Progress in Chronic Disease Prevention Chronic Disease Prevention and Control Activities -- United States, 1989

Although chronic diseases account for 75% of the mortality and a substantial proportion of serious disability in the United States, data regarding the activities and capacity of public health agencies to control chronic diseases are limited. To assess resources, needs, and priorities in chronic disease prevention and control during fiscal year (FY) 1989, the Association of State and Territorial Chronic Disease Program Directors (ASTCDPD), in cooperation with the Public Health Foundation, recently completed a national survey of all state and territorial health agencies. This report summarizes those findings of the survey that address resources and planning/evaluation activities (1).

In June 1990, a questionnaire was mailed to the ASTCDPD voting member in each state and territory. The survey addressed five areas: 1) resources, 2) planning and evaluation, 3) links with other organizations, 4) continuing education needs, and 5) policies and standards. Responses were received from the 50 states, the District of Columbia, Guam, and the Virgin Islands.

During FY 1989, the total reported expenditure for chronic disease control activities in the United States was $245,371,377 (Table 1), less than 3% of FY 1989 expenditures by all surveyed public health agencies. Reported per capita expenditures varied widely, from $3.83 in California to zero in Oregon. Although certain states (e.g., Alaska and Nevada) ranked high in per capita spending, funding from state sources accounted for a small proportion of total expenditures for chronic disease control and prevention activities. Per capita spending for chronic disease control in the continental United States generally was higher in the southwestern and southeastern states and lower in the south central and midwestern states.

Although fewer than half the states and territories had developed health objectives for 1990 for any chronic disease priority area, most had developed or were planning year 2000 objectives in each area except chronic obstructive pulmonary disease and arthritis (Table 2). When asked an open-ended question on their highest chronic disease priorities, the most frequently cited responses were cancer, cardiovascular disease, tobacco use, diabetes mellitus, unintentional injuries, and minority health. As of October 31, 1990, most states and territories were routinely collecting data on chronic disease mortality (100%), behavioral risk factors (92%), cancer incidence (72%), and hospital discharges (62%); fewer states obtained data on spinal cord injuries (32%), ambulatory care (23%), and Alzheimer disease (15%).

Reported by: R Brownson, PhD, J Taylor, PhD, F Bright, MS, D Momrow, MPH, R Moon, MPH, G Stoodt, MD, P Remington, MD, S Benn, J Bowie, MPH, S Foerster, MPH, C Laramey, L Larsen, R Schwartz, MSPH, R Spengler, ScD, F Wheeler, PhD, G Wright, MD, A Yerkes, MPH, W Young, Association of State and Territorial Chronic Disease Program Directors. A Chacon, S Madden, J Dimas, MPA, Public Health Foundation. K Marconi, PhD, National Cancer Institute, National Institutes of Health. National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note:

In the United States, six chronic diseases--heart disease, cancer, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and chronic liver disease--are among the major causes of death, disability, and medical expenditures (2). In 1988, these six diseases accounted for 71.5% of all deaths in the United States (3). Six (27%) of the 22 priority areas of the year 2000 national health objectives (4) relate directly to control of chronic diseases (i.e., heart disease and stroke, cancer, and diabetes and other chronic disabling conditions) or major chronic disease risk factors (i.e., tobacco use, poor nutrition, and physical inactivity). Four other priority areas address issues indirectly related to chronic disease control (i.e., prevention of alcohol and other drug abuse, educational and community-based programs, clinical preventive services, and surveillance and data systems).

During FY 1989, programs for maternal and child health accounted for 13% of state public health expenditures; environmental health, 6%; human immunodeficiency virus infection/acquired immunodeficiency syndrome, 3%; and communicable disease control, 3% (Public Health Foundation, unpublished data). The proportion of expenditures dedicated to chronic diseases is likely to increase with the implementation of several new programs (e.g., the Breast and Cervical Cancer Screening Initiative from CDC and the American Stop Smoking Intervention Study for Cancer Prevention from the National Cancer Institute and the American Cancer Society (Project ASSIST)).

Although a variety of data sets were available for chronic disease surveillance in most jurisdictions, 85% of respondents reported that these data were inadequate, reflecting in part the collection and location of data sets outside the chronic disease unit or an insufficient analytic capacity. In addition, lack of adequate data on minority groups was reported as a major deficiency. Therefore, improved chronic disease surveillance systems are needed, particularly to address the needs of high-risk groups and to measure progress toward year 2000 national health objectives.

Based on recent estimates, eliminating a single risk factor for each of nine key chronic diseases could reduce mortality from these causes by 47%, from 427 per 100,000 persons to 224 per 100,000 (5). Preventable risk factors for chronic diseases include cigarette smoking, high blood pressure, high blood cholesterol, overweight, physical inactivity, poor nutrition, heavy alcohol consumption, and failure to use screening tests such as mammography and Papanicolaou smears (2,5). However, the well-established public health approaches to controlling these risk factors are underused (2). Factors that contribute to the success of public health strategies include targeting high-risk populations, addressing multiple risk factors, and intervening through multiple channels (e.g., schools, health-care settings, worksites, and community settings.)

References

1. Association of State and Territorial Chronic Disease Program Directors. Reducing the burden of chronic disease: needs of the states. Washington, DC: Public Health Foundation, 1991.

2. Mason JO, Koplan JP, Layde PM. The prevention and control of chronic diseases: reducing unnecessary deaths and disability--a conference report. Public Health Rep 1987;102:17-20.

3. NCHS. Health--United States 1990. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1991; DHHS publication no. (PHS)91-1232.

4. Public Health Service. Healthy people 2000: national health promotion and disease pre vention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

5. Hahn RA, Teutsch SM, Rothenberg RB, Marks JS. Excess deaths from nine chronic diseases in the United States, 1986. JAMA 1990;264:2654-9.

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