Leading Chronic Disease Prevention With Evidence-Based Policy: The ASTHO Example

Preventable chronic diseases represent the nation's leading causes of death, disability, and health care costs. State and territorial public health agencies consistently prioritize chronic disease prevention and control in their health improvement plans either as general prevention and reduction of chronic diseases or as a focus on one or more specific chronic diseases or behavioral risk factors such as tobacco use, lack of physical activity, and poor nutrition.¹ Based on these priorities, ASTHO has sought to provide technical assistance and staff expertise to better support state health officials and partner in the implementation of evidence-based chronic disease prevention and control efforts.

A wide range of evidence-based interventions is effective to prevent and control chronic diseases at the population level,^2,3 and among the most effective are interventions that target policy and systems change.^4,5 State and territorial legislative policies and regulatory actions are important because they affect entire populations and often require fewer resources than individually focused programs and interventions. Policy and regulatory actions have been used to discourage tobacco use and encourage tobacco cessation, as well as to remove barriers to improved nutrition and to promote physical activity. Such policy approaches are intended to make the healthy choice the “default” or “easy”⁶ choice.

Policy-Making Authority

A principal role of state and territorial health officials (S/THOs) is formulating sound public health policy. As health policy advisors to governors and secretaries of health and human services agenices, health officials are positioned to advise the executive and legislative branches of government. In addition to policy formulation and development, state and territorial public health officials have specific statutory authorities that allow them to develop and enforce specific policies. In their efforts to address chronic disease, public health officials frequently lead efforts to implement tobacco control, as well as policies that promote healthy food access and proper nutrition—including healthy food procurement and contracting policies—and policies that promote and support breastfeeding.

Influence on Policy Decision Making

Many policies that impact the public's health are not specific to the direct authority of public health agencies. For example, school nutrition and physical education standards are important policy interventions to prevent childhood obesity, but state health officials often do not have authority over state or local education agency policy making. Organizations outside government—from private schools to major corporations—create internal policies on matters as diverse as tobacco use and paid sick leave. Health care systems and insurers set coverage and payment policies that can be highly effective and far-reaching. Developing policy change in these areas of public health requires practitioners to use their professional influence and boundary-spanning leadership skills⁷ to develop and leverage relationships with leaders in other local and state agencies, tribal communities, health care organizations, and community settings. As such, S/THOs can play a key role in influencing policies that promote health even in areas in which they have no direct authority but do have influence.

National Work to Support State and Territorial Policy Making

A central tenet of ASTHO's strategic plan is to improve public health through capacity building, technical assistance, and thought leadership. Over the last year, ASTHO has expanded its efforts to increase state and territorial health leaders' competency in evidence-based public health. Given the priority placed on chronic disease and prevention across state and territorial public health agencies, ASTHO focused its attention on opportunities for health officials to advance evidence-based policies to prevent chronic disease. This included forming learning and practice communities around specific topics, supporting state policy academies, and holding training opportunities for state and territorial heath officials and their leadership teams.

In most state and territorial public health agencies, chronic disease programmatic work is organized around categorical federal funding lines. A workforce dedicated to each disease area typically leads program intervention efforts and is often supported by the National Association of Chronic Disease Directors (NACDD) and other national partners. In partnership with chronic disease directors, S/THOs work to support, champion, and lead initiatives to address chronic conditions and risk factors.

ASTHO used several sources to identify and categorize evidence-based chronic disease policy areas. The main sources were evidence reviews compiled by The Guide to Community Preventive Services, the World Health Organization's Non-Communicable Disease (Best Buys), the Centers for Disease Control and Prevention's (CDC's) 6-18 Initiative, CDC's Winnable Battles Initiative, and CDC's Chronic Disease Indicators. In addition, ASTHO reviewed a wide range of secondary resources and scientific recommendations including Harvard University's CHOICES Project, Trust for America's Health's (TFAH's) State of Obesity Report and Promoting Health and Cost Control in States (PHACCS), the American Lung Association's tobacco control guidelines, the US Guide to Clinical Preventive Services, the University of Wisconsin's County Health Rankings, CDC's HI-5 Initiative, CDC's Healthy Brain Initiative Road Map, and the CEO Cancer Gold Standard.

These evidence-based policy focus areas were categorized on the basis of whether S/THOs were likely to have direct authority to introduce and champion these policies through the executive or legislative branches of government or whether officials would use their influence and relationships to advocate for other entities to implement these policies. The policies were further refined through meetings with CDC subject matter experts, focus groups with health officials, and input from ASTHO's community health and prevention policy committee. ASTHO then examined existing reviews and reports to assess state-by-state progress in the policy areas (Table).

TABLE - Essential Policies for Chronic Disease Prevention and Control: Priorities for State and Territorial Health Officials

	Authority	Influence	Jurisdictions With Progress Toward the Policy Areas
Tobacco
1. Increase taxes on all tobacco products	•		16
2. Create and enforce comprehensive tobacco-free air policies	•		10
3. Restrict all forms of tobacco product advertising	•		1
5. Protect local authority to enact tobacco control policies	•		39
6. Promote policies that increase access to tobacco cessation programs		•	16
Nutrition
1. Implement multicomponent policies that reduce sugar consumption	•		23
2. Implement policies that promote breastfeeding	•	•	27
3. Implement procurement, contracting, and retail policies that increase access to healthy foods	•	•	51
4. Implement nutrition policies in early childcare facilities		•	35
5. Enhance access to, utilization of, and nutritional quality of school meals		•	47
Physical activity
1. Increase support and resources for physical activity in community settings	•		47
2. Support built environment policies that promote physical activity		•	31
3. Enhance physical education and recess standards in schools		•	51
4. Implement policies to increase physical activity and reduce screen time in early childhood education settings		•	30
Chronic disease control
1. Create policies and structures to establish community health workers in the public health workforce	•	•	Pending
2. Prohibit tanning bed use among minors younger than 18 y	•		24
3. Introduce policies that increase access to diabetes prevention programs		•	27
4. Support policies that improve prescribing of, and adherence to, hypertensive treatment plans including blood pressure self-monitoring		•	Pending
5. Support policies that incentivize the early detection and diagnosis of cognitive impairment and dementia in health care settings		•	3

Data on tobacco policy were compiled from a review of state tobacco policy analyses completed by the American Lung Association, the Campaign for Tobacco-Free Kids, Public Health Law Center, the National Conference of State legislatures (NCSL), the American Nonsmokers' Rights Foundation, and the CDC Office of Smoking and Health. Data on nutrition policy were compiled from analyses completed by TFAH, the Robert Wood Johnson Foundation (RWJF), Healthy Food America, NCSL, Healthy Food Access portal, the Center for Science in the Public Interest, National Resource Center for Health and Safety in Child Care and Early Education, and the School Nutrition Association. Data on physical activity policy were taken from data compiled by TFAH, NCSL, and RWJF, and data on skin cancer policy were based on reports from the Melanoma Foundation. Data on diabetes policy were based on reports from TFAH and NACDD, and the data on cognitive impairment policy were based on reports from the Alzheimer's Association and NACDD. Published data are not currently available to document (1) policies or structures to establish community health workers in the public health workforce, or (2) policies that improve prescribing of and adherence to hypertensive treatment plans including blood pressure self-monitoring. ASTHO is developing mechanisms to monitor progress in these areas. See Supplemental Digital Content Appendix A (available at https://links.lww.com/JPHMP/A706) for complete description of the policy criteria and data sources for the chronic disease essential policies.

Expanding Essential Chronic Disease Policies Across the Nation

S/THOs are tasked with addressing many areas of public health and oftentimes have a short tenure to make an impact on the health of their state. Many S/THOs focus on improving chronic disease risk factors because of the significant human burden and cost of these conditions. The essential chronic disease policies represent an approach to technical assistance at ASTHO that is evidence-based, policy-oriented, and proactive. It will be used as a guide for health officials and their leadership to prioritize state efforts in addressing chronic disease and will allow states to determine areas of success as well as opportunities for significant impact.

In terms of implementation, ASTHO staff will work with states individually to review progress in each of the policy areas and will assess policy interventions that have not been addressed or that could benefit from a more comprehensive approach. ASTHO staff will also work proactively to identify opportunities to increase implementation of these policies across the nation by engaging state public health leaders, identifying existing best practices, seeking funding opportunities to support this work, and collaborating with CDC. ASTHO will work with its membership to introduce and prioritize the recommended chronic disease policies within policy committees and the government affairs annual priorities and position statements. ASTHO will engage in partnerships with affiliates and other national organizations to ensure the state health leadership is supported beyond their individual efforts. Overall, the essential policies for chronic disease framework serves as a guide for health officials to use in their unique position to ensure that the greatest amount of impact is made to address the burden of chronic disease.