Health Promotion Research and Dissemination Act

Preparing to Introduce Legislation in the U.S. Congress

Below is the narrative draft of the Health Promotion Research and Dissemination Act. This draft is being used to prepare legislation which we expect to be introduced in the U.S. Senate and House of Representatives in the first or second quarter of 2003. Minor revisions in specific focus areas, budgeted amounts, and positioning are expected before it is introduced, but the overall focus will remain the same. (Note: at the time of publication, budget levels for 2003 had not been confirmed by Congress, so the baseline budget values in the narrative are based on 2002 budget levels.)

This proposal was developed with input from over 300 health promotion professionals and organizations, the staffs of over 100 members of Congress, and the legislative directors of the government agencies impacted.

If passed, this legislation will provide almost $800 million dollars in new funding over a span of five years to develop the basic and applied science of health promotion. In addition to enhancing the impact of health promotion programs and thus the health of the nation, this legislation will provide a significant influx of funding to government agencies responsible for health promotion, as well as the universities, research organizations, and health promotion vendors with whom they work.

Our timing for this legislation is both excellent and terrible. Health promotion is finally recognized as a viable strategy to address many of the nation's health problems by the White House, Congress, and the Department of Health and Human Services. Furthermore, we are working with almost all of the chair and ranking members of all the appropriate committees and subcommittees in the Senate and House, as well as champions within those committees. However, the U.S. economy has been mired in an economic slowdown for almost two years, the government is operating at a deficit, the Congressional calendar is clogged with legislation not passed by the previous congress, and extra spending related to national defense will reduce the amount of money available.

Steps to Success

To be successful in introducing and passing this legislation we need to do three things: 1. Gather additional resources. To date, the time and funding required to support this effort has been contributed by the members of the Executive Committee of the Health Promotion Advocates. We must attract others who are able to bear some of this burden. 2. Work collaboratively. In developing this legislation, we have collaborated directly with more than 50 organizations and indirectly with at least 50 others. However, many of these relationships have been superficial or intermittent. We need to increase both the number of groups involved and the level of their involvement. 3. Be persistent. Passing this legislation is a two-step process. First, we need to pass legislation "authorizing" it through the Senate Health, Education, Labor and Pensions (HELP) Committee and the House Energy and Commerce Committee. Second, we need to secure money to fund it through the Appropriations Committees in both the House and the Senate. If we are more successful than most groups, both pieces of legislation will pass within two years. We will also have to renew the appropriations each year with new legislative efforts.

What Can You Do?

As an individual, you can become a member of our grassroots advocacy network, or join one of six committees. To join, go to our website, www.HealthPromotionAdvocates.org, and click on the "Get Involved" button. If you are a member of a professional association, advocacy group, or any organization that can contribute resources, contact me directly at American Journal of Health Promotion, 248-682-0707.

Together, we can change the field of health promotion, and the world in which we live.

Michael P. O'Donnell, PhD, MBA, MPH
 Editor in Chief and President American Journal of Health Promotion

Proposed Health Promotion Research and Dissemination Act

Preamble

Whereas,

• Lifestyle factors are responsible for almost half of the premature deaths in developed nations, and a large portion of the deaths in developing nations; 
  
•  Lifestyle factors are a primary cause of the six leading causes of death in the United States including heart disease, cancer, stroke, respiratory diseases, accidents, and diabetes, which collectively account for almost 75% of all deaths in the United States; 
  
• A significant portion of the health disparities in the United States are caused by lifestyle factors which could be improved by health promotion programs; 
  
•  The United States is experiencing epidemics in diabetes and obesity among adults and children, while at the same time a majority of the population is sedentary and eats an unhealthy diet; 
  
• The aging population in the United States will create an onerous burden on the medical care system and strain the Medicare budget beyond its current limits unless the disability levels of older adults can be reduced; 
  
• Health promotion programs have been shown to be effective in improving health knowledge, attitudes, behaviors and conditions, and delaying disability in older age; 
  
• Per capita medical care costs in the United States are more than double those of all but two other countries in the world, yet the United States ranks 24th in terms of disability-adjusted life expectancy, infant mortality and other positive lifestyle measures; 
  
•  Medical care costs are second only to education on state government budgets; 
  
•  Lifestyle factors are responsible for at least one quarter of employers' medical care costs in the United States; 
  
• Health promotion programs have been shown to be effective in reducing medical costs and enhancing productivity; 
  
• Significant gaps exist in the basic and applied research base of health promotion regarding how to best reach and serve people of color, low income, low education, children, and older adults, how to create long-term health improvements, how to create supportive environments, and how to address gender issues. More focused research can reduce these gaps; 
  
• Significant gaps exist between the best and the typical health promotion programs. Better synthesis and dissemination of results can reduce these gaps; 
  
• The genomic revolution will soon allow genetic information to be used to identify individual susceptibility to common disorders such as heart disease, diabetes, cancer, stroke and respiratory diseases, and the most effective method to prevent many of these diseases will be health promotion; 
  
•  Health promotion is the most effective strategy to achieve a majority of the major objectives in Healthy People 2010 Objectives for the Nation developed by the Department of Health and Human Services;
  
• The federal government has provided minimal funding to date to develop the basic and applied science of health promotion; 
  
• A significant increase in demand for health promotion programs is expected in the next decade, and a stable infrastructure must be in place to ensure continual development of the health promotion science base to be able to service this demand effectively;

The Health Promotion Research and Dissemination Act is hereby introduced.

For the purposes of this legislation, health promotion is defined as the art and science of motivating people to enhance their lifestyle to achieve complete health, not just the absence of disease. Complete health involves a balance of physical, mental, and social health. The most effective health promotion programs will include a combination of strategies to increase awareness, facilitate behavior change, and develop cultures and physical environments which encourage and support healthy lifestyle practices. Health promotion programs focus on practices such as exercising regularly, eating a nutritious diet, maintaining a healthy weight, managing stress, avoiding dangerous substances such as tobacco and illegal drugs, drinking alcohol in moderation or not at all, driving safely, being wise consumers of health care, and a number of other health-related practices. Health promotion programs can be provided in clinical, school, workplace, state, federal, and community settings.

Proposed Programs

Relative to funding levels in 2002, the Health Promotion Research and Dissemination Act will provide additional annual funding in the amounts of $127 million in 2004, $111 million in 2005, $146 million in 2006, $186 million in 2007, and $225 million in 2008 to create a focused and coordinated effort to develop the basic and applied science of health promotion. This effort includes coordination, basic science, applied science and synthesis and dissemination. During the years 2004-2008 this represents an increase of $794 million more than would have been invested if funding levels had remained at 2002 funding levels.

Coordination Approximately $6 million would be allocated in 2004, $4 million in 2005 and $3 million in 2006, 2007 and 2008 to a central coordinating office which would develop a five-year plan with five major components listed below, and provide ongoing leadership for this effort.

1.  How to best develop the basic and applied science of health promotion. This plan would include a research agenda, identification of the best combination of federal agency, university, and other community resources most qualified to pursue each of the components of the research agenda, protocols to facilitate ongoing cooperation and collaboration among the federal agencies to pursue this research agenda, and budgetary requirements. An advisory panel consisting of the membership described below would provide input on this research agenda.
2.  How to best synthesize and disseminate health promotion research findings to scientists, professionals, and the public. This plan would include protocols for ongoing monitoring of all health promotion research, preparation of systematic reviews and meta-analyses, distillation of findings into practice guidelines for programs offered in clinical, workplace, school, and community settings, strategies to incorporate findings into college, university, and continuing educational curriculum for all related health professions, and communication of key findings to policy makers in business, government, educational and, community settings who influence investment decisions. It would also identify the optimal combination of government agencies to coordinate these efforts. These plans would be developed by a combination of Department of Health and Human Services (HHS) employees, outside consultants, and an advisory panel. The advisory panel would include experts in publishing, information technology, and educational curriculum development, in addition to the membership described below.
3.  How to best support and develop the health promotion professional and scientific community through enhancement of existing or development of new professional organizations. This advisory panel would include experts in association management in addition to the membership described below.
4.  How resources, policies, structures, and legislation within HHS could best be modified or developed to integrate health promotion into all health professions and sectors of society and make health promoting opportunities available to all members of the public. The advisory panel would include representatives of all the HHS agencies.
5.  How overall federal government policies, structures, and legislation external to HHS could best be modified or developed to integrate health promotion into all health professions and sectors of society and to make health promoting opportunities available to all people. The advisory panel would include representatives from all government departments in addition to the membership described below.

Each of these five plans would be developed through a combination of efforts by government staff, outside consultants, and advisory panels. All advisory panels would include scientists, practitioners, managers, and health promotion vendors representing medicine, nursing, psychology, exercise science, health education, economics, financial analysis, business, environmental planning, and health policy, as well as professionals representing schools, workplaces, clinical and community settings, and others with specific expertise in each of the topics of focus. Members of these panels would receive a modest stipend to cover time and expenses. This planning process would be open to the public and input would be welcome from those not serving on the advisory panels.

Within the Department of Health and Human Services, the Office of Disease Prevention and Health Promotion and/or the Office of the Assistant Secretary for Planning and Evaluation might be utilized to serve in this coordinating role. The White House would be encouraged to play a visible role in these efforts as well. The coordinating office would have the option of managing this process internally or contracting with an outside management group.

Basic Science The Office of Behavioral and Social Sciences Research (OBSSR) within the National Institutes of Health (NIH) would receive $1 million to guide a trans-institute initiative to develop a five-year plan for how to best develop the basic science of health promotion within NIH. This plan would include a research agenda to develop the basic science of health promotion, recommendations on the best combination of Institutes, Centers, and Offices within NIH and outside research organizations to execute these plans, and funding levels required. Over time, NIH would be expected to allocate resources to this area relative to other areas of health, which are appropriate given the burden of lifestyle factors on morbidity and mortality, and the progress likely in advancing the science of health promotion given the current and evolving level of science in this area, and the relative cost of conducting research in this area compared to other areas. An advisory panel including scientists based at NIH and outside of NIH, as well as health promotion practitioners, would be organized to provide input on the research agenda and the overall plan.

In addition, seed funding of $30 million would be provided in 2004 to stimulate early research programs. These funds would be distributed through OBSSR. At least $27 million of the $30 million in seed funding would be distributed through contracts and grants to not-for-profit and for-profit non-government organizations including universities, hospitals, research organizations, and health promotion vendors. Some of this funding would support training grants to enhance the skills and increase the numbers of scientists trained in health promotion.

Applied Science Relative to funding levels at the Centers for Disease Control and Prevention (CDC) in 2002, funding in the specific programs discussed below would increase by $74 million in 2004, $105 million in 2005, $139 million in 2006, $180 million in 2007, and $219 million in 2008, for a total increase of $718 million between 2004 and 2008 for applied research to develop the most effective individual and group strategies for clinical, workplace, school, and community-based programs. At least 75% of this amount would be distributed through contracts and grants to not-for-profit and for-profit non-government organizations including universities, hospitals, research organizations, and local and national health promotion vendors through collaborative efforts. Local and state health departments would be expected to develop a basic staff infrastructure to manage programs, but would contract with providers in their communities to secure many of the programs and skills required to deliver these programs.

Applied Research Applied research efforts would include the development of an applied health promotion research agenda, support for the health promotion profession, and expansion of the Behavioral Risk Factor Surveillance System, Prevention Research Centers, and Extramural Research Program at CDC. An applied health promotion research agenda would be developed through the Office of the Director of CDC, and updated every two years; $300,000 per year from 2004 to 2008 would be allocated to support this effort. This research agenda would draw on the overall health promotion research agenda developed by the HHS director's office, with input from the health promotion research and practice communities. An advisory panel would be organized to help develop this research agenda. This panel would include scientists, practitioners, managers, and health promotion vendors representing medicine, nursing, psychology, exercise science, health education, economics, financial analysis, business, environmental planning, and health policy, as well as professionals representing schools, workplaces, clinical, and community settings. Members of this panel would receive a modest stipend to cover time and expenses. This process would be open to the public and input would be welcome from those not serving on the advisory panels. Funding for the Behavioral Risk Factor Surveillance System would increase from $3 million in 2002 to $8 million in 2004 and $10 million in 2005. Funding levels after 2005 would be determined in the future. This level of funding would improve the response rate, allow the sample size in each state to reach at least 4000, improve the timeliness of data summaries, and improve access to data for the planning and research communities. Funding for the Prevention Research Centers would increase from $26 million in 2002 to 34 million in 2004, $41 million in 2005, $51 million in 2006, $65 million in 2007, and $80 million by 2008. This would allow the number of Centers to increase from 28 to 40 and increase the funding for each. It would allow the Centers to address three new priority areas: evaluation and dissemination of national public health strategies, training of the public health workforce and translation of findings into public health practice, and national leadership and technical support. At least one Center would concentrate its efforts on developing the applied science of health promotion in each of the following areas: workplace, schools, clinical settings, and community settings. All Centers would be encouraged to address these areas within the scope of their other work. The work of the centers would also be influenced by the priorities identified in the applied research agenda developed by CDC. All Centers would be required to form relationships with and provide limited ongoing advice to the health departments in their county and state, and to organize local networks of scientists, program managers, vendors, and other professionals interested in health promotion and disease prevention. When conducting intervention research, centers would be required to review the capabilities of local not-for-profit and for-profit program vendors who could provide the programming and services required for the interventions, and utilize these resources if they provide a quality and cost advantage relative to developing these capabilities internally. Schools of public health and departments of preventive medicine would continue to be eligible to be designated Centers, but other types of schools would become eligible as well. At least 6 of the new Centers would be in schools which have a more applied focus and provide undergraduate and graduate education. Funding for the Extramural Research Program would increase from $19 million in 2003 (it was $27 million in 2002) to $24 million in 2004, $30 million in 2005, $36 million in 2006, and $40 million in 2007. Funding after 2007 would be determined in the future. This increase would allow the program to fund the increasing number of research programs required to develop the applied science of health promotion. Fifty planning grants of $50,000 each would be awarded each year to fund the organizing necessary to prepare a large research grant application. A panel of advisors including scientists, practitioners, managers, and health promotion vendors representing medicine, nursing, psychology, exercise science, health education, economics, financial analysis, business, environmental planning, and health policy, as well as professionals representing schools, workplaces, clinical, and community settings would identify the important areas of research that would be addressed by the extramural research program in the following year. Members of this panel would receive a modest stipend to cover time and expenses. This process would be open to the public and input would be welcome from those not serving on the advisory panels. Priorities identified in the applied research agenda developed by CDC would be considered in identifying important areas, and developing the applied science of health promotion for workplace, school, clinical, and community settings would also be a priority. Seven hundred thousand dollars would be provided annually for local and national support of the health promotion profession through professional organization. Focused Applied Research. Funding would be increased for each of the following programs to develop the applied science of health promotion specific to the focus of these programs. Additional funding from other sources would be required to meet the program delivery needs of each of these programs. Funding for the Tobacco Control program budget would increase from $101 million in 2002 to $110 million in 2004. Funding requirements beyond 2004 would be determined in the future. Funding for the Nutrition and Physical Activity program would increase from $27.5 million in 2002 to $60 million in 2004, $62 in 2005, $65 million in 2006, $69 million in 2007, and $74 million in 2008. This funding would allow CDC to begin to build a nationwide network of programs to encourage nutritious eating and physical activity. Funding for the non-HIV/AIDS portion of the School Health program would increase from $11 million in 2002 to $17 million in 2004, $21 million in 2005, $21 million in 2006, $26 million in 2007, and $33 million in 2008. This would allow CDC to expand comprehensive programming from 20 to all 50 states. Funding for the Healthy Aging program would increase from no allocated funds in 2002 to $6 million in 2004, $8 million in 2005, $10 million in 2006, $13 million in 2007, and $17 million in 2008. This would allow the program to begin to establish a program of state-based efforts, a prevention research agenda, public and provider education and technical assistance. Funding for the REACH 2010 program (to address health disparities) would increase from $38 million in 2002 to $42 million in 2004, $47 million in 2005, $53 million in 2006, $60 million in 2007, and $68 million in 2008. This would allow CDC to increase the number of programs it is supporting from 40 communities to 75 communities. A new program area on Workplace Health would be created and receive funding of $6 million in 2004, $8 million in 2005, $11 million in 2006, $15 million in 2007, and $20 million in 2008. This would allow CDC to develop and begin to implement a research agenda on the optimal structure of workplace-based programs, and the impact of health promotion on medical costs, absenteeism, productivity, and financial outcomes important to employers. It would also support synthesis of these findings and dissemination to practitioners, business leaders, and health policy leaders.

Synthesis and Dissemination. Approximately $15 million would be allocated in 2004 to support increased efforts for synthesis and dissemination of health promotion research. Appropriate funding in subsequent years would be allocated based on the five-year plan discussed above. At least $10 million of these funds would be distributed through contracts and grants to for-profit and not-for-profit non-government organizations including universities, hospitals, publishers, research organizations, and health promotion vendors through collaborative efforts. The Agency for Healthcare Research and Quality (AHRQ), the OBSSR, ODPHP, or the National Center for Chronic Disease Prevention and Health Promotion at CDC might coordinate these efforts. This would be determined by the five-year plan.

Involving the Most Qualified Scientists and Practitioners and Developing an Infrastructure of the Field of Health Promotion For all of the grants and contracts above, mechanisms would be developed to modify the grant and contract process to attract the most qualified individuals and organizations, rather than those most sophisticated in the contracting and grant applications processes. Furthermore, funds would be distributed with the priority of helping to develop the health promotion infrastructure among universities, non-profit organizations, and for-profit organizations, rather than increasing the size of local, state, or federal governments.

Michael P. O'Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion