug Administration is charged
with implementing new federal
requirements for nutrition labeling of foods sold at certain chain
restaurants and similar retail food
establishments. Menu labeling will
raise awareness of the caloric load
in foods and, in conjunction with
other initiatives, has the potential to
reduce intake as much as 10%.16
One health impact assessment of
January 2012, Vol 102, No. 1 | American Journal of Public Health
this strategy estimated that caloric
information on the menus and
menu boards at fast food restaurants could substantially reduce
weight gain in adults and children
older than five years.17
To encourage employers to address overweight and obesity, authorized provisions in the ACA
include expanding the premium
discount that employers can offer
as financial incentive to induce
participation in weight control
programs, providing employers
with technical assistance and best
practices, and establishing grants
to small employers that wish to
begin offering comprehensive
worksite wellness programs. In
addition, the ACA supports the
creation of a Healthy Weight Collaborative administered by the
Department of Health and Human
Services’ Health Resources and
Despite some progress in reducing tobacco use, smoking rates
have stalled and remain unsatisfactorily high (20% among adolescents and 21% in adults compared with Healthy People targets
of 16% and 12%, respectively).11
The ACA directly addresses this
issue through numerous health
system and broader public health
reforms. For example, clinician
interventions should be enhanced
through the ACA by removing
financial barriers to accessing cessation services and creating medical homes and primary care systems that can ensure appropriate
counseling, cessation treatments,
and follow-up. In 2010, the Prevention and Public Health Fund
awarded $15 million to states and
communities to stimulate the delivery of evidence-based tobacco
control programs and policies.
These included community prevention activities that support
telephone-based tobacco cessation
services, outreach programs targeting vulnerable populations, and
antitobacco media campaigns
showing the negative health consequences of tobacco use.
Substance Abuse and
Mental Health
Alcohol abuse and substance
abuse remain major problems and
require a multipronged approach.
Twenty percent of adolescents
aged 12 to 17 years used alcohol in
the preceding month in 2008
(HP2010 target 9%), almost one
quarter of adults binge drank over
the same period (HP2010 target
13.4%), and 8.1% of adults used
Fielding et al. | Peer Reviewed | Commentaries | 31
COMMENTARIES
illicit drugs (HP2010 target 3.2%).11
Screening for alcohol use in primary
care should be enhanced by the
ACA’s strengthening the primary
care system and its assurance of
first-dollar coverage for clinical preventive services for new plans.
Similarly, depression, the leading cause of disability, accounts for
two thirds of suicides.18 The ACA
builds on previous laws requiring
parity of coverage for mental
health treatment, which should
bring the country toward the
modest Healthy People target of
50% of mental health and substance abuse patients receiving
treatment. These measures can be
augmented through the minimum
benefits package to be made
available through health insurance
exchanges in 2014, which could
ensure that essential mental health
and substance abuse services are
available to lower income populations through Medicaid and subsidized private insurance. The
formal establishment of the Community Preventive Services Task
Force in the ACA will enhance
systematic approaches to prevent
substance abuse and provide
timely treatment. In 2010, funds
from the Prevention and Public
Health Fund were also dedicated
to the integration of behavioral
health into primary care settings to
help prevent and reduce chronic
disease and promote wellness by
meeting the full range of patient
health care needs.
Responsible Sexual Behavior
Ongoing challenges exist with
the rising rates of sexually
transmitted diseases and teen
pregnancy. Nearly one in four
women aged 14 to 19 years in the
United States acquires at least
one sexually transmitted infection.19 Rates of chlamydia infection continue to climb and, as
with most sexually transmitted
diseases, disproportionately affect non-White populations. The
encouraging 34% decrease in
teen pregnancies (from 1991 to
2005) halted in 2006, followed
by a 5% increase over the next
two years.20
The Community Guide recommends evidence-based sex education programs because they
enhance positive youth development, reduce risk behaviors, increase use of barrier protection,
and reduce sexually transmitted
infection.21 Increased access to
care and creation of medical
homes under the ACA will provide greater opportunities for
counseling and screening, including first-dollar coverage for US
Preventive Services Task Force–recommended sexually transmitted infection screening tests in all
new health insurance policies.
These efforts should diminish
transmission and reduce sequelae
of untreated infections, such as
pelvic inflammatory disease and
infertility.22
Injury and Violence
Unintentional injuries continue
to be the leading cause of death for
people aged one to 44 years, and
suicide and homicide are the next
two leading causes for the 15- to
34-year age group.23 Rates of
motor vehicle crash deaths (14.4/
100 000 in 2006) have declined
modestly, whereas rates of homicides (6.2/100 000) have been
stubbornly stable.11 Both rates are
virtually double their HP2010
targets of 8.0 and 2.8, respectively. Such violent deaths, a major
cause of disparities in life expectancy, reflect the challenges of
ensuring supportive communities
and families, safety, educational
and income opportunities, and
a healthful built environment.
The National Prevention,
Health Promotion, and Public
32 | Commentaries | Peer Reviewed | Fielding et al.
Health Council created under the
ACA will begin to address these
multisector problems through
a social determinants of health
approach. Specifically, the federal
government can partner more
closely with a diverse group of
stakeholders (including state,
tribal, and local governments; private industry; and faith communities) to prevent injury within
worksites, homes, neighborhoods,
schools, and other settings.
Environmental Quality
Poor air quality, a focus of the
leading health indicators, results
in more than 60 000 premature
deaths a year as the result of
particulate matter smaller than 2.5
micrometers alone.24 Current
ozone exposure (36% of Americans in 2009), an important component of air pollution, exceeds
the HP2010 target (0%).11 Over
the past decade, the importance of
the built and natural environments to our health has become
increasingly apparent. From climate change to our transportation
systems and the design of our
communities and homes, the
physical environment is a major
determinant of our health. Our
automobile-dependent transportation system, for example, not only
generates pollutants but also reduces our physical activity.
The National Health Promotion
and Prevention Council has an
opportunity to increase attention
to our physical environment, a
key determinant of health. Along
with the US Department of Health
and Human Services, the Environmental Protection Agency has
long focused on health consequences of environmental exposures. The council, however, can
look more broadly at the consequences of our transportation systems, agricultural policies, and community design and development,
prompting a focus on health in all
policies. Such a multisectoral discussion could, for example, highlight
the advantages of increased investment in mass transit and in making
communities more walkable and
bikeable. The ACA also addresses
these issues through the Community
Transformation Grants.
Immunization
Although in the United States
many of the vaccine-preventable
diseases of childhood have almost
disappeared and 70.5% of children younger than 3 years were
fully vaccinated in 2009 (short of
the 80% target), risks continue.25
Many highly effective adult vaccinations remain significantly underutilized. Only 60% of adults
older than 65 years have had
pneumococcal vaccine and 67%
an annual influenza vaccine, far
below the HP2010 targets of
90%.11 The ACA will ensure
first-dollar cost coverage for immunizations recommended by the
Advisory Committee on Immunization Practices for those in private insurance plans, reducing the
financial barrier to immunization.
In addition, electronic health records can bolster decision support
to ensure adults and children are
immunized in a timely fashion.26
Access to Health Care
In 2008, 83% of Americans
younger than 65 years were covered by insurance, compared with
the HP2010 target of 100%.11
One of health reform’s major objectives has been to provide insurance and access to primary
care for all Americans. Because of
the ACA, 32 million Americans
will have access to quality, affordable health insurance coverage.
In recognition of the need to
strengthen the primary care system, $250 million of the new
Prevention Fund in the ACA was
American Journal of Public Health | January 2012, Vol 102, No. 1
COMMENTARIES
used to bolster the primary care
workforce in fiscal year 2010. In
addition, the ACA includes $11
billion in funding over the next
five years for the expansion, creation, and support of community
health centers making affordable,
high-quality primary care services
available to nearly 40 million
people regardless of their insurance status or ability to pay.27
Increased access to and use of
primary care and clinical preventive services are essential to reduce breast and colorectal cancer
mortality and control blood pressure and dyslipidemia.
HEALTHY PEOPLE 2020,
A GENERATIONAL
OPPORTUNITY
HP2020 places great emphasis
on the social determinants of
health and health disparities and
includes education and income
objectives. HP2020 also takes
a more expansive view of the
impact on health resulting from
the built and natural environments. Building on HP2020, the
National Health Promotion and
Prevention Council provides
a new vehicle for implementing
a ‘‘health in all policies’’ strategy
across government agencies.
Many interventions in the National Prevention Strategy will
span departments and sectors, affecting multiple health outcomes.
Implementation of the ACA is
a generational opportunity to
strategically attack underlying social and physical environmental
determinants of health. Although
it does not address all current
challenges in population health, it
will foster stronger links between
population health institutions and
medical care providers to create
a healthier population. As an important complement to implementation, HP2020 will serve as
the foundation for the National
Prevention Strategy and facilitate
national, state, and local prioritization of policy and program
interventions. The National Prevention Strategy and other components of health reform
strengthen evidence-based public
health functions and work toward a health improvement and
maintenance system embracing
both medical care and public
health that can improve the
health of all Americans. j
About the Authors
Jonathan E. Fielding and Steven Teutsch
are with the Los Angeles County Department of Public Health, Los Angeles, CA.
Jonathan E. Fielding is also with the University of California at Los Angeles Schools
of Public Health and Medicine, Los
Angeles. Howard Koh is with the US Department of Health and Human Services,
Washington, DC.
Correspondence should be sent to Steven
Teutsch, 313 N Figueroa, Rm 708, Los
Angeles, CA 90012 (e-mail: steutsch@ph.
lacounty.gov). Reprints can be ordered
at http://www.ajph.org by clicking the
‘‘Reprints/Eprints’’ link.
This commentary was accepted May 27,
2011.
Contributors
J. E. Fielding and H. Koh conceptualized
the article. S. Teutsch drafted the article.
All authors made critical edits.
References
1. Koh HK, Sebelius KG. Promoting
prevention through the Affordable Care
Act. N Engl J Med. 2010;363(14):1296–1299.
www.thecommunityguide.org/index.
html. Accessed July 8, 2010.
html/uih/uih_4.htm. Accessed December
19, 2010.
7. U.S. Preventive Services Task Force.
Prevention and Care Management. Available at: http://www.ahrq.gov/clinic/
prevenix.htm. Accessed November 15,
2010.
19. Gavin LE, Catalano RF, Markham
CM. Positive youth development as a
strategy to promote adolescent sexual and
reproductive health. J Adolesc Health.
2010;46(3):S …
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