Running head: HEALTH PROMOTION

Health Promotion: Reduction of Stroke Deaths
Jeffrey M. Heist
Indiana State University

Introduction
The development of health care policy in the United States has historically, been based on the fact that clinicians were responsible to treat primary illness rather than the promotion of health as it related to personal health behaviors (U.S. Preventative Services Task Force, 2011). This paper will examine the Healthy People 2020 objective HDS-3, Reducing Stroke Deaths (U. S. Department of Health and Human Services, 2011), and how the promotion of this objective has progressed since it’s Healthy People 2010, 12-7, predecessor. History
The Healthy People initiative was introduced in 1979, by the Department of Health and Human Services (DHHS), in an effort to provide a systematic approach to improving health (Koh, 2010). The plans, known as HP 1990-Promoting Health/Preventing Disease (Centers for Disease Control, 2011), Healthy People 2000, Healthy People 2010 and the current Healthy People 2020 have focused on identifying health priorities and aligning the strategies to effectively implement those strategies.
The goals related to each version of the initiative have changed, as have the number of objectives/measures. HP 1990 goals were to decrease mortality in infants and adults and to increase the independence among older adults while the Healthy People 2020 goals were aimed at:
- attaining high quality, longer lives
- achieving health equity, eliminating disparities
- creating social and physical environments that promote good health
- promoting quality of life, healthy development, healthy behaviors (Centers for Disease Control, 2011)
Literature Review
One can see that the earlier goals were focused on treatment and outcomes and new goals now look at how we can improve behaviors and lifestyles that allow the patient to become a part of the health care puzzle. The 15 topics in 1990 have ballooned to 39 in HP 2020 and the objectives have went from 226 to >580 respectively (Centers for Disease Control, 2011). These changes show how our knowledge of health care deficits has greatly expanded over the years. With the increased knowledge comes an increase in realization that non-health sectors in the U. S have a role in addressing health issues. Healthy People 2020 (2011) is now including education, housing, environment, transportation, labor and agriculture as a means to define and improve the U.S. health care delivery.
I have specifically chosen to address the HP 2020, HDS-3 objective of reducing stroke deaths (U.S.Department of Health and Human Services, 2010) as the basis many for this paper. While the reduction of stroke deaths is included under the topic of Heart Disease and Stroke, many of the same objectives are intertwined with the general goal of positively affecting cardiovascular disease patterns. Stroke is the third leading cause of death in the United States and when combined with the health problems associated with heart disease, they are the most costly health problems facing the U.S., accounting for more than $500 billion in 2010 (U.S.Department of Health and Human Services, 2010). The primary goal of HP 2020 as it relates to stroke is to: “improve cardiovascular health and quality of life though prevention, detection and treatment of risk factors for heart attack and stroke; early identification and treatment of heart attacks and strokes; and prevention of repeat cardiovascular events” (U.S.Department of Health and Human Services, 2010).
In comparing data from Health People (HP) 2010 to Healthy People (HP) 2020 the baseline rate of stroke deaths (per 100,000population) have significantly decreased (U.S.Department of Health and Human Services, 2010). The HP 2010/HP 2020 initiatives showed the following data: Table 1: HP definition comparisons Stroke Data for HP 2010 & HP 2020 Comparison(all measure is per 100,000 pop.) | | HP 2010 | HP 2020 | Baseline/Yr. | 62/1999 | 42.2/2007 | Target | 50 | 33.8 | Target setting | 20% improve | 20% improve |

(Centers for Disease Control, 2001) (U.S.Department of Health and Human Services, 2010)

According to the National Stroke Association (2011), the annual stroke death rate 35% between the years of 1998-2008. During 2000, stroke deaths accounted for 167,000 persons and was the third leading cause of death in the United States (Centers for Disease Control and Prevention, 2001). Currently, stroke is the fourth leading cause of death in the United States with an annual death rate of 133,000 persons (National Stroke Association, 2011).
As discussed earlier, the HP 2020 initiative is also addressing the relationships that education, environment, transportation and agriculture may have on health care and health disparities. These disparities, related to cardiovascular care are significant and disproportionately disbursed across the population (U.S.Department of Health and Human Services, 2010). The disparities are based on gender, age, race/ethnicity, geographic area, and socioeconomic status. The above disparities show up as problems associated with prevalence of risk factors, access to treatment, appropriate and timely treatment, and treatment outcomes (U.S.Department of Health and Human Services, 2010). Combined with the disparities, are the modifiable risk factors that must also be approached on behavioral change level rather than just a mass health promotion level. The risk factors include hypertension, hypercholesterolemia, cigarette smoking, diabetes, poor diet and physical inactivity and obesity (U.S.Department of Health and Human Services, 2010).
With hypertension as the primary factor involved with stroke and one of the most modifiable risks (National Stroke Association, 2011), data supports that the incidence of stroke have gone up in patients over 65 years of age, the death rates for stroke and rates of uncontrolled hypertension have both gone down considerably since 1999 (Centers for Disease Control and Prevention, 2011). See table 2 for details.
Table 2: Rates of stroke, stroke death and uncontrolled hypertension (per 100,000 pop.) | 1999-2000 | 2009-2010 | | Male >65 | Female >65 | Male >65 | Female>65 | Stroke | 12.3 | 10.6 | 12.9 | 11.1 | Stroke Deaths | 62.4 | 59.1 | 40.9 | 39.9 | Uncontrolled Hypertension | 66.7% | 75.8% | 46.4% | 50.4% |
(Centers for Disease Control and Prevention, 2011)
While the practice of routine health screening is routinely in question, related to the advancement of health care, the screening for hypertension is still highly recommended and given high priority in the screening process. This is evidence by a 2007 study in the Annals of Internal Medicine that documented that the benefits outweigh the risks of screening for uncontrolled hypertension (U. S. Preventive Services Task Force, 2007).
Government Roles and Implementation Strategies
In an attempt to reduce stroke deaths it is important to recognize current practices in health care and associated program that will assist in improving the health status in the United States. Over the past decade, the number of individuals with medical insurance actually decreased as well as those who had a primary care provider (U.S. Department of Health and Human Services, 2012). With fewer individuals covered, and able to seek care, closer identification of those at risk will assist to focus the goals of health programs. Orleans and Cassidy (2011) noted that a 2004 health risk analysis by Mokdad, Marks, Stroup, and Gerberding confirmed that four leading behavioral risk factors (tobacco use, alcohol abuse, sedentary lifestyle, and unhealthy diet) accounted for more than 900,000 deaths in the year 2000. With fewer primary care providers available for the predicted increase in insured patients suggested by the Patient Protection and Affordable Care Act of 2010 (ACA) (Sparer, 2011), timely and efficient management of the health status of patients will be crucial to good care. Local and federal interventions that address patients’ personal health practices prove to be the most effective (Orleans & Cassidy, 2011).
Many interventions are in place and are being utilized to reduce the stroke death rate. These interventions include both screening and behavior modifying interventions (U. S. Preventive Services Task Force, 2009). Some of the U.S. Preventive Services Task Force interventions (not all inclusive) that are aimed at stroke death reduction are: * Behavioral Counseling in Primary Care to Promote a Healthy Diet * Screening for High Blood Pressure * Healthy Youth! Nutrition * Screening for Obesity in Children and Adults * Dietary Guidelines for Americans 2005
The Centers for Disease Control and Prevention (CDC) estimated in 2010 that $1 of every $6 spent on health care in the U. S. was related to cardiovascular diseases. While death rates have decreased in the U.S. related to stroke, they are still high, and stroke costs alone are estimated at over $53.9 billion in 2010 (Centers for Disease Control and Prevention, 2010). The CDC has funded health departments in 41 states to conduct heart disease and stroke programs (2010). Some CDC programs include, ABCS Initiative (Aspiring therapy, Blood pressure control, Cholesterol control, and Smoking cessation), National Heart Disease and Stroke Prevention Program and the Paul Coverdell National Acute Stroke Registry (Centers for Disease Control and Prevention, 2010). In 2007, the CDC and The Joint Commission developed performance measures for acute stroke care which are now core measure for development of acute stroke centers (Centers for Disease Control and Prevention, 2010). The CDC is also active at state levels as evidence by funding provide to Michigan to improved cardiovascular and stroke care by assessing state emergency medical services, develop regional trauma guidelines, update and improve protocols related to heart and stroke care, sponsor training and distribute clinical information to EMS providers that promotes improved pre-hospital care (Centers for Disease Control and Prevention, 2010).
A primary care source that assists in development of stroke care and care of transient ischemic attacks is the Agency for Healthcare Research and Quality guideline (Sacco, et al., 2008). This guideline is also the foundation for the American Heart Association/American Stroke Association guideline for care of stroke patients (Sacco, et al., 2008).

Supporting Groups
While supporting groups are varied in their dedication and concentration on the advancement of stroke care, two particularly are important in the national attention to stroke and health care. The National Stroke was founded in 1984 and became the first national non-profit organization 100% financially dedicated to the prevention, research, and education about stroke (National Stroke Association, 2010). The mission of the stroke association is to “ reduce the incidence and impact of stroke by developing programs to prevent and treat all people impacted by stroke” (National Stroke Association, 2010).
Another national support group, specifically related to professionals in the care of stroke patient and other neurological disorders is the American Association of Neuroscience Nurses ( AANN) (American Association of Neuroscience Nurses, 2012). This professional organization, established in 1968, consists of over 4000 members nationwide and 71 chapters in 33 states and has a mission to the “advancement of neuroscience nursing as a specialty through the development and support of nurses to promote excellence in patient care” (American Association of Neuroscience Nurses, 2012).
On a more local level, the advancement of care in the field of stroke is supported and defined by the Greater Cincinnati-Northern Kentucky Stroke Team, the first multidisciplinary stroke team in the U. S., that was founded in 1984, and currently serves 17 regional hospitals (University of Cincinnati, 2012). This team of physicians, nurses, and neuro-radiologists provides on-site and most recently, telemedicine consultation to emergency departments and hospitals throughout the Greater Cincinnati-Northern Kentucky area (University of Cincinnati, 2012). This program provides acute stroke care and also trains 2-4 stroke fellows/year in emergency medicine and vascular neurology (UC Health Neurology, 2012).
One other source that reference and support for care of strokes patients is the American Stroke Association, an affiliate of the American Heart Association, which has many local chapters across the U. S. (American Stroke Association, 2010). The American Heart Association was founded in 1924 by six cardiologists with a mission to address the public ignorance about heart disease, and then became a public organization in 1948. (American Stroke Association, 2010).
Conclusion
The changing goals of healthcare as outlined in the ACA (Sparer, 2011), provide advanced practice nurses an opportunity to provide care to patients that primary care physicians would not be able to otherwise provide. As care providers who are in direct contact with patients, nurses can actively promote the implementation practices set forth by the HP 2020 guidelines and encourage health policies and behavioral goals that are consistent with the individual needs of each patient (Orleans & Cassidy, 2011). The impact of regular and reliable access to health care can prevent disease and disability, detect and treat illnesses, increase life quality, and increase life expectancy (U.S. Department of Health and Human Services, 2012). While HP 2020 objective to reduce stroke deaths have been successful, many lives and healthcare expenses can be saved with further, dedicated healthcare interventions.

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