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NOVEMBER / DECEMBER 2014 :: 75(6)
Improving Population Health in North Carolina

Population health examines the health outcomes of groups and the disparities in health among subgroups. This issue of the NCMJ illustrates population health efforts in the areas of obesity prevention, tobacco cessation, and clean water. Articles in this issue also discuss community health needs assessments, integrated health improvement, social determinants of health, and the Healthy North Carolina 2020 program.

INVITED COMMENTARY

Achieving “A Better State of Health”: Healthy North Carolina 2020 and the Center for Healthy North Carolina

Laura Emerson Edwards, Andrea D. Radford, Donna M. Albertone, Joanne Rinker

N C Med J. 2014;75(6):398-402.PDF | TABLE OF CONTENTS



Healthy North Carolina 2020 is the state’s health improvement plan, which has 40 objectives focused on making North Carolina a healthier state. Communities in the state have identified health priorities aligned with those objectives, and the Center for Healthy North Carolina is helping these communities implement evidence-based strategies to address their goals.

Since 1990 North Carolina has set health objectives every 10 years. In 2010 the state’s public health leaders, with support from the North Carolina Institute of Medicine (NCIOM), worked to identify a targeted set of 40 objectives to tackle over the next decade. These objectives are collectively known as Healthy North Carolina 2020; they serve as the state’s health improvement plan and are focused on the state’s most pressing health priorities [1].

North Carolina’s goal is to become one of the healthiest states in the nation. However, North Carolina currently ranks 35th among US states in terms of overall population health, and it has ranked even lower in the past (see Figure 1) [2].

Improving the overall health of North Carolinians requires a concerted and coordinated effort on the part of policy makers, health professionals, business and community leaders, state and local government officials, the faith community, and individual North Carolinians. The goal of Healthy North Carolina 2020 is for all North Carolinians to achieve and maintain optimal health, so the plan focuses on the promotion of health and the prevention of disease. Over the course of the current decade, Healthy North Carolina 2020 is propelling state and local activities to improve population health.

Healthy North Carolina 2020 provides a framework to assist health and community leaders across the state in collaborating to achieve real and measurable health improvements for all the state’s residents. It targets 40 specific objectives in 13 focus areas (see Table 1); achieving these objectives will have a significant impact on population health [1]. Healthy North Carolina 2020 builds directly on the work of the NCIOM Task Force on Prevention and its prevention action plan, Prevention for the Health of North Carolina, which the task force published in 2009 and revised in 2010 [3]. Many of the Healthy North Carolina 2020 objectives focus on preventing and reducing the incidence of chronic diseases and injuries, which are responsible for more than two-thirds of all deaths in North Carolina; cancer, heart disease, chronic lower respiratory diseases, stroke, and nonvehicular injuries are the top 5 causes of death in the state [4]. Healthy North Carolina 2020 aims to address these health problems before they occur. Investing time, energy, and resources in prevention can save lives, reduce disability, and improve quality of life.

The North Carolina State Center for Health Statistics (SCHS) collects and reports data for each of the Healthy North Carolina 2020 objectives; in partnership with the Center for Healthy North Carolina, the SCHS also produces a comprehensive annual report summarizing the state’s progress to date. The annual update released in March 2014 [5] showed that, of the 31 objectives for which comparable updated data were available, North Carolina was moving in a positive direction on 15 objectives, had stayed the same on 1 objective, and was moving in a negative direction on 15 objectives. Among all 40 objectives, successes included a decrease in the percentage of high school students reporting current use of any tobacco product, a decrease in the incidence rate of newly diagnosed cases of HIV that exceeded the goal for this metric, a reduction in the overall infant mortality rate, an increase in the percentage of children aged 1–5 years enrolled in Medicaid who received any dental service during the previous 12 months, and a reduction in the percentage of people exposed to secondhand smoke in the workplace in the past 7 days.

To promote the NCIOM’s prevention action plan [3] and the Healthy North Carolina 2020 objectives, the Center for Healthy North Carolina was established in July 2011 as a program of the North Carolina Public Health Foundation. The center, which was established with funding from The Duke Endowment, works in partnership with the North Carolina Division of Public Health (DPH) to build capacity in communities so that they can implement evidence-based strategies that target community-identified health priorities related to the Healthy North Carolina 2020 objectives. The Center for Healthy North Carolina provides technical assistance, links community groups and organizations to existing resources, and works with communities to identify strategies for sustainability. All of these efforts focus on the stated mission of Healthy North Carolina 2020, which is to move North Carolina to “a better state of health.”

The Center for Healthy North Carolina serves to unify the work of multiple programs and agencies and supports a comprehensive statewide effort focused on the Healthy North Carolina 2020 objectives. The center serves as a liaison that can provide technical assistance and resources to local health departments, the statewide network of Healthy Carolinians partnerships, and other broad-based community coalitions. The center also works with communities to identify and foster public-private partnerships that sustain population health improvement efforts.

The Center for Healthy North Carolina partners with DPH to lead the Healthy North Carolina 2020 implementation team. The implementation team works to focus DPH’s efforts on achieving targeted improvements and emphasizes the importance of measuring and demonstrating the achievement of specific health improvements. The team currently includes representatives from several divisions of DPH (the Chronic Disease and Injury Section, the SCHS, the Women’s and Children’s Health Section, and the Communicable Disease Branch) plus the Person County Health Department; the North Carolina Office of Rural Health and Community Care; the Center for Healthy North Carolina; the Center for Public Health Quality; and the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services.

One of the implementation team’s primary charges was to identify high-priority areas within Healthy North Carolina 2020. The team began with focus areas and objectives that multiple local health departments and communities had already identified as priorities, and it then decided which of these were amenable to assistance from DPH and the Center for Healthy North Carolina. The team identified 5 priority focus areas and 10 priority objectives (see Table 2). In May 2013, the implementation team shared its recommendations with local health directors and asked for feedback, and the focus areas and objectives were subsequently approved by DPH and by the North Carolina Association of Local Health Directors.

The Center for Healthy North Carolina uses the overarching framework of the Healthy North Carolina 2020 objectives to promote the widespread adoption of evidence-based strategies for improving population health outcomes. It works directly with community coalitions to increase their capacity to effectively implement such strategies and to sustain improvements. The Center for Healthy North Carolina is also partnering with the Center for Public Health Quality to create the Community Health Improvement Application (IMAPP), a comprehensive and user-friendly Web-based resource that helps community partnerships select and implement evidence-based interventions targeting high-priority population health conditions.

In the spring of 2012, the NCIOM—in collaboration with the Center for Public Health Quality, the Center for Healthy North Carolina, and DPH—convened the Task Force on Implementing Evidence-Based Strategies in Public Health. This task force found that selecting, implementing, and evaluating evidence-based strategies is not a simple process; it requires skills, knowledge, and resources that local health departments and other community-based organizations may not currently possess. Education, training, and other types of support are needed to promote increased use of such strategies. In their report, Improving North Carolina’s Health: Applying Evidence for Success [6], the task force established 6 key recommendations that provide a road map showing how DPH, local health departments, and other state and local partners can work together to facilitate the adoption or expansion of evidence-based strategies with the goal of improving health outcomes in communities. The Center for Healthy North Carolina is working with DPH to respond to these recommendations and to encourage coordination and leveraging of resources across programs and agencies.

One key task force recommendation was that the Center for Healthy North Carolina work with partners to establish a training curriculum—for local health departments, other health care providers, and community organizations—that addresses the identification, selection, implementation, and evaluation of evidence-based strategies. The Center for Healthy North Carolina thus partnered with the Center for Public Health Quality, the North Carolina Institute for Public Health (which is part of the University of North Carolina [UNC] Gillings School of Global Public Health), the UNC Center for Health Promotion and Disease Prevention, and the Granville-Vance District Health Department to develop modules on a variety of topics relating to evidence-based strategies. These modules begin with the basics in EBS 101 and then move into more advanced concepts. Two trainings were held in Raleigh and Asheville in March and April of 2014, and additional trainings are planned for 2014 and 2015.

Every county in North Carolina has now adopted Healthy North Carolina 2020. In 2012, language specific to Healthy North Carolina 2020 was added to the consolidated agreement between DPH and local health departments. A component of this agreement requires each local health department to perform a community health assessment every 3–4 years. Since 2013, local health departments have been required to submit an action plan after completing their community health assessment; this action plan must address identified priorities and must include a minimum of 2 new evidence-based strategies (or an expansion of current evidence-based strategies to new target populations) targeting at least 2 Healthy North Carolina 2020 objectives from different focus areas. Since July 2014, action plans have been required to include information on staffing and training and on the implementation, monitoring, and evaluation of each evidence-based strategy [7].

Community Coalitions
In addition to the work of local health departments, many community coalitions across the state are implementing evidence-based strategies specifically targeting Healthy North Carolina 2020 objectives. The Center for Healthy North Carolina is currently providing technical assistance to 5 of these community coalitions.

Active Living Outer Banks, an initiative of the Childhood Healthy Weight Task Force of Healthy Carolinians of the Outer Banks, is implementing a mass media and social media campaign targeting elementary and middle school students and their families. The Center for Healthy North Carolina is providing technical assistance with implementation and evaluation of this campaign.

Mountain Projects, a community action agency in Haywood and Jackson counties, is improving access to and expanding the number and reach of naloxone distribution kits in Haywood County so that they will be readily available to first responders in opioid overdose emergencies. The agency is also working to create an environment in which the utility of naloxone as a public health intervention is accepted. The Center for Healthy North Carolina is providing technical assistance with coalition building and team building, data collection and analysis, priority setting, identification of funding, and evaluation.

The Wilson County Substance Abuse Coalition is investigating evidence-based substance abuse prevention programs for elementary, middle, and high school students. The Center for Healthy North Carolina is providing technical assistance with identification of evidence-based strategies and funding sources, development of an implementation timeline, and program evaluation.

The Harnett County Health Department and Healthy Harnett are replicating the Mountain Project’s naloxone distribution program as well as implementing a comprehensive opioid harm reduction program. The latter includes an awareness campaign, more effective dispensing policies, and medication drop-off programs. The Center for Healthy North Carolina is providing technical assistance with coalition building, priority and goal setting, action planning, and evaluation.

pLastly, the Healthy Weight Action Team of the Northeastern North Carolina Partnership for Public Health is implementing the Faithful Families Eating Smart and Moving More program in all of the counties in their region. The Center for Healthy North Carolina is providing technical assistance with meeting facilitation, goal setting, and the identification of additional community-appropriate evidence-based strategies.

Snapshots of Community Efforts
The Center for Healthy North Carolina also spotlights other community efforts through its quarterly series, Snapshots of Success. To date, the center has published 5 snapshots of community efforts to implement evidence-based strategies that are targeting Healthy North Carolina 2020 objectives.

Dare County Department of Public Health has successfully implemented a school-based substance abuse prevention education initiative; this initiative has contributed to a decrease in the number of drug arrests among youths aged 16–20 years and a reduction in the number of positive or refused random drug tests [8]. Mitchell Yancey Healthy Families has partnered with the Toe River Health District to launch the Healthy Families America Initiative in their community, which is building a healthy foundation for at-risk mothers, infants, and their families [9]. Granville-Vance District Health Department has implemented Teen PEP (Prevention Education Program), which trains teen peer educators in Vance County schools as part of the community’s response to high teen pregnancy rates [10]. The Healthy Wayne Task Force is using a collective impact approach to address adult obesity through a community-wide campaign promoting increased physical activity and healthy eating [11]. Finally, the Northeastern North Carolina Partnership for Public Health, a 17-county initiative, identified prescription drug poisoning and overdose as a regional priority. This partnership has increased awareness of the issue, provided training to providers and dispensers on the North Carolina Controlled Substances Reporting System, and formed 3 community coalitions (to date) to address prescription drug abuse at the local level [12]. Snapshots of Success is available in the Evidence Based Resources and Measures section of the Center for Public Health Quality’s Web site.

Conclusion
North Carolina has long promoted and supported community-identified initiatives that address local priorities and improve population health. The Center for Healthy North Carolina is supporting an increased focus on implementation of evidence-based strategies that target the Healthy North Carolina 2020 objectives. Ultimately, the Center for Healthy North Carolina aims to help North Carolina achieve its goal for “a better state of health.”

Acknowledgments
Financial support. The Center for Healthy North Carolina is a program of the North Carolina Public Health Foundation and is funded by The Duke Endowment.

Potential conflicts of interest. A.D.R. is an employee of Care Share Health Alliance and works as a contractor for the Center for Healthy North Carolina. All other authors are employees of the Center for Healthy North Carolina.

References
1. North Carolina Institute of Medicine (NCIOM). Healthy North Carolina 2020: A Better State of Health. Morrisville, NC: NCIOM; 2011. http://www.nciom.org/wp-content/uploads/2011/01/HNC2020_FINAL-March-revised.pdf. Accessed July 14, 2014.

2. United Health Foundation. America’s Health Rankings: 2013 Edition North Carolina. America’s Health Rankings Web site. http://cdnfiles.americashealthrankings.org/SiteFiles/StateProfiles/NorthCarolina-Health-Profile-2013.pdf. Accessed July 28, 2014.

3. North Carolina Institute of Medicine (NCIOM) Task Force on Prevention. Prevention for the Health of North Carolina: Prevention Action Plan. Morrisville, NC: NCIOM; 2010. http://www.nciom.org/wp-content/uploads/NCIOM/projects/prevention/finalreport/PreventionReport-July2010.pdf. Accessed July 14, 2014.

4. North Carolina State Center for Health Statistics. North Carolina Vital Statistics Volume 2: Leading Causes of Death 2012. http://www.schs.state.nc.us/schs/deaths/lcd/2012/pdf/Vol2_2012_PRT.pdf. Accessed July 14, 2014.

5. North Carolina Department of Health and Human Services, Division of Public Health (DPH). Healthy North Carolina 2020: A Better State of Health: Update. Annual Data Report, March 2014. DPH Web site. http://publichealth.nc.gov/HNC2020/docs/HealthyNC2020-UpdateMarch-2014-0324.pdf. Accessed July 14, 2014.

6. North Carolina Institute of Medicine (NCIOM). Improving North Carolina’s Health: Applying Evidence for Success. Morrisville, NC: NCIOM; 2012. http://www.nciom.org/wp-content/uploads/2012/10/EvidenceBased_100912web.pdf. Accessed July 14, 2014.

7. North Carolina Division of Public Health (DPH). Community Health Assessment. DPH Web site. http://publichealth.nc.gov/lhd/cha/. Accessed July 14, 2014.

8. Dare County Department of Public Health. School-Based Substance Abuse Prevention Education. Center for Public Health Quality Web site. http://www.centerforpublichealthquality.org/images/documents/snapshots_of_success_ebs_at_work_dare_county.pdf. Accessed August 3, 2014.

9. Mitchell Yancey Healthy Families. Healthy Families America Initiative—Building a Healthy Foundation. Center for Public Health Quality Web site. http://www.centerforpublichealthquality.org/images/documents/snapshots_of_success_ebs_at_work_mitchell_yancey_healthy_families.pdf. Accessed August 3, 2014.

10. Granville-Vance District Health Department. Teen PEP (Prevention Education Program). Center for Public Health Quality Web site. http://www.centerforpublichealthquality.org/images/documents/snapshots_of_success_ebs_at_work_granville_vance_district_health_dept.pdf. Accessed August 3, 2014.

11. Healthy Wayne Task Force. GoWayneGo and Goldsboro Builder’s Supply—A Community Campaign in Action. Center for Public Health Quality Web site. http://www.centerforpublichealthquality.org/images/documents/snapshots_of_success_ebs_at_work_healthy_wayne_task_force.pdf. Accessed August 3, 2014.

12. Northeastern North Carolina Partnership for Public Health: Targeting Prescription Drug Poisoning and Overdose. Center for Public Health Quality Web site. http://www.centerforpublichealthquality.org/images/documents/snapshots_of_success_ebs_at_work_nencpph_targeting_prescription_drug_poisoning%20_overdose.pdf. Accessed October 18, 2014.


Laura Emerson Edwards, RN, MPA director, Center for Healthy North Carolina, Raleigh, North Carolina.
Andrea D. Radford, DrPH, MHA director of evaluation and outcomes, Care Share Health Alliance; evaluator, Center for Healthy North Carolina, Raleigh, North Carolina.
Donna M. Albertone, MS director of community development, Center for Healthy North Carolina, Raleigh, North Carolina.
Joanne Rinker, MS, RD, CDE, LDN director of training and technical assistance, Center for Healthy North Carolina, Raleigh, North Carolina.

Address correspondence to Ms. Laura Emerson Edwards, North Carolina Public Health Foundation, Center for Healthy North Carolina, PO Box 18763, Raleigh, NC 27619 (Laura.edwards@centerforhealthync.org).