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US. DEPARTMENT OF HEALTH AND HUMAN SERVICES TIMN 364878

DEPARTMENT OF HEALTH & HUMAN SERVICES Office of the Assistant Secretary for Health Washington DC 20201 I am pleased to share with you Promoting Health/Preventing Disease: Objectives for the Nation. Our national strategy for achieving further improvements in the health of Americans was established in Healthy People, a document that notes our accomplishments in prevention, identifies the major health problems, and sets national goals for reducing death and disability. This volume sets out specific and measurable objectives for fifteen priority areas that are key to achieving our national health aspirations. We appreciate the work of so many people to define quantifiable objectives against which we can assess the effectiveness of our efforts. Achievement of these objectives by 1990 is a shared responsibility, requiring a concerted effort not only by the health community, but also by leaders in education, industry, labor, community organizations and many others. These challenges for the eighties demand creative approaches and by working together we can realize our aspirations and really make a difference. ulius B. 'Assistant Secretary fo and Surgeon General November, 1980 TIMN 364879

E EVENTI NG B I SEASE OBJECTIVES FOR THE NATION FALL 1980 HUMAN SERVICES UBLIC HEALTH SERVICE TIMN 364880

DEPARTMENT OF HEALTH AND HUMAN SERVICES Patricia Roberts Harris, Secretary C HEALTH SERVICE Julius B. Richmond, M.D., Assistant Secretary for Health and Surgeon General OFFICE OF DISEASE PREVENTION AND HEALTH PROMOTION J. Michael McGinnis, M.D., Deputy Assistant Secretary for Health CENTER FOR DISEASE CONTROL William H. Foege, M.D., Director HEALTH RESOURCES ADMINISTRATION Henry A. Foley, Ph.D., Administrator

CONTENTS INTR{lI1UCT IOAI ANI} OVERVIESd . . . . . . . . . . . . . . . . . . . . . v PREVENTIVE HEALTH SERVICES HIGH BL(}(}]} PRESSURP CQNTR€lL . . . . . . . . . . . . . . . . . I ' Specific Object1ve5. . . s . . a , . a . . . . . . . . . 6 FAls'IZLY PLANNING . . . a . • . , . a . a • . • . • . . . • a . Il Specific t3bjactives. . . . . . . . . . . . . . . . . . . 16 PREGNANCY AND INFANT HEALTH . . . . . . . . . . . . . . . . . 21 Specific Objectives. . . . . . . . . . . . . ... . . . . 26 IMMUNZZAT I(3N . . . . . . a . . . . . . . . . . . . . . . . . . 3 5 Specific tlbjectzves. . . . . • . . . . . . . , . . . . . 38 SEXUALLY TRANSMITTED DISEASES . . . . . . . . . . . . . , a . 45 Specific Objectives. . . . . . . • . , . a . . . . • . . 49 HEALTH PROTECTION TCXIC AGENT C{3NTR4L . . . . . . . . . . . . . . . . . . . . . 55 Specific (3b,jectives. . . , . a . . . a a a . . . . . . . 64 €3CCiIPAT IUNAL SAFETY AND HEALTH . . . . . . . . . . . . . . . . 71 Specific Objectives. . . . a . . . . a . a . . . . . . . 77 ACCIDENT PREVENTION AND INJURY CONTR{)L. . . . . . . . . . . . 83 SpeL3fi(..' Objectives . . . . . . . . . . . . . . . . . . . 89 FLUORIDATION AND DENTAL HEAZ.TH . . • • . . . . . . . . . • . . 95 Specific Objectives. . . • . . a , a . . . . . . . . • a I(72 SURVEILLANCE AND CONTROL OF INFECTIOUS DISEASES a..•...1C7 Specific Objectives . . . . . . . . . . . . . . . . . . . III SMCKING f1NB HEALTH. . • . a . . . . . . . . . . . . • . . . .II7 Specific Objectives . . . . . . . . . . . . . . . . . . .122 MISUSE OF ALC(1HOL ANT3 DRUGS . . . . . . . . . . . . . . . . .3.23 Specific C1b ject3ves. . . . . . . . . . . . • . a . . . . }.36 NUTRITION . . . . , a . . . . . . . . • . . . a , . . a . , .143 Specific (}bjectiV28. . . a . . . . . . . . . . . . . . . }.48 PHYSICAL FITNESS AND EXERCISE . . . . . a • . . • • 155 Specific Objectives. . . • . , . . . . . . • . . . . . .159 CONTROL OF STRESS AND 4FIOLENT BEHAVIOR. . , . . . . . . . . .IEr3 Spe(:iii~.' Vi}jQctjvesa . . t . . a . a . a a . • . . , a .169 ACKNOWLEDGEMENTS . . . . . . . • • . . • . . . . . . • . . . . . . 173 TIMN 364882

INTRODUCTION AND OVERVIEW The Pur ose and the Process In 1979 the first Surgeon General's Report on Health Promotion and Disease Prevention, Healthy People, was issued. That report chronicled a century of dramatic gains . in the health of the American people, reviewed present preventable threats to health, and identified fifteen priority areas in which, with appropriate actions, further gains can be expected over the decade. The report established broad National goals--expressed as reductions in overall death rates or days of disability--for the improvement of the health of Americans at the five major life stages. Specifically, the goals established were: • To continue to improve infant health, and, by 1990, to reduce infant mortality by at least 35 percent, to fewer than nine deaths per 1,000 live births. s To improve child health, foster optimal childhood development, and, by 1990, reduce deaths among children ages one to 14 years by at least 20 percent, to fewer than 34 per 1.0[i, 0()0. s To improve the health and health habits of adolescents and, young adults, and, by 1990, to reduce deaths among people ages 15 to 24 by at least 20 percent, to fewer than 93 per 100,000. s To improve the health of adults, and, by 1990, to reduce deaths among people ages 25 to 64 by at least 25 percent, to fewer than 400 per 100, 0(10. s To improve the health and quality of life for older adults and, by 1990, to reduce the average annual number of days of restricted activity due to acute and chronic conditions by 20 percent, to fewer than 30 days per year for people aged 65 and older. This volume, Promoting Heaith/Preventing Disease, sets out some specific and quantifiable objectives necessary for the attainment of these broad goals. Objectives are established for each of the 15 priority areas identified in the Surgeon General's report: high blood pressure control; family planning; pregnancy and infant health; immunization; sexually transmitted diseases; toxic agent control; occupational safety and health; accident prevention and injury control; fluoridation and dental health; surveillance and control of in€ectious - diseases; smoking and health; misuse of alcohol and drugs; nutrition; physical fitness and exercise; and control of stress and violent behavior. A number of TIM'S 364883

different objectives are specified for each of the 15 areas. Taken together the targets established in Promoting Health/ Preventing Disease, when attained, should permit the realization of the overall National goals set down in the Surgeon General's report. The objectives are the result of a year long effort involving more than 500 individuals and organizations from both the private and governmental sectors. First drafts were drawn up by 167 invited experts at a conference held in Atlanta, Georgia, on June 13 and 14, 1979, sponsored by the then Department of Health, Education, and Weifare. The conference, organized into work groups for the 15 subject areas, was a joint effort of the Center for Disease Control and the Health Resources Administration, coordinated by the Office of Disease Prevention and Health Promotion of the Office of the Assistant Secretary for Health. An invitation for public comment on these drafts was published in the Federal Register and the volume containing them was also circulated widely to people and agencies concerned with the various subjects. During the fall of 1979 the objectives and reports were revised according to the suggestions received. In early 1980 the revised objectives were circulated within the Department of Health and Human Services, to other relevant Federal agencies, and to Atlanta conference work group chairpersons to elicit further comment. Final revisions were made in the spring of 1980. Because the process received such a substantial contribution from the 1979 Atlanta conference, it merits special note. The conference participants and invited observers were all knowledgeable about some aspect of risk reducing actions that can improve the opportunities for health. The chairpersons and members of each of the 15 work groups were expressly selected to provide a mix of backgrounds which could bring to the task not only technical expertise and consumer and professional viewpoints, but also practical experience with planning and program implementation. Thus, participants were drawn from a variety of affiliations--providers, academic centers, State and local health agencies, voluntary health associations, and many others. To facilitate the discussions, each work group member received a draft background paper, prepared by staff of an HEW office with program responsibility in the relevant prevention activity. Other HEW activities in setting goals and standards for prevention were taken into account both in the background papers and in work group discussions, particularly the National Health Planning Goals called for by Section 1501 of P.L. 93-641, presently under development by the Health Resources Administration, and the Model Standards for Community Preventive Health Services called for by Section 314 of P.L. 95-83, whose development was coordinated by the Center for Disease Control.* Vi TIMN 364884

While the objectives were developed under Public Health Service sponsorship, and are consistent with Federal policies, they are far wider in purpose and scope. They are intended to be National--not Federal--objectives. To realize the potential for reducing the rates of premature death and disability to the levels set forth here requires a truly National commitment, including, but going far beyond, that of government. To achieve these objectives demands actions by Americans in all walks of life, in their roles as concerned individuals, parents, and as citizens of their Nation and of States and local communities. Sustained interest and action is required not only by physicians and other health professionals, but also by industry and labor, by voluntary health associations, schools, churches, and consumer groups, by health planners, and by legislators and public officials in health departments and in other agencies of local and State governments and at the Federal level. While the diagnosis and treatment of disease are the responsibility of health professionals and health organizations, actions to reduce the risks of disease or injury extend far beyond health services per se. The range of preventive activities is broad. Included are key preventive services, such as immunization, delivered to individuals by physicians, nurses, other health professionals, and trained allied health workers. Also important- are standards, voluntary agreements, laws and regulations, such as engineering standards, safety regulations and toxic agent control, to protect people from hazards to health in their living, travel and working envircnments. In addition, and perhaps most important for today's health threats, there are activities that individuals may take voluntarily to promote healthier habits of living and activities that employers and communities may take to encourage them. This document is designed for the use of leadership in the wide range of private and public sector organizations with important roles in these various areas. At a time in the Nation's history when budgets become ever tighter, legislators, public officials and governing boards of industry, foundations, universities and voluntary agencies are beginning to re-examine their traditional bases for allocating their limited health-related resources. It is anticipated that in the years to come policy makers will be able to use the objectives in this volume to track the Nation's successes or failures in prevention. *Readers who want to place disease prevention priorities in the perspective of overall national health policy should refer to the draft National Health Planning Goals, forthcoming from the Health Resources Administration which address broad health status and health system considerations. Readers who want more specifics on how to put prevention measures to work are referred to Model Standards for Community Preventive Heaith Services, issued in 1979 by the Center for Disease Control. VI i TI~~VIN 364885

The Reports Each of the reports focuscs on one of the 15 prevention areas and is presented in a standard format allowing a review of ; the nature and extent of the problem, including health implications, status and trends; s prevention/promotion measures illustrative - of approaches in education and information, services, technology, legislation and regulation, and economic incentives, followed by observations on the relative strength of these measures; • specific national objectives for: improved health status reduced risk factors improved public/ professionai awareness improved scrviceslprotection improved surveillance/evaluation; s the p objectives ; e the data necessary for tracking progress. Discussion of the objectives is limited to some extent by the need to distill often comprehensive and complex issues into a short outline form as well as by limitations in the knowledge base. In some instances, for example, it is not possible to relate the magnitude of a targeted problem to a specific disease incidence--e.g., the prevalence of a particular carcinogen in the environment to an identifiable level of cancer incidence. Also, the discussions of the various intervention measures are offered principally as checklists rather than as detailed blueprints with appropriate sequencing carefully established, and presented. They do not necessarily reflect Federal policy--rather they represent a broader range of possible measures available throughout the public and But these limitations are dictated by the character of the existing data, as well as the necessity to tailor efforts to local conditions. Given these considerations, the discussions provide a concise review of the central issues relevant to each area. With respect to the objectives themselves, certain premises are inherent. First, the stated objectives should reflect a careful balancing of potentials for benefits and harm to the individuals or populations vii' TMN 364886

concerned. Second, specific actions suggested should be in line wi professional consensus on likely efficacy of the action. Thir continued biomedical, epidemiological and behavioral science researc and systematic evaluation will result in improved judgments. , The objectives focus on interventions and supports designed primarily for well people; to reduce their risks of becoming ill or injured at some future date. Thus, few of the objectives deal with secondary prevention. Objectives relating to the frequency and content of physical examinations and other means of detecting early conditions (such as cervical, breast and colon cancer, diabetes, vision and hearing problems and dental caries) were deliberately excluded from consideration, despite their obvious importance in signaling needs for intervention. Finally, an attempt has been made to confine objectives to what might feasibly be attained during the coming decade, assuming neither major breakthroughs in prevention technology, nor massive infusions of new Federal spending. For example, the goal for infant health is to reduce the infant mortality rate to no more than 9 deaths per 1, 000 live births. In theory the Nation should be able to do much better. Several areas in western Europe, and certain political jurisdictions within the United States already have achieved rates of 5 per 1, 000. Yet, the size of the gaps that presently exist between the risks experienced by pregnant women in different age, ethnic and income groups of the population, and the limited resources that now appear likely to become available to narrow those gaps make 9 per 1,000 a more realistic objective. Inn sum, the objectives were framed in the context of current knowledge and the current aggregate level of public and private resources for the 15 prevention areas. While this parameter was not adhered to in every instance, it promoted a greater measure of restraint--or realism--on the process. No effort has been made to establish priorities among the 15 areas, or even among the various objectives within any given area. Given the nature of our pluralistic society and the diversity of regional and local needs and capabilities, both the setting of priorities and the choice of program directions are best left to those responsible for planning, coordinating, and implementing prevention strategies--namely State and local health agencies, State health planning development agencies, health system agencies, and governing boards of the wide range of private sector organizations involved. It is important to note that some themes can be identified which group the activities of the 15 areas into subcategories with common elements.. "Substance abuse," for example, links the areas of smoking and health and misuse of alcohol and drugs. Common elements in these areas ix TIMN 364887