What Works to Promote Health? Task Force on Community Preventive Servi - PDF document

What Works to Promote Health? Task Force
What Works to Promote Health? Task Force on Community Preventive ServicesStephanie Zaza,Project Co-DirectorPeter A.Briss,Project Co-DirectorKate W.Harris,Managing Editor2005Task Force on Community Preventive ServicesJonathan E. Fielding, MD, MPH, MBA (Member since 1996; Chair since 2001) Los Angeles, CaliforniaRoss Brownson, PhD (1996Ð2003)St. Louis University School of Public HealthSt. Louis, MissouriPatricia A. Buffler, PhD, MPH (1996Ð2001)University of California, BerkeleyNoreen Morrison Clark, PhD (2003Ðpresent)University of Michigan School of Public HealthAnn Arbor, MichiganJohn Clymer (2002Ðpresent)Partnership for PreventionWashington, D.C.Mary Jane England, MD (1996Ð2001)Regis CollegeWeston, MassachusettsCaswell A. Evans, Jr., DDS, MPH (Chair of the Task Force, 1996Ð2001)National Oral Health Initiative, Office of the U.S. Surgeon GeneralRockville, MarylandDavid W. Fleming, MD (1996Ð2000)The Gates FoundationSeattle, WashingtonMindy Thompson Fullilove, MD (1996Ð2004)New York State Psychiatric Institute and Columbia UniversityNew York, New YorkRobert S. Thompson, MD (1996Ð2003)Group Health Cooperative of Puget SoundSeattle, WashingtonCONSULTANTSRobert S. Lawrence, MD (1996Ðpresent)Bloomberg School of Public HealthJohns Hopkins UniversityBaltimore, MarylandJ. Michael McGinnis, MD (1996Ðpresent)Robert Wood Johnson FoundationPrinceton, New JerseyLloyd F. Novick, MD, MPH (1996Ðpresent)Syracuse, New YorkSylvie Stachenko, MD, Msc (1996Ð1999)Ottawa, OntarioSteven M. Teutsch, MD, MPH (1998Ð2001)Merck & Company, Inc.West Point, PennsylvaniaTask Force on Community Preventive ServicesIt is a great pleasure to present this landmark first edition of Community Preventive Services (Community Guide)is the product of eight years of work by the Task Force on Community Pre-ventive Services. At its inception in 1996, the Task Force was charged withdeveloping recommendations for interventions that promote health and pre-vent diseases in our nationÕs communities and healthcare systems. These rec-ommendations were to be based on systematically derived scientific evidenceof their effectiveness. At that time, some deemed the task impossible andmaintained that complex community-based interventio

ns could not be evalu-ated systematicall
ns could not be evalu-ated systematically, would not stand up to scientific scrutiny, and could notbenefit from focusing on what works. In contrast to those reservations, theCommunity GuideÕsresearch into scientific studies has illuminated and helpedclarify what we know about what works to promote health and prevent dis-ease, and what we still need to learn. The is a credible,practical, and essential reference. It is important for helping public health,healthcare provider, academic, business, community planning and advocacy,and research audiences select effective interventions for their communitiesand for expanding the science base underlying public health practice. The work of this Task Force follows in the footsteps of the U.S. PreventiveServices Task Force, which developed and continues to update the Clinical Preventive Servicesis an important reference pro-viding recommendations for clinical (i.e., individual) prevention interven-tions. The complements this work and recommends inter-ventions to improve the performance of healthcare systems; interventionsimplemented in community settings such as schools, worksites, and commu-nity organizations; and interventions applied to entire communities (e.g., laws,regulations, enforcement, mass media, and environmental changes). Together,these two guides provide recommendations that address the needs of bothour health and public health systems. The Task Force on Community Preventive Services is ably supported bystaff at the Department of Health and Human Services (led by HHSÕs Centersfor Disease Control and Prevention), other federal agencies, major health or-ganizations, state and local health departments, managed care and otherhealthcare delivery organizations, academic centers, and voluntary organi-zations. These broad collaborations are essential to ensure that the approachtaken in each chapterÑthe interventions selected for review, the reviews ofWhat do we know, how do we know it, and how can we use what we knowto improve the publicÕs health? These questions sparked the creation of theTask Force on Community Preventive Services.Anybody who makes or influences decisions that can affect the health ofpopulations deserves ready access

to the best evidence on what works, for
to the best evidence on what works, forwhat purpose, and at what cost, in order to make good choices among poli-cies and to consider alternative uses of resources. This perceived need in per-sonal healthcare led to the establishment of the U.S. Preventive Services TaskForce and similar efforts to make available the best scientific evidence to sup-port decisions in various fields of medicine. Fundamental to all of these ef-forts was the development of standard approaches to search the literature forevidence; to identify and synthesize the subset of best evidence; and to trans-late it into specific recommendations for practitioners.Despite the success of this approach in improving medical care, somedoubted whether a complementary effort to assess interventions aimed atpopulations could succeed. Did high quality evidence exist in the broad do-main that constitutes public health? If so, could that evidence be harnessedIn 1996, the Department of Health and Human Services (HHS) acknowl-edged these concerns and committed to assessing and improving the qualityof knowledge about what works to improve population health by establish-ing the Task Force on Community Preventive Services. This action placed asolemn responsibility in the hands of a 15-member panel of experts and es-tablished a special relationship between the Task Force and the Centers forDisease Control and Prevention (CDC), an agency of HHS. CDC provides theresearch teams that gather and evaluate evidence on the effectiveness of awide array of public health interventions; the Task Force reviews this evidenceand uses it to makes decisions and recommendations. Other federal agencies,voluntary organizations, and many national experts also make importantcontributions to fulfilling the charge of the Task Force. CDC and other part-ners also are working to ensure the wide dissemination and use of the results.This book, a milestone reflecting important new work, is but one aspect ofthe combined work of the Task Force, CDC, and our many partners. Over thepast eight years, we have learned much about which public health interven-tions are effective, but to do this we had to develop credible, reproduciblemethods to amass and weigh evide

nce. First, we developed, tested, and re
nce. First, we developed, tested, and re-This book is the result of years of research, conducted by many people. Fromthose who first proposed the idea of a Guide to Community Preventive Ser-vices in the early 1990s to those who continue to work every day to expandCommunity Guide,we express our thanks. If we leftanyone off this list, our sincere apologies.EARLY CONTRIBUTORS TO THE FORMATION OF THE COMMUNITY GUIDEClaude Earl Fox, MD, MPHÑJohns Hopkins Urban Health Institute, Balti-more, MDKristine M. Gebbie, DrPH, RNÑColumbia University, New York, NYCatherine Gordon, MDÑCenters for Disease Control and Prevention, Wash-William HarlanÑNational Institute of Mental Health, Bethesda, MDAlan R. Hinman, MD, MPHÑTask Force for Child Survival and Development,Atlanta, GADouglas B. Kamerow, MD, MPHÑEditor,BMJ USADouglas S. Lloyd, MD, MPHÑHealth Resources and Services Administration,Bureau of Health Professions, Rockville, MDJ. Michael McGinnis, MDÑRobert Wood Johnson Foundation, Princeton,David Satcher, MD, PhDÑNational Center for Primary Care, Morehouse Schoolof Medicine, Atlanta, GASteven M. Teutsch, MD, MPHÑMerck & Co. Inc., West Point, PARandy Wykoff, MD, MPH, TMÑProject HOPE, Millwood, Virginia (formerlyDeputy Assistant Secretary for HealthÑDisease Prevention and Health Pro-INTERNAL CDC EXECUTIVE ADVISORY COMMITTEEEdward L. Baker, MD, MPHÑCurrent affiliation, Public Health LeadershipInstitute, University of North CarolinaClaire V. Broome, MDJeffrey R. Harris, MD, MPHÑCurrent affiliation, University of WashingtonDixie E. Snider, Jr., MD, MPHStephen B. Thacker, MD, MScDavid Atkins, MD, MPHÑAgency for Healthcare Research and Quality, Rock-ville, MDRonald Bialek, MPPÑPublic Health Foundation, Washington, DCHudson H. Birden, Jr., MPHÑNorthern Rivers University Department ofRural Health, University of Sydney, AustraliaDaniel S. Blumenthal, MD, MPHÑAssociation of Teachers of PreventiveMary B. Burdick, PhD, RNÑDepartment of Veterans Affairs, Durham, NCBill Calvert, MS, MPH, MBAÑU.S. Navy Environmental Health Center, Ports-mouth, VAJoseph Chin, MD, MSÑCenters for Medicare and Medicaid Services, Balti-more, MDNathaniel Cobb, MDÑIndian Health Service, Albuquerque, NMArthur B. Elster, MDÑAmerican

Medical Association Jessie Gruman, PhDÑ
Medical Association Jessie Gruman, PhDÑCenter for the Advancement of Health, Washington, DCTom Houston, MDÑAmerican Medical AssociationJames D. Leeper, PhDÑAmerican Public Health AssociationRose Martinez, ScDÑInstitute of Medicine, Washington, DCRobert J. McNellis, MPH, PA-CÑAmerican Academy of Physician Assistants,Alexandria, VAEmmeline Ochiai, MPHÑOffice of Disease Prevention and Health Promotion,Washington, DCBob Rehm, MBAÑAmerican Association of Health Plans, Washington, DCJordan H. Richland, MPHÑAmerican College of Preventive Medicine, Wash-Elizabeth S. Safran, MD, MPHÑAmerican Association of Public HealthPhysiciansRuth Sanchez-Way, PhDÑSubstance Abuse and Mental Health Services Ad-ministration, Rockville, MDJames H. Scully, Jr., MDÑNational Association of State Mental Health Pro-gram DirectorsHarrison Spencer, MDÑAssociation of Schools of Public Health, Washing-Col. Linda Spencer, PhD, RNÑU.S. Army Kristy Straits-Troster, PhDÑV.A. National Center for Health Promotion andDisease Prevention, Durham, NCJonathan B. VanGeest, PhDÑAmerican Medical AssociationMartina Vogel-Taylor, MT(ASCP)ÑNational Institutes of Health, Bethesda, MDDeborah Willis-Fillinger, MD, MPHÑHealth Resources and Services Admin-istration, Rockville, MDSteven H. Woolf, MD, MPHÑAmerican College of Preventive Medicine, Fair-fax, VAAcknowledgmentsOTHER AUTHORS,RESEARCHERS,AND STAFF WHO HAVE BEEN PART OF THE COMMUNITY GUIDE INITIATIVEGeorgina Agyekum, MPHFemi Alao, PhDTara J. Balsley, MPHRosalind Breslow, PhD, MPHS. Scott Brown, MPHVilma G. Carande-Kulis, PhD, MS (Branch ChiefÑPrevention Effectiveness:2001Ð2004)Linda Carnes, DrPAJuanita ChukwaraPhaedra Corso, PhDDebjani Das, MPHTanisha Denny, MPHTho Bella Dinh-Zarr, PhD, MPHApril DixonErica Dunbar, MPHRandy W. Elder, PhDErin Finley, BAAdele Franks, MDPrethibha George, MPHLynn Gibbs, MPHKathleen Green-Raleigh, PhDKathy W. Grooms, BSPrakash L. Grover, PhD, MPHDonna Higgins, PhDKrista Hopkins, MPHAngela B. Hutchinson, PhDLisa Jeannotte, MAEvelyn Johnson, PhDEmily B. Kahn, PhD, MPHKarol Kumpfer, PhDAmy LevinsonJessica Lowy, MPH, CHESAcknowledgmentsBenedict I. Truman, MD, MPHKaren Taylor Valverde, MAJulie A. WasilCarla D. WayeLori L. Westphal, MA, MPHLinda Wright-

De AgŸero, PhD, MPHLinda C. Yarbrough, B
De AgŸero, PhD, MPHLinda C. Yarbrough, BSPatrice Young-Curtis, MSHCAStephanie Zaza, MD, MPH (Branch ChiefÑ1999Ð2003)AcknowledgmentsConventions Used in This BookxxiiiIntroduction:How to Use The Guide to Community Preventive Services1TobaccoReducing Initiation,Increasing Cessation,Reducing Exposure to Environmental Tobacco Smoke2Physical ActivityIncreasing Physical Activity through Informational Approaches,Behavioral and Social Approaches,and Environmental and Policy Approaches3The Social EnvironmentEarly Childhood Development Programs,Housing,Part II: Reducing Disease, Injury, and Impairment4CancerPreventing Skin Cancer,Promoting Informed Decision Making5DiabetesDisease Management,Case Management,Diabetes Self-Management Education6Vaccine-Preventable DiseasesImproving Vaccination Coverage through Increasing Community Demand,Enhancing Access to Vaccination Services,and through Provider- and System-Based Interventions7Oral HealthDental Caries,Oral and Pharyngeal Cancers,Sports-Related Craniofacial InjuriesWhat do you want to find in this book? HereÕs where to look.Chapters 1Ð9 each cover a specific topic area. Each chapter follows this pattern:Title page,listing all interventions and findings included in the chapter, whenthe research was conducted, and where this information has been published.Introductionto the topic area, including the public health burden it poses.Recommendations from other advisory groups,Healthy People 2010goals and objectives in this topic area, as well as information from othergroups and agencies.a brief summary of methods used in this topic area to evaluatethe effectiveness of interventions.economic efficiency of all recommended interventions.Recommendations and findings:¥Interventions are grouped under strategies (e.g., in Tobacco, the threestrategies reviewed are Reducing Tobacco Use Initiation, Increasing TobaccoUse Cessation, and Reducing Exposure to Environmental Tobacco Smoke).¥One or two paragraphs give a general introduction to the strategy.¥A summary of the published findings is provided for each intervention (seeTable CÐ1).Using these recommendations:additional considerations for deciding if useof a particular intervention is appropriate to your

situation.summary of the interventions
situation.summary of the interventions reviewed in this area and the rec-ommendations or findings.SEE ALL RECOMMENDATIONS AND FINDINGS OF THE TASK FORCE LISTED ALPHABETICALLY BY TOPICThe Appendix provides this list.GET A BETTER UNDERSTANDING OF The Introduction, ÒHow to Use TheGuide to Community Preventive Ser-vices,Ó serves as an orientation to the Community Guide,discussing variousaspects of this book, as well as related publications and our website, www.thecommunityguide.org.Introduction: How to Use TheGuide to Community Preventive ServicesWHAT IS THE TheGuide to Community Preventive) is a resource to help you select interventions to improve health andprevent disease in your state, community, community organization, business,healthcare organization, or school. It is designed to answer three questions:1.What has worked for others and how well?2.How can I select among interventions with proven effectiveness?3.What might this intervention cost, and what am I likely to achievethrough my investment?is also a resource for researchers and research fundersto identify important gaps in what we know and to determine how to allo-cate scarce research funds.reviews evidence about interventions designed to im-prove health across a wide range of topics. Interventions that combat such riskybehaviors as tobacco use, physical inactivity, and violence are included. Otherreviewed interventions address specific health conditions such as cancer, dia-betes, vaccine-preventable diseases, and motor vehicle injuries. Interventionsthat address the broad social determinants of health such as education, hous-ing, and access to care are also reviewed in the Community Guide.Even withthis broad scope, the is not comprehensive. These initialtopics were chosen because together they address the health behaviors, dis-eases, injuries, and social factors that impose the greatest burden of suffer-ing and that offer the broadest range of intervention opportunities.vention reviews are underway for a number of additional topics includingnutrition, improving pregnancy outcomes, and reducing depression. In addi-tion, we are updating and expanding most of the chapters in this book.For each of these broad topics, inte

rventions that promise to improve im-por
rventions that promise to improve im-portant health outcomes are reviewed. (For criteria used to select interven-tions for review, see Chapter 10, Methods Used for Reviewing Evidence andLinking Evidence to Recommendations in the Community Guide.ventions are applicable to groups, communities, or other populations and in-clude strategies such as healthcare system changes, public laws, workplaceand school programs and policies, and community-based programs. All of theA FAMILY OF PRODUCTSis a family of products that provides systematic reviewfindings, recommendations, and other types of information in different formats.The Guide to Community Preventive Services: What Works to Promote Health?This book provides a snapshot of the information available through late 2003. Following this chapter, the intervention reviews are organized into two) Changing Risk Behaviors and Addressing Environmental Challenges) Reducing Disease, Injury, and Impairment. Each part contains chap-ters about specific topics, and each chapter covers about 5Ð20 different inter-ventions.As mentioned, all topics of importance in public health are not yet ad-dressed directly (e.g., cardiovascular disease or HIV/AIDS). However, manychapters contain information directly relevant to these two and other criticalhealth issues (e.g., the chapters on tobacco and physical activity are relevantfor reducing cardiovascular disease). As you consult this book, keep in mindthat interventions in one or more chapters might be useful to achieve relatedobjectives (e.g., the chapters on tobacco, cancer, and physical activity mightbe used together to achieve a cancer reduction goal).Journal ArticlesBecause book publications can provide information available at only onepoint in time, reviews are published in journals as they arecompleted. In addition, journal publication has allowed for rapid dissemina-tion of the Task ForceÕs findings in advance of publication in book format.reviews and recommendations are publishedMorbidity and Mortality Weekly Report (Recommendations and ReportsDetailed scientific information about each systematic review is pub-American Journal of Preventive Medicine). Accompanyingarticles are editorial commentaries f

rom a variety of expertsdescrib-ing how
rom a variety of expertsdescrib-ing how different audiences can use the (e.g., managedcare, public health, or voluntary organizations). Finally, various articles aboutCommunity Guide,specific recommendations, and other aspects of theinitiative occasionally appear in other journals.The WebsiteThe website www.thecommunityguide.org is the most comprehensive andzations can select effective interventions for their populations and advocatefor adoption of effective interventions by their local governments. Researchersto identify research gaps and advocate forfunding to conduct research to fill those gaps. In addition, researchers canevaluation criteria (see Chapter 10) to en-sure that their studies and reports are of the highest quality and eligible forreviews. Educators and studentsin all of these arenas can use the as part of comprehensivetraining in evidence-based public health and prevention decision making.IS PART OF COMPREHENSIVE PREVENTION PLANNINGComprehensive program planning involves a series of activities: assessment,priority setting, objective setting, intervention selection, implementation, andevaluation.primarily assists with intervention se-Table IÐ2.Assessment¥National Public Health Performance Standards (www.naccho.org/project48.cfm)¥MAPP: Mobilizing for Action through Planning and Partnerships (www.naccho.org/ project77.cfm)¥APEX-PH: Assessment Protocol for Excellence in Public Health (www.naccho.org/project47.cfm)Healthy People 2010objectives (www.healthypeople.gov)In most states, Healthy People objectives have been tailored for state-level priorities.Your state health department will be able to provide you with state-specific objectives.Healthy People 2010Leading Health Indicators (www.healthypeople.gov/LHI/)¥HEDIS: Health Plan Employer Data Set performance measures (www.ncqa.org/Programs/HEDIS/)Guide to Clinical Preventive Services(www.ahrq.gov/clinic/uspstfix.htm)Guide to Community Preventive Services(www.thecommunityguide.org)¥National Guideline Clearinghouse (www.guideline.gov)¥www.PreventionInfo.org has links to resources for intervention implementation¥Framework for Program Evaluation in Public Health can be found at www.cdc.gov/mmwr/PDF/RR/RR4811.pdf¥Resour

ces for implementing interventions are a
ces for implementing interventions are available in the Community Tool Box,http://ctb.ku.edu¥Approaches to help you etwork with evidence-based tools areavailable at Cancer Control PLANET (http://cancercontrolplanet.cancer.gov)Figure IÐ1.Example of a logic framework.(Reprinted from Am J Prev Med,Vol.18,No.1S,Briss PA et al.,Reviews ofevidence regarding interventions to improve vaccination coverage in children,adolescents,and adults,p.99,Copyright2000,with permission from American Journal of Preventive Medicine.)scope of the Community Guide,excellent resources for this step exist.Briefly,the intervention must be well constructed, well implemented, and evaluated.Successful intervention implementation rests first with careful construc-tion of the intervention. Be advised that recommendationsare based on summaries of numerous individual interventions that had simi-lar components and were trying to achieve the same outcomes. Thus, the rec-ommendations are for conceptual categories rather than particular interven-tion programs that have been implemented elsewhere. Therefore, whendeveloping your local intervention, consider including all the components in-intervention re-view. Because it is rarely possible to determine how each component con-tributed to intervention effectiveness, recommendationsare for the entire constellation of components. Next, consider local needs, cul-ture, language, and political or social norms to help you adapt the intervention.Finally, consider how the intervention processes will be managed to make itsustainable over time.Related to intervention construction is the implementation itself. Resourcesfor implementing interventions well are available elsewhere (e.g., the Com-munity Tool Box, http://ctb.ku.edu). Interventions must be implemented wellto be effective. Timing, attention to detail, training of personnel, and buy-infrom stakeholders are all important in ensuring success. Finally, every inter-vention should be evaluated over time (using formal or informal methods) toensure that it is being implemented as intended and is achieving its desiredends. Excellent program evaluation resources are also available.7,9Ð12can help with objective setting (by identif

ying thetypes of outcomes and effect siz
ying thetypes of outcomes and effect size that can reasonably be expected from theinterventions) and with evaluation (by identifying the important outcomes tomeasure after an intervention is implemented). It is, however, primarily de-signed to provide a menu of effective population-based interventions (i.e.,itself is not a cookbook that showsyou how to implement the recommended interventions, although some im-plementation advice is provided in each chapter and additional informationis provided at www.thecommunityguide.org (see Table IÐ2). An example ofhow the can be used as part of comprehensive preventionplanning is provided in Table IÐ3.The systematic review process has three possible results: we learn that anintervention is effective, that it is ineffective or harmful, or that evidence is in-sufficient to determine its effectiveness. Any of these findings is important in-formation for decision making. Thus, the knowledge gaps identified throughtion of research beyond that needed for appropriate replication and help al-locate limited research resources more efficiently.is an important resource for identifying researchgaps, but the Task Force has purposely not established an order of priority foraddressing the questions identified through their systematic review process.Research agenda setting is largely driven by the priorities and resources of thevarious organizations and government agencies that fund and conduct re-search. Thus, it is left to those groups to determine how to set priorities amongthe various research questions identified here.SUMMARYis a resource for selecting interventions to improvehealth and prevent disease. Systematic reviews of published literature in threekey areasÑchanging risk behaviors; reducing specific diseases, injuries, andimpairments; and addressing environmental and ecosystem challengesÑprovide evidence-based answers to three basic questions: What has workedfor others and how well? How can I select among interventions of proveneffectiveness? What might this intervention cost, and what am I likely toachieve through my investment? The is also a resource foridentifying areas where additional research is needed.is really a family of products, of wh

ich this book isone part. The other part
ich this book isone part. The other parts are a website, www.thecommunityguide.org, andarticles published in peer-reviewed journals. Many different audiences willuseful, including public health professionals,healthcare service providers, purchasers of health care, employers, legisla-tors, community-based organizations, and researchers. The is part of comprehensive planning for prevention activities, which includes) setting objectives to measure progress; (effective interventions (this is where the ) implementing the selected interventions.can be a valuable tool in helping you decide howto allocate limited resources and achieve desired outcomes.AcknowledgmentsThis chapter was written by Stephanie Zaza, MD, MPH, Office of the Director, Na-tional Center for Chronic Disease Prevention and Health Promotion, Centers for DiseaseControl and Prevention (CDC), Atlanta, Georgia; Peter A. Briss, MD, MPH, CommunityGuide Branch, Division of Prevention Research and Analytic Methods (DPRAM), Epi-demiology Program Office (EPO), CDC, Atlanta; Jonathan E. Fielding, MD, MPH, MBA,Los Angeles Department of Health Services, University of California School of PublicHealth, Los Angeles, and the Task Force on Community Preventive Services; BradfordA.Myers, MPH, Community Guide Branch, DPRAM/EPO/CDC, Atlanta; and Steven M.Teutsch, MD, MPH, Outcomes Research and Management, Merck & Co., Inc., West Point,Pennsylvania.1. Zaza S, Lawrence RS, Mahan CS, et al. Scope and organization of the Guide tocommunity preventive services. Am J Prev Med 2000;18(1S):27Ð34.2. U.S. Preventive Services Task Force. Guide to clinical preventive services: report ofthe U.S. Preventive Services Task Force. 2nd ed. Baltimore: Williams & Wilkins, 1996.3. Glass GV. Primary, secondary, and meta-analysis. Educ Res 1976;5:3Ð8.4. The Cochrane Collaboration. The Cochrane Library. Available at www.cochrane.org. Accessed March 26, 2004.5. McGinnis JM, Foege W. Guide to community preventive services: harnessing thescience [commentary]. Am J Prev Med 2000;18(1S):1Ð2.6. U.S. Department of Health and Human Services. Healthy people 2010. 2nd ed.Washington, DC: U.S. Government Printing Office, 2000.7. Brownson RC, Baker EA, Leet TL, Gillespie

KN. Evidence-based public health. NewYo
KN. Evidence-based public health. NewYork: Oxford University Press, 2003.8. Green LW, Kreuter MW. Health promotion planning: an educational and ecologicalapproach. 3rd ed. Mountain View, CA: Mayfield, 1999.9. Goodman RM. Principals and tools for evaluating community-based preventionand health promotion programs. J Public Health Manag Pract 1998;4(2):37Ð47.10. Israel BA, Cummings KM, Dignan MB, et al. Evaluation of health education pro-grams: current assessment and future directions. Health Educ Q 1995;22(3):364Ð89.11. Rossi PH, Freeman HE, Lipsey MW. Evaluation: a systematic approach. 6th ed.Thousand Oaks, CA: Sage, 1999.12. Center for Disease Control and Prevention. Framework for program evaluation inpublic health. MMWR 1999;48(RR-11):1Ð40.This book is out of print. For current reviews, visit www.thecommunityguide.orgtion of research beyond that needed for appropriate replication and help al-locate limited research resources more efficiently.is an important resource for identifying researchgaps, but the Task Force has purposely not established an order of priority foraddressing the questions identified through their systematic review process.Research agenda setting is largely driven by the priorities and resources of thevarious organizations and government agencies that fund and conduct re-search. Thus, it is left to those groups to determine how to set priorities amongthe various research questions identified here.SUMMARYis a resource for selecting interventions to improvehealth and prevent disease. Systematic reviews of published literature in threekey areasÑchanging risk behaviors; reducing specific diseases, injuries, andimpairments; and addressing environmental and ecosystem challengesÑprovide evidence-based answers to three basic questions: What has workedfor others and how well? How can I select among interventions of proveneffectiveness? What might this intervention cost, and what am I likely toachieve through my investment? The is also a resource foridentifying areas where additional research is needed.is really a family of products, of which this book isone part. The other parts are a website, www.thecommunityguide.org, andarticles published in peer-reviewed

journals. Many different audiences willu
journals. Many different audiences willuseful, including public health professionals,healthcare service providers, purchasers of health care, employers, legisla-tors, community-based organizations, and researchers. The is part of comprehensive planning for prevention activities, which includes) setting objectives to measure progress; (effective interventions (this is where the ) implementing the selected interventions.can be a valuable tool in helping you decide howto allocate limited resources and achieve desired outcomes.AcknowledgmentsThis chapter was written by Stephanie Zaza, MD, MPH, Office of the Director, Na-tional Center for Chronic Disease Prevention and Health Promotion, Centers for DiseaseControl and Prevention (CDC), Atlanta, Georgia; Peter A. Briss, MD, MPH, CommunityGuide Branch, Division of Prevention Research and Analytic Methods (DPRAM), Epi-demiology Program Office (EPO), CDC, Atlanta; Jonathan E. Fielding, MD, MPH, MBA,Los Angeles Department of Health Services, University of California School of PublicThis book is out of print. For current reviews, visit www.thecommunityguide.orgthe systematic review process are an important product.Chapter 12, Continuing Research Needs, can guide the organizations andgovernment agencies that fund research to important but understudied areas.In addition, that chapter can guide researchers to important areas for devel-oping research programs and requests for research funding.reviews identify promising but understudied areas withimportant public health implications. They can also reduce excessive repeti-Table IÐ3.for Strategic Intervention Selection and Implementation:Improving Influenza Vaccination RatesImagine that your goal is to increase influenza vaccination rates among adults aged 65years and older. In Chapter 6, ÒVaccine-Preventable Diseases,Ó youlearn that vaccine rates might be low in your population because:1.People lack knowledge about or have attitudinal barriers to being vaccinatedagainst a particular disease.2.People know that they need to be vaccinated but do not have access to vaccina-tion services.3.People know that they need to be vaccinated and have access to services, butproviders or healthcare system

s are missing opportunities to vaccinate
s are missing opportunities to vaccinate.To select an intervention, itÕs important to know which of these three problems areoccurring or in what combinations they are occurring. You conduct a survey and findthat vaccination rates are lower than the national average and that 80% of unvacci-nated adults were seen in healthcare settings during the last vaccination year but thatinfluenza vaccine wasnÕt offered. Thus, you decide to start with an intervention tohelp providers and healthcare systems offer the vaccine more consistently.Armed with this information, you turn to the section on Provider-and System-Based Interventions for increasing coverage with universally recom-mended vaccines (vaccines, like influenza vaccine, recommended for all people in aparticular age group). This section identifies standing orders programs as an effectivestrategy that can be implemented in clinics or managed care organizations. Togetherwith your partners from local health plans, you collect more information about imple-menting such programs,and you determine that there are no local legal, regulatory,or other barriers to implementing these programs in your area. You then decide toimplement a standing orders program that identifies clients needing the vaccine andallows nurses to provide the vaccine without direct physician involvement at the timeof the vaccination.recommendation for standing orders means that these pro-grams, which allow identification of people needing vaccination and allow them to bevaccinated without direct physician involvement at the time of the visit, generallyhave been shown to be effective in a variety of settings. As already noted, the imple-mentation of such a program will vary based on characteristics of the local clinicalsetting (e.g., inpatient or outpatient, staff model HMO versus health departmentclinic) and on characteristics of the local legal and regulatory environment. However,looking at the applicability of the intervention review, you find that reasonably consis-tent results occurred across a broad range of populations, settings, and interventioncharacteristics, increasing your confidence that the interventionÕs effectiveness will berobust when it is adapted i

n your local context.This book is out o
n your local context.This book is out of print. For current reviews, visit www.thecommunityguide.orgscope of the Community Guide,excellent resources for this step exist.Briefly,the intervention must be well constructed, well implemented, and evaluated.Successful intervention implementation rests first with careful construc-tion of the intervention. Be advised that recommendationsare based on summaries of numerous individual interventions that had simi-lar components and were trying to achieve the same outcomes. Thus, the rec-ommendations are for conceptual categories rather than particular interven-tion programs that have been implemented elsewhere. Therefore, whendeveloping your local intervention, consider including all the components in-intervention re-view. Because it is rarely possible to determine how each component con-tributed to intervention effectiveness, recommendationsare for the entire constellation of components. Next, consider local needs, cul-ture, language, and political or social norms to help you adapt the intervention.Finally, consider how the intervention processes will be managed to make itsustainable over time.Related to intervention construction is the implementation itself. Resourcesfor implementing interventions well are available elsewhere (e.g., the Com-munity Tool Box, http://ctb.ku.edu). Interventions must be implemented wellto be effective. Timing, attention to detail, training of personnel, and buy-infrom stakeholders are all important in ensuring success. Finally, every inter-vention should be evaluated over time (using formal or informal methods) toensure that it is being implemented as intended and is achieving its desiredends. Excellent program evaluation resources are also available.7,9Ð12can help with objective setting (by identifying thetypes of outcomes and effect size that can reasonably be expected from theinterventions) and with evaluation (by identifying the important outcomes tomeasure after an intervention is implemented). It is, however, primarily de-signed to provide a menu of effective population-based interventions (i.e.,itself is not a cookbook that showsyou how to implement the recommended interventions, although some im-pl

ementation advice is provided in each ch
ementation advice is provided in each chapter and additional informationis provided at www.thecommunityguide.org (see Table IÐ2). An example ofhow the can be used as part of comprehensive preventionplanning is provided in Table IÐ3.The systematic review process has three possible results: we learn that anintervention is effective, that it is ineffective or harmful, or that evidence is in-sufficient to determine its effectiveness. Any of these findings is important in-formation for decision making. Thus, the knowledge gaps identified throughThis book is out of print. For current reviews, visit www.thecommunityguide.orgpense of buying a child safety seat). Or it might be aggravated by missed op-portunities within the healthcare system (e.g., failure to identify a patientwho smokes and to provide appropriate counseling and therapy). To selectan intervention, itÕs important to know what problems are occurring or inwhat proportion they are occurring. Note that the address all of the possible interventions that could be or have been used fora particular health issue. Inclusion in the is not a prereq-uisite for implementing an intervention, particularly if it is a new interven-tion being tested for its effectiveness. Some chapters in-clude lengthy lists of intervention strategies that are applicable to the topicbut have not been reviewed. However, you should take into account whetheror not sufficient human and financial resources exist to develop, implement,and evaluate new or untested interventions.Once youÕve determined the nature of the problem youÕre trying to ad-dress, the remainder of the interventions designed to address these specific areas. YouÕll find out whetherthe intervention has been shown to be effective, ineffective, or if thereÕs notenough information yet to make a decision about effectiveness. And, for mostinterventions, youÕll find the effect size and variability that might be expectedfrom implementing the intervention.With the list of intervention options narrowed, the helps you assess several other issues that should be taken into account. Forexample, you might be interested in the applicability of various interventionsto different settings and populatio

ns. Where has the intervention been im-p
ns. Where has the intervention been im-plemented successfully? In which populations has the intervention worked?For all interventions for which effectiveness has been established, our appli-cability information addresses both questions. In addition, citations for thestudies included in the review allow you to refer back to the original studiesor study authors.Whenever sufficient information is available, a systematic review of thecosts, cost effectiveness, or costÐbenefit of each effective intervention is pro-vided to help you determine if you can afford to implement the interventionand what can be achieved through your investment (see Chapter 11, Under-standing and Using the Economic Evidence Provided in the ). Each review also includes information on other possible benefits andharms of the intervention. Finally, each review includes information on bar-riers you might encounter in implementing the intervention.Implement and Evaluate the Selected InterventionsCareful action planning is key to successful implementation of an interven-tion. Although a comprehensive treatment of action planning is beyond theThis book is out of print. For current reviews, visit www.thecommunityguide.orgFigure IÐ1.Example of a logic framework.(Reprinted from Am J Prev Med,Vol.18,No.1S,Briss PA et al.,Reviews ofevidence regarding interventions to improve vaccination coverage in children,adolescents,and adults,p.99,Copyright2000,with permission from American Journal of Preventive Medicine.)This book is out of print. For current reviews, visit www.thecommunityguide.orglection. Other resources assist planners and decision makers with the othersteps (see Table IÐ2). Together, these resources can help you develop a compre-hensive prevention plan for your patients, workers, students, or communitymembers. Four key steps are briefly described below. At each step, involve-ment of stakeholders, recognition of intermediate objectives, monitoring ofthe process, and feedback of results are critical.Assess the Primary Health Issues within Your State,Community,Workplace,School,or Health SystemEvidence-based decision making requires data at each step in the process. Forthis first step, it is important to kno

w which health problems and risk factors
w which health problems and risk factorsare prevalent in the community or population of interest and which healthoutcomes are frequent, severe, or costly. Understanding which health issuesare a priority for the population, the local human and financial resources, andthe political acceptability of addressing certain topics in a community is alsoIdentifying stakeholders and soliciting and incorporating their input at thisand all steps in the prevention process is crucial for successfully identifyingand addressing health issues. Planning tools are available to help in identify-ing and addressing priority health areas, and to work effectively with stake-holders (see Table IÐ2).Progress in Addressing Primary Health IssuesOnce you identify which health issues are priorities to address, it is helpfulto set specific objectives. Objectives should be reasonably attainable and mustbe measurable. Again, stakeholder input is important in selecting objectivesso that measuring progress toward objectives will be enthusiastically endorsedby community members. Objective-setting resources for public and privateentities are available (see Table IÐ2).Select Effective Interventions to Help Achieve Objectivesis a primary resource for this step. Most chapters inlogic frameworkor conceptual model for the topic cov-ered in that chapter (for an example, see Figure IÐ1). The logic frameworkhelps to identify the different ways in which the problem might be addressedand is essential for selecting appropriate interventions. For example, a healthproblem may be caused or complicated by a lack of knowledge on the part ofthe community members (e.g., not knowing when to get flu shots). It mightbe caused by the inaccessibility of health care or other resources (e.g., the ex-This book is out of print. For current reviews, visit www.thecommunityguide.orgzations can select effective interventions for their populations and advocatefor adoption of effective interventions by their local governments. Researchersto identify research gaps and advocate forfunding to conduct research to fill those gaps. In addition, researchers canevaluation criteria (see Chapter 10) to en-sure that their studies and reports are of the

highest quality and eligible forreviews.
highest quality and eligible forreviews. Educators and studentsin all of these arenas can use the as part of comprehensivetraining in evidence-based public health and prevention decision making.IS PART OF COMPREHENSIVE PREVENTION PLANNINGComprehensive program planning involves a series of activities: assessment,priority setting, objective setting, intervention selection, implementation, andevaluation.primarily assists with intervention se-Table IÐ2.Assessment¥National Public Health Performance Standards (www.naccho.org/project48.cfm)¥MAPP: Mobilizing for Action through Planning and Partnerships (www.naccho.org/ project77.cfm)¥APEX-PH: Assessment Protocol for Excellence in Public Health (www.naccho.org/project47.cfm)Healthy People 2010objectives (www.healthypeople.gov)In most states, Healthy People objectives have been tailored for state-level priorities.Your state health department will be able to provide you with state-specific objectives.Healthy People 2010Leading Health Indicators (www.healthypeople.gov/LHI/)¥HEDIS: Health Plan Employer Data Set performance measures (www.ncqa.org/Programs/HEDIS/)Guide to Clinical Preventive Services(www.ahrq.gov/clinic/uspstfix.htm)Guide to Community Preventive Services(www.thecommunityguide.org)¥National Guideline Clearinghouse (www.guideline.gov)¥www.PreventionInfo.org has links to resources for intervention implementation¥Framework for Program Evaluation in Public Health can be found at www.cdc.gov/mmwr/PDF/RR/RR4811.pdf¥Resources for implementing interventions are available in the Community Tool Box,http://ctb.ku.edu¥Approaches to help you etwork with evidence-based tools areavailable at Cancer Control PLANET (http://cancercontrolplanet.cancer.gov)This book is out of print. For current reviews, visit www.thecommunityguide.orgreviews, short (one- or two-page) summaries of chap-ters and interventions, additional intervention reviews and updates com-pleted after the publication of this book, and slide sets for use in presenta-tions or training. For each review, details on each study included are providedin tables. Finally, links from the home page provide access to resources thatinterventions to related Healthy People 2010ject

ives, to related Guide to Clinical Preve
ives, to related Guide to Clinical Preventive Servicesinterventions, and to some helpful information about how to implement interventions recom-Community Guide.HOW DIFFERENT AUDIENCES CAN USE THE can be used by decision makers in a variety of set-tings. Public health professionals can use the for programplanning and to encourage the use of effective interventions through grantguidance and planning criteria. They can also focus research on the knowl-edge gaps identified through the systematic review processor seek resources for additional studies. Healthcare service providers can im-plement effective healthcare system interventions (e.g., provider remindersystems) to improve the delivery of effective clinical preventive services (e.g.,advising patients to quit using tobacco products). Purchasers of health care(e.g., employers or state Medicaid officials) can use the construct and select benefit plans (e.g., reducing patientsÕ out-of-pocket costsfor vaccines or tobacco cessation therapies). In addition, employers can useto implement workplace interventions and to partici-pate in community planning efforts. Legislators and other elected officialscan support population health by enacting effective legislation (e.g., smokingbans, child safety seat laws, vaccination requirements for school admission,water fluoridation). Table IÐ1 provides an example of how a recommendation influenced lifesaving legislation. Community-based organi-Table IÐ1.Evidence-Based Recommendations at WorkAn example of successful implementation of recommended interventions from theillustrates the power and importance of evidence-based informa-tion. In 2001, the recommendation for reducing the legal bloodalcohol concentration (BAC) limit for adult drivers from 0.10% to 0.08% was influen-tial in the decision of the U.S. Congress to include a requirement that all states passsuch legislation or risk losing some federal highway construction funds. At the timethe law was passed, 17 states had 0.08% BAC laws on their books. By the end of2004, all 50 states, the District of Columbia, and Puerto Rico had enacted 0.08% BAClaws. Although most states had multiple laws aimed at reducing alcohol-impaireddriving, this chan

ge should save at least 400Ð600 lives e
ge should save at least 400Ð600 lives each year.This book is out of print. For current reviews, visit www.thecommunityguide.orgA FAMILY OF PRODUCTSis a family of products that provides systematic reviewfindings, recommendations, and other types of information in different formats.The Guide to Community Preventive Services: What Works to Promote Health?This book provides a snapshot of the information available through late 2003. Following this chapter, the intervention reviews are organized into two) Changing Risk Behaviors and Addressing Environmental Challenges) Reducing Disease, Injury, and Impairment. Each part contains chap-ters about specific topics, and each chapter covers about 5Ð20 different inter-ventions.As mentioned, all topics of importance in public health are not yet ad-dressed directly (e.g., cardiovascular disease or HIV/AIDS). However, manychapters contain information directly relevant to these two and other criticalhealth issues (e.g., the chapters on tobacco and physical activity are relevantfor reducing cardiovascular disease). As you consult this book, keep in mindthat interventions in one or more chapters might be useful to achieve relatedobjectives (e.g., the chapters on tobacco, cancer, and physical activity mightbe used together to achieve a cancer reduction goal).Journal ArticlesBecause book publications can provide information available at only onepoint in time, reviews are published in journals as they arecompleted. In addition, journal publication has allowed for rapid dissemina-tion of the Task ForceÕs findings in advance of publication in book format.reviews and recommendations are publishedMorbidity and Mortality Weekly Report (Recommendations and ReportsDetailed scientific information about each systematic review is pub-American Journal of Preventive Medicine). Accompanyingarticles are editorial commentaries from a variety of expertsdescrib-ing how different audiences can use the (e.g., managedcare, public health, or voluntary organizations). Finally, various articles aboutCommunity Guide,specific recommendations, and other aspects of theinitiative occasionally appear in other journals.The WebsiteThe website www.thecommunityguide.org is the

most comprehensive andThis book is out
most comprehensive andThis book is out of print. For current reviews, visit www.thecommunityguide.orginterventions are intended to improve health directly; prevent or reduce riskybehaviors, disease, injuries, complications, or detrimental environmental orsocial factors; or promote healthy behaviors and environments. Diagnosticand treatment interventions are not covered in the Community Guide,nor arethe clinical preventive services provided by a healthcare professional to anindividual patient. Clinical preventive services are reviewed in the Clinical Preventive Services.Together, the provide information on a broad range of preventive services applicableto individuals and populations.vicesÕ committed effort to strengthen the scientific basis for public healthpractice. The is led by the independent Task Force on Com-munity Preventive Services (the Task Force), composed of nonfederal expertsfrom diverse backgrounds. The work of the Task Force is supported by staffat the Centers for Disease Control and Prevention and by numerous other fed-eral and nonfederal experts.NOT JUST ANY SET OF GUIDELINESuses a technique known as a systematic reviewto pro-vide scientific evidence of the effectiveness of interventions. Recommendationsare explicitly linked to this evidence and are therefore evidence-based. Sys-tematic reviews are conducted according to methods and processes intendedto be comprehensive and to minimize bias in the review process. The meth-ods, processes, and rationale for systematic reviews areprovided in Chapter 10. Systematic reviews have undergone considerable de-velopment in the social sciences, statistics, epidemiology, medicine, and otherdisciplines since the 1960s as tools to improve the quality of scientific litera-ture synthesis.They are increasingly popular for summarizing informationon the efficacy of medical treatmentsand clinical preventive services,are sometimes used as the foundation for developing clinical practice guide-lines. The systematic review is also a useful methodology for summarizingthe effectiveness of public health and population-based interventions. Theinitiative is a large, high-profile, well-regarded example ofthe application of systematic revi

ew methods to population-oriented health
ew methods to population-oriented healthinterventions in the United States. The use of systematic reviews to supportlic health to the same level of scientific scrutinyÓ as clinical care.This book is out of print. For current reviews, visit www.thecommunityguide.orgIntroduction: How to Use TheGuide to Community Preventive ServicesWHAT IS THE TheGuide to Community Preventive) is a resource to help you select interventions to improve health andprevent disease in your state, community, community organization, business,healthcare organization, or school. It is designed to answer three questions:1.What has worked for others and how well?2.How can I select among interventions with proven effectiveness?3.What might this intervention cost, and what am I likely to achievethrough my investment?is also a resource for researchers and research fundersto identify important gaps in what we know and to determine how to allo-cate scarce research funds.reviews evidence about interventions designed to im-prove health across a wide range of topics. Interventions that combat such riskybehaviors as tobacco use, physical inactivity, and violence are included. Otherreviewed interventions address specific health conditions such as cancer, dia-betes, vaccine-preventable diseases, and motor vehicle injuries. Interventionsthat address the broad social determinants of health such as education, hous-ing, and access to care are also reviewed in the Community Guide.Even withthis broad scope, the is not comprehensive. These initialtopics were chosen because together they address the health behaviors, dis-eases, injuries, and social factors that impose the greatest burden of suffer-ing and that offer the broadest range of intervention opportunities.vention reviews are underway for a number of additional topics includingnutrition, improving pregnancy outcomes, and reducing depression. In addi-tion, we are updating and expanding most of the chapters in this book.For each of these broad topics, interventions that promise to improve im-portant health outcomes are reviewed. (For criteria used to select interven-tions for review, see Chapter 10, Methods Used for Reviewing Evidence andLinking Evidence to Recommenda

tions in the Community Guide.ventions ar
tions in the Community Guide.ventions are applicable to groups, communities, or other populations and in-clude strategies such as healthcare system changes, public laws, workplaceand school programs and policies, and community-based programs. All of theThis book is out of print. For current reviews, visit www.thecommunityguide.orgChapter 10, ÒMethods Used for Reviewing Evidence and Linking Evidenceto Recommendations in the Community Guide,Ó explains the basics of themethodology used to select topic areas for review, as well as the systematicreview methods used to evaluate interventions and the ways in which evi-dence is linked to Task Force recommendations.Chapter 11, ÒUnderstanding and Using the Economic Evidence Provided inCommunity Guide,Ó provides an orientation to the kinds of economicanalyses used in the to evaluate public health interven-tions, as well as general information about how the economic reviews for theare conducted.Chapter 12, ÒContinuing Research Needs: Scientific Challenges and Op-portunities,Ó discusses the implications of the finding that available evidenceis insufficient to determine the effectiveness of an intervention and that ad-ditional research is needed.UNDERSTAND OUR TERMINOLOGYIn the Glossary, we define terms as they are used in the Community Guide.Table CÐ1.How Reviews of Interventions Are Presented in This BookIntervention Name, Recommendation or Finding, and Strength of Evidence for Recommended InterventionsOne or two short paragraphs describing this type of intervention¥Bulleted list of key findings on effectiveness and, as appropriate, applicability, othereffects, economic efficiency, and/or barriers to implementationOne or two paragraphs describing specific characteristics of the interventions studiedfor this reviewFindings of the systematic review in the following order:EffectivenessOther (positive or negative) effects of the interventionPotential barriers to implementationConclusionÑsummary of key findingsInformation on applicability, economic efficiency, and potential barriers to implementation is in-cluded only for recommended interventions.If no other effects have been found, this section is not included.This book is out o

f print. For current reviews, visit www
f print. For current reviews, visit www.thecommunityguide.orgWhat do you want to find in this book? HereÕs where to look.Chapters 1Ð9 each cover a specific topic area. Each chapter follows this pattern:Title page,listing all interventions and findings included in the chapter, whenthe research was conducted, and where this information has been published.Introductionto the topic area, including the public health burden it poses.Recommendations from other advisory groups,Healthy People 2010goals and objectives in this topic area, as well as information from othergroups and agencies.a brief summary of methods used in this topic area to evaluatethe effectiveness of interventions.economic efficiency of all recommended interventions.Recommendations and findings:¥Interventions are grouped under strategies (e.g., in Tobacco, the threestrategies reviewed are Reducing Tobacco Use Initiation, Increasing TobaccoUse Cessation, and Reducing Exposure to Environmental Tobacco Smoke).¥One or two paragraphs give a general introduction to the strategy.¥A summary of the published findings is provided for each intervention (seeTable CÐ1).Using these recommendations:additional considerations for deciding if useof a particular intervention is appropriate to your situation.summary of the interventions reviewed in this area and the rec-ommendations or findings.SEE ALL RECOMMENDATIONS AND FINDINGS OF THE TASK FORCE LISTED ALPHABETICALLY BY TOPICThe Appendix provides this list.GET A BETTER UNDERSTANDING OF The Introduction, ÒHow to Use TheGuide to Community Preventive Ser-vices,Ó serves as an orientation to the Community Guide,discussing variousaspects of this book, as well as related publications and our website, www.thecommunityguide.org.This book is out of print. For current reviews, visit www.thecommunityguide.org8Motor Vehicle Occupant InjuryChild Safety Seats,Safety Belts,Alcohol-Impaired Driving9ViolenceHome Visitation,Therapeutic Foster Care,Firearms Laws10Methods Used for Reviewing Evidence and Linking Evidence to Recommendations11Understanding and Using the Economic Evidence12Continuing Research NeedsGlossary477Appendix483Index493This book is out of print. For current reviews, visi

t www.thecommunityguide.orgConventions
t www.thecommunityguide.orgConventions Used in This BookIntroduction:How to Use The Guide to Community Preventive Services1TobaccoReducing Initiation,Increasing Cessation,Reducing Exposure to Environmental Tobacco Smoke2Physical ActivityIncreasing Physical Activity through Informational Approaches,Behavioral and Social Approaches,and Environmental and Policy Approaches3The Social EnvironmentEarly Childhood Development Programs,Housing,Part II: Reducing Disease, Injury, and Impairment4CancerPreventing Skin Cancer,Promoting Informed Decision Making5DiabetesDisease Management,Case Management,Diabetes Self-Management Education6Vaccine-Preventable DiseasesImproving Vaccination Coverage through Increasing Community Demand,Enhancing Access to Vaccination Services,and through Provider- and System-Based Interventions7Oral HealthDental Caries,Oral and Pharyngeal Cancers,Sports-Related Craniofacial InjuriesThis book is out of print. For current reviews, visit www.thecommunityguide.orgThis book is out of print. For current reviews, visit www.thecommunityguide.orgBenedict I. Truman, MD, MPHKaren Taylor Valverde, MAJulie A. WasilCarla D. WayeLori L. Westphal, MA, MPHLinda Wright-De AgŸero, PhD, MPHLinda C. Yarbrough, BSPatrice Young-Curtis, MSHCAStephanie Zaza, MD, MPH (Branch ChiefÑ1999Ð2003)AcknowledgmentsThis book is out of print. For current reviews, visit www.thecommunityguide.orgCynthia C. LyonsMike V. Maciosek, PhDRika Maeshiro, MD, MPHMelissa McPheeters, PhD, MPHWasseem Mina, MAGerald A. Mumma, PhDSerigne Ndiaye, PhDPhyllis J. Nichols, MPHEnrique Nieves, MS (Deputy Branch ChiefÑ2001Ð2003)Susan L. Norris, MD, MPHMarguerite Pappaioanou, DVM, PhD (Branch Chief, 1996ÐJeri D. Pickett, MSMummy Warda Rajab, MSLeigh T. Ramsey, PhDVicki RathelDavid Rebanal, MPH, CHESConnie Ricard, MPH, CHESIdania RodriguezJ. Niels Rosenquist, BSJoseph (Jay) Roth, MPHJoseph St. Charles, MPAMona Saraiya, MD, MPHCarolynne Shinn, MSRuth A. Shults, PhD, MPHPomeroy Sinnock, PhDLynne T. Smith, PhD, MPH, RDNancy Smith, MHPAS. Jay Smith, MIS, MSSusan R. Snyder, PhDJonathan StevensGlenda A. Stone, PhDBernice Tannor, MPHCraig Thomas, PhDAcknowledgmentsThis book is out of print. For current reviews, v

isit www.thecommunityguide.orgOTHER AUT
isit www.thecommunityguide.orgOTHER AUTHORS,RESEARCHERS,AND STAFF WHO HAVE BEEN PART OF THE COMMUNITY GUIDE INITIATIVEGeorgina Agyekum, MPHFemi Alao, PhDTara J. Balsley, MPHRosalind Breslow, PhD, MPHS. Scott Brown, MPHVilma G. Carande-Kulis, PhD, MS (Branch ChiefÑPrevention Effectiveness:2001Ð2004)Linda Carnes, DrPAJuanita ChukwaraPhaedra Corso, PhDDebjani Das, MPHTanisha Denny, MPHTho Bella Dinh-Zarr, PhD, MPHApril DixonErica Dunbar, MPHRandy W. Elder, PhDErin Finley, BAAdele Franks, MDPrethibha George, MPHLynn Gibbs, MPHKathleen Green-Raleigh, PhDKathy W. Grooms, BSPrakash L. Grover, PhD, MPHDonna Higgins, PhDKrista Hopkins, MPHAngela B. Hutchinson, PhDLisa Jeannotte, MAEvelyn Johnson, PhDEmily B. Kahn, PhD, MPHKarol Kumpfer, PhDAmy LevinsonJessica Lowy, MPH, CHESAcknowledgmentsThis book is out of print. For current reviews, visit www.thecommunityguide.orgOTHER COMMUNITY GUIDE PARTNERSScott Grosse, PhDÑCenters for Disease Control and PreventionKenji Hayashi, MDÑInstitute of Public Health, JapanHazel K. Keimowitz, MAÑretired from Agency for Healthcare Research andSally Herndon Malek, MPHÑNorth Carolina Department of Health and HumanServices, RaleighJames L. Nichols, PhDÑretired from National Highway Transportation SafetyAdministration, Washington, DCC. Tracy Orleans, PhDÑRobert Wood Johnson FoundationDeborah S. Porterfield, MD, MPHÑDepartment of Social Medicine, Univer-sity of North Carolina at Chapel HillCONSULTANTS FOR THE SYSTEMATIC REVIEWSEach team of consultants is listed at the end of the chapter to which they lenttheir expertise.STAFFÑCURRENTPeter A. Briss, MD, MPH (Branch ChiefÑSajal K. Chattopadhyay, PhD (Branch ChiefÑPrevention Effectiveness)Brad Myers, MPHLaurie M. Anderson, PhD, MPHRoy C. Baron, MD, MPHCarolyn Beeker, PhDDawna S. Fuqua-Whitley, MARobert A. Hahn, PhD, MPHKate W. Harris, BADavid P. Hopkins, MD, MPHGail R. Janes, PhD, MSStella Kozlova, MPHAmy Lovvorn, MPHAngela K. McGowan, JD, MPHTarra K. McNally, MA, MPHTony Pearson-Clarke, MSCornelia K. White, PhDAcknowledgmentsThis book is out of print. For current reviews, visit www.thecommunityguide.orgDavid Atkins, MD, MPHÑAgency for Healthcare Research and Quality, Rock-ville, MDRonald Bialek

, MPPÑPublic Health Foundation, Washing
, MPPÑPublic Health Foundation, Washington, DCHudson H. Birden, Jr., MPHÑNorthern Rivers University Department ofRural Health, University of Sydney, AustraliaDaniel S. Blumenthal, MD, MPHÑAssociation of Teachers of PreventiveMary B. Burdick, PhD, RNÑDepartment of Veterans Affairs, Durham, NCBill Calvert, MS, MPH, MBAÑU.S. Navy Environmental Health Center, Ports-mouth, VAJoseph Chin, MD, MSÑCenters for Medicare and Medicaid Services, Balti-more, MDNathaniel Cobb, MDÑIndian Health Service, Albuquerque, NMArthur B. Elster, MDÑAmerican Medical Association Jessie Gruman, PhDÑCenter for the Advancement of Health, Washington, DCTom Houston, MDÑAmerican Medical AssociationJames D. Leeper, PhDÑAmerican Public Health AssociationRose Martinez, ScDÑInstitute of Medicine, Washington, DCRobert J. McNellis, MPH, PA-CÑAmerican Academy of Physician Assistants,Alexandria, VAEmmeline Ochiai, MPHÑOffice of Disease Prevention and Health Promotion,Washington, DCBob Rehm, MBAÑAmerican Association of Health Plans, Washington, DCJordan H. Richland, MPHÑAmerican College of Preventive Medicine, Wash-Elizabeth S. Safran, MD, MPHÑAmerican Association of Public HealthPhysiciansRuth Sanchez-Way, PhDÑSubstance Abuse and Mental Health Services Ad-ministration, Rockville, MDJames H. Scully, Jr., MDÑNational Association of State Mental Health Pro-gram DirectorsHarrison Spencer, MDÑAssociation of Schools of Public Health, Washing-Col. Linda Spencer, PhD, RNÑU.S. Army Kristy Straits-Troster, PhDÑV.A. National Center for Health Promotion andDisease Prevention, Durham, NCJonathan B. VanGeest, PhDÑAmerican Medical AssociationMartina Vogel-Taylor, MT(ASCP)ÑNational Institutes of Health, Bethesda, MDDeborah Willis-Fillinger, MD, MPHÑHealth Resources and Services Admin-istration, Rockville, MDSteven H. Woolf, MD, MPHÑAmerican College of Preventive Medicine, Fair-fax, VAAcknowledgmentsThis book is out of print. For current reviews, visit www.thecommunityguide.orgLynda A. Anderson, PhDSevgi O. Aral, PhDPeter A. Briss, MD, MPHBlake Caldwell, MD, MPHNancy E. Cheal, PhDJosŽ F. Cordero, MD, MPHAlison Kelly, MPIARichard Keenlyside, MDKenneth G. Keppel, PhDRaymond M. (Bud) Nicola, MD, MHSAPhil N

ieburg, MD, MPHMarguerite Pappaioanou, D
ieburg, MD, MPHMarguerite Pappaioanou, DVM, PhDJoseph A. Reid, PhDSteven L. Solomon, MDTerrie Stirling, PhDMichael H. Hennessey, PhD, MPHDavid V. McQueen, ScDÑNational Center for Chronic Disease Preventionand Health Promotion, CDCLance E. Rodewald, MDÑNational Immunization Program, CDCDavid A. Sleet, PhD, MAÑNational Center for Injury Prevention and Con-trol, CDCMichael A. Stoto, PhDÑRAND, Arlington, VASteven M. Teutsch, MD, MPHÑMerck & Co., Inc., West Point, PATASK FORCE LIAISONS CURRENT AND PASTJacqelyn Admire-Borgelt, MSPHÑAmerican Academy of Family Physicians,Leawood, KSJ. Frederick AgelÑNational Association of Local Boards of Health, Atlanta,AcknowledgmentsThis book is out of print. For current reviews, visit www.thecommunityguide.orgThis book is the result of years of research, conducted by many people. Fromthose who first proposed the idea of a Guide to Community Preventive Ser-vices in the early 1990s to those who continue to work every day to expandCommunity Guide,we express our thanks. If we leftanyone off this list, our sincere apologies.EARLY CONTRIBUTORS TO THE FORMATION OF THE COMMUNITY GUIDEClaude Earl Fox, MD, MPHÑJohns Hopkins Urban Health Institute, Balti-more, MDKristine M. Gebbie, DrPH, RNÑColumbia University, New York, NYCatherine Gordon, MDÑCenters for Disease Control and Prevention, Wash-William HarlanÑNational Institute of Mental Health, Bethesda, MDAlan R. Hinman, MD, MPHÑTask Force for Child Survival and Development,Atlanta, GADouglas B. Kamerow, MD, MPHÑEditor,BMJ USADouglas S. Lloyd, MD, MPHÑHealth Resources and Services Administration,Bureau of Health Professions, Rockville, MDJ. Michael McGinnis, MDÑRobert Wood Johnson Foundation, Princeton,David Satcher, MD, PhDÑNational Center for Primary Care, Morehouse Schoolof Medicine, Atlanta, GASteven M. Teutsch, MD, MPHÑMerck & Co. Inc., West Point, PARandy Wykoff, MD, MPH, TMÑProject HOPE, Millwood, Virginia (formerlyDeputy Assistant Secretary for HealthÑDisease Prevention and Health Pro-INTERNAL CDC EXECUTIVE ADVISORY COMMITTEEEdward L. Baker, MD, MPHÑCurrent affiliation, Public Health LeadershipInstitute, University of North CarolinaClaire V. Broome, MDJeffrey R. Harris, MD, MPHÑC

urrent affiliation, University of Washin
urrent affiliation, University of WashingtonDixie E. Snider, Jr., MD, MPHStephen B. Thacker, MD, MScThis book is out of print. For current reviews, visit www.thecommunityguide.orgfined a standard methodology to search for and sift through evidence from awide range of studies reflecting many disciplinary perspectives. Second, theTask Force determined which topics and interventions to address initially, ac-cording to the perceived value to practitioners and decision makers. Third, weapplied the methods to topics as diverse as immunization, physical activity,diabetes, motor vehicle occupant safety, and housing. Fourth, we developedan approach to translating the evidence into recommendations. Not onlywere we interested in reaching conclusions, we also wanted to help providemethods that others could use in similar pursuits.The material found in this guide, in related publications, and on our web-site, provides a transparent record that allows users to evaluate, from theirown perspectives, the credibility and prudency of the recommendations.The Task Force makes recommendations when enough good quality evi-dence is available. Unfortunately, in many areas the available evidence issparse. A major benefit of our efforts in developing the guide has been ourability to identify the gaps in our knowledge. Expanding public health re-search is critical to improving health and reducing health disparities in thefuture. The research needs reflected by this process assist CDC and others indeciding what kinds of research to support. Over time, use of this researchagenda can lead to better evidence and can provide answers that supportsound public health policy.This first edition of the guide summarizes an enormous body of work, yetit is just the beginning of a longer journey. Continued investment will beneeded, as we move ahead in our exploration of the topics already chosen,addressing new interventions and, as evidence becomes available, updatingour findings.The authors wish to acknowledge the enormous contributions of all whohave participated in this collective effort. We thank you, and hope that youwill continue to work with us as we pursue our goals of contributing to im-proving the health of

all Americans and reducing the persisten
all Americans and reducing the persistent health dis-parities that affect our communities.Jonathan E. Fielding, MD, MPH, MBAChair, Task Force on Community Preventive ServicesThis book is out of print. For current reviews, visit www.thecommunityguide.orgWhat do we know, how do we know it, and how can we use what we knowto improve the publicÕs health? These questions sparked the creation of theTask Force on Community Preventive Services.Anybody who makes or influences decisions that can affect the health ofpopulations deserves ready access to the best evidence on what works, forwhat purpose, and at what cost, in order to make good choices among poli-cies and to consider alternative uses of resources. This perceived need in per-sonal healthcare led to the establishment of the U.S. Preventive Services TaskForce and similar efforts to make available the best scientific evidence to sup-port decisions in various fields of medicine. Fundamental to all of these ef-forts was the development of standard approaches to search the literature forevidence; to identify and synthesize the subset of best evidence; and to trans-late it into specific recommendations for practitioners.Despite the success of this approach in improving medical care, somedoubted whether a complementary effort to assess interventions aimed atpopulations could succeed. Did high quality evidence exist in the broad do-main that constitutes public health? If so, could that evidence be harnessedIn 1996, the Department of Health and Human Services (HHS) acknowl-edged these concerns and committed to assessing and improving the qualityof knowledge about what works to improve population health by establish-ing the Task Force on Community Preventive Services. This action placed asolemn responsibility in the hands of a 15-member panel of experts and es-tablished a special relationship between the Task Force and the Centers forDisease Control and Prevention (CDC), an agency of HHS. CDC provides theresearch teams that gather and evaluate evidence on the effectiveness of awide array of public health interventions; the Task Force reviews this evidenceand uses it to makes decisions and recommendations. Other federal agencies,volunta

ry organizations, and many national expe
ry organizations, and many national experts also make importantcontributions to fulfilling the charge of the Task Force. CDC and other part-ners also are working to ensure the wide dissemination and use of the results.This book, a milestone reflecting important new work, is but one aspect ofthe combined work of the Task Force, CDC, and our many partners. Over thepast eight years, we have learned much about which public health interven-tions are effective, but to do this we had to develop credible, reproduciblemethods to amass and weigh evidence. First, we developed, tested, and re-This book is out of print. For current reviews, visit www.thecommunityguide.orgevidence, and the recommendationsÑare accurate, meaningful, and useful.Icongratulate the Task Force for this productive collaboration and the exampleit sets for all of us as we work to improve our nationÕs health and well-being. As a nation, we have set challenging goals for improving the health of allAmericans. Only by working togetherÑas clinicians, healthcare executives,employers, public health professionals, researchers, policymakers, and com-munity health workersÑwill we meet those sweeping goals. Community Preventive Serviceswill surely help us move toward a healthiernation and world, and I recommend this report to all of you. Julie Louise Gerberding, MD, MPH Director, Centers for Disease Control and PreventionForewordThis book is out of print. For current reviews, visit www.thecommunityguide.orgIt is a great pleasure to present this landmark first edition of Community Preventive Services (Community Guide)is the product of eight years of work by the Task Force on Community Pre-ventive Services. At its inception in 1996, the Task Force was charged withdeveloping recommendations for interventions that promote health and pre-vent diseases in our nationÕs communities and healthcare systems. These rec-ommendations were to be based on systematically derived scientific evidenceof their effectiveness. At that time, some deemed the task impossible andmaintained that complex community-based interventions could not be evalu-ated systematically, would not stand up to scientific scrutiny, and could notbenefit from focusi

ng on what works. In contrast to those r
ng on what works. In contrast to those reservations, theCommunity GuideÕsresearch into scientific studies has illuminated and helpedclarify what we know about what works to promote health and prevent dis-ease, and what we still need to learn. The is a credible,practical, and essential reference. It is important for helping public health,healthcare provider, academic, business, community planning and advocacy,and research audiences select effective interventions for their communitiesand for expanding the science base underlying public health practice. The work of this Task Force follows in the footsteps of the U.S. PreventiveServices Task Force, which developed and continues to update the Clinical Preventive Servicesis an important reference pro-viding recommendations for clinical (i.e., individual) prevention interven-tions. The complements this work and recommends inter-ventions to improve the performance of healthcare systems; interventionsimplemented in community settings such as schools, worksites, and commu-nity organizations; and interventions applied to entire communities (e.g., laws,regulations, enforcement, mass media, and environmental changes). Together,these two guides provide recommendations that address the needs of bothour health and public health systems. The Task Force on Community Preventive Services is ably supported bystaff at the Department of Health and Human Services (led by HHSÕs Centersfor Disease Control and Prevention), other federal agencies, major health or-ganizations, state and local health departments, managed care and otherhealthcare delivery organizations, academic centers, and voluntary organi-zations. These broad collaborations are essential to ensure that the approachtaken in each chapterÑthe interventions selected for review, the reviews ofThis book is out of print. For current reviews, visit www.thecommunityguide.orgThis book is out of print. For current reviews, visit www.thecommunityguide.orgRobert S. Thompson, MD (1996Ð2003)Group Health Cooperative of Puget SoundSeattle, WashingtonCONSULTANTSRobert S. Lawrence, MD (1996Ðpresent)Bloomberg School of Public HealthJohns Hopkins UniversityBaltimore, MarylandJ. Michael McGinnis, MD (

1996Ðpresent)Robert Wood Johnson Founda
1996Ðpresent)Robert Wood Johnson FoundationPrinceton, New JerseyLloyd F. Novick, MD, MPH (1996Ðpresent)Syracuse, New YorkSylvie Stachenko, MD, Msc (1996Ð1999)Ottawa, OntarioSteven M. Teutsch, MD, MPH (1998Ð2001)Merck & Company, Inc.West Point, PennsylvaniaTask Force on Community Preventive ServicesThis book is out of print. For current reviews, visit www.thecommunityguide.orgFernando A. Guerra, MD, MPH (1996Ð2002)San Antonio Metropolitan Health DistrictSan Antonio, TexasAlan R. Hinman, MD, MPH (1996Ðpresent)Task Force for Child Survival and DevelopmentAtlanta, GeorgiaGeorge J. Isham, MD (1996Ð2004)HealthPartnersMinneapolis, MinnesotaRobert L. Johnson, MD (2003Ðpresent)New Jersey Medical School, Department of PediatricsNewark, New JerseyGarland H. Land, MPH (1997Ðpresent)Jefferson City, MissouriCharles S. Mahan, MD (1996Ð2002)University of South Florida College of Public HealthTampa, FloridaPatricia Dolan Mullen, DrPH (1996Ð2004)University of TexasÐHouston School of Public HealthHouston, TexasPatricia A. Nolan, MD, MPH (2001Ðpresent)Providence, Rhode IslandDennis E. Richling, MD (2002Ðpresent)Union Pacific RailroadOmaha, NebraskaBarbara K. Rimer, DrPH (2003Ðpresent)School of Public Health, University of North CarolinaChapel Hill, North CarolinaSusan C. Scrimshaw, PhD (1996Ð2003)University of Illinois School of Public HealthSteven M. Teutsch, MD, MPH (2001Ðpresent)Merck & Company, Inc.West Point, PennsylvaniaTask Force on Community Preventive ServicesThis book is out of print. For current reviews, visit www.thecommunityguide.orgTask Force on Community Preventive ServicesJonathan E. Fielding, MD, MPH, MBA (Member since 1996; Chair since 2001) Los Angeles, CaliforniaRoss Brownson, PhD (1996Ð2003)St. Louis University School of Public HealthSt. Louis, MissouriPatricia A. Buffler, PhD, MPH (1996Ð2001)University of California, BerkeleyNoreen Morrison Clark, PhD (2003Ðpresent)University of Michigan School of Public HealthAnn Arbor, MichiganJohn Clymer (2002Ðpresent)Partnership for PreventionWashington, D.C.Mary Jane England, MD (1996Ð2001)Regis CollegeWeston, MassachusettsCaswell A. Evans, Jr., DDS, MPH (Chair of the Task Force, 1996Ð2001)National Oral Health

Initiative, Office of the U.S. Surgeon
Initiative, Office of the U.S. Surgeon GeneralRockville, MarylandDavid W. Fleming, MD (1996Ð2000)The Gates FoundationSeattle, WashingtonMindy Thompson Fullilove, MD (1996Ð2004)New York State Psychiatric Institute and Columbia UniversityNew York, New YorkThis book is out of print. For current reviews, visit www.thecommunityguide.orgOxfordNew YorkAucklandBangkokBuenos AiresCape TownChennaiDar es SalaamDelhiHong KongIstanbulKarachiKolkataKuala LumpurMadridMelbourneMexico CityMumbaiNairobiS‹o PaoloShanghaiTaipeiTokyoTorontoCopyright 2005 by Oxford University PressPublished by Oxford University Press, Inc.198 Madison Avenue, New York, New York 10016http://www.oup.comOxford is a registered trademark of Oxford University PressThe format and design of this publication may not be reproduced by any means without the prior permission of Oxford University Press. The text was produced by the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, and is in the Library of Congress Cataloging-in-Publication DataThe guide to community preventive services : what works to promote health? / Task Forceon Community Preventive Services ; edited by Stephanie Zaza, Peter A. Briss, Kate W. Harris.p.cm.Includes bibliographical references and index.ISBN-13 978-0-19-515108-4; 978-0-19-515109-1 (pbk.)ISBN 0-19-515108-9; 0-19-515109-7 (pbk.)1. Community health servicesÑUnited States.2. Preventive health servicesÑUnited States.3. Health promotionÑUnited States.I. Zaza, Stephanie.II. Briss, Peter A. III. Harris, Kate W.IV. Task Force on Community Preventive Services (U.S.)RA445.G785 20050973Ñdc222004050129on acid-free paperThis book is out of print. For current reviews, visit www.thecommunityguide.orgWhat Works to Promote Health? Task Force on Community Preventive ServicesStephanie Zaza,Project Co-DirectorPeter A.Briss,Project Co-DirectorKate W.Harris,Managing Editor2005This book is out of print. For current reviews, visit www.thecommunityguide.orgTheGuidetoCommunity This book is out of print. For current reviews, visit www.thecommunityguide.orgThe Guide to Community Preventive ServicesThis book is out of print. For current reviews, visit www.the