Public Health American Perspectives on Chronic Disease and Control
by
Noreen M. Clark
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 22 April 2013
  • DOI: 10.1093/obo/9780199756797-0036

Introduction

Chronic conditions have been recognized by the World Health Organization as the primary worldwide disease-related cause of morbidity and premature mortality. The medical and public health systems of most countries have traditionally focused on acute and infectious ailments. However, the dramatic increase in the global prevalence of chronic illness has caused a slow but steady shift by public health and medicine toward prevention and management of chronic disease. As the means for primary prevention of most chronic conditions are unknown (an important exception being smoking and cancer), emphasis is generally given to secondary prevention; that is, the reduction in the extent of complications, deterioration of health status, and burden of disease. Several types of action are required in chronic disease control. One is the identification of, and intervention with, common factors known to exacerbate disease onset or management. Poverty, sedentary living, and poor diets are some examples of the most common factors. Another level of action is the reformulation of health systems that are organized to respond to acute ailments to account for the longer-term services and assistance required to effect chronic disease control. Yet another is building the capacity of individuals, families, communities, and systems to prevent and manage chronic illness. The strength of these capacities is influenced by the policies that create the training, resources, and systems required for effective community-wide disease control. The list of chronic diseases that plague the health of the world’s peoples is long. Rather than focusing on each of the illnesses that add to the dismaying health outcomes evident around the globe, this article will focus on the area of noncommunicable disease in general so as to provide a broad view of sources of information regarding major issues that may be common across conditions. This author would like to thank Ms. Lee Rose Schrauben, MPH, for her assistance in the preparation of this article.

Introductory Works

For a comprehensive picture of the global chronic disease control challenge, the United Nations, especially the World Health Organization (WHO), is an important source of information through its home page and widely available reports. Many reports set the stage for recognizing and controlling the effect and impact of chronic diseases. Beaglehole, et al. 2011 describes the recent UN meeting focused on global mobilization for control. A United Nations report established noncommunicable disease as a worldwide dominant health concern (World Health Organization 2010). For data regarding the United States, Centers for Disease Control and Prevention 2011 provides an online portal for understanding both the epidemiology of chronic disease and the primary federal US programs that respond to the challenge . A number of important articles explicate the central issues in disease control and provide perspectives on effective intervention. Geneau, et al. 2010 provides a model for generating political support for control efforts. Clark 2003 and Slonim, et al. 2010 provide views on the capacities required to manage noncommunicable conditions. For chronic disease control in the United States, US Department of Health and Human Services 2010, a new framework for action, is a highly relevant source of information. These publications intentionally shift perspectives and recommendations for actions toward Noncommunicable disease control. They recognize that strategies that are operative in infectious disease control are not necessarily appropriate for chronic conditions. The notions of rescue, cure, and elimination that are reflected in infection control are rethought. They are replaced with ideas that include reduction of disruption of daily life, maintenance of general health, adherence to long-term clinical recommendations, and relevant clinical, community, and social support systems available over the life span.

  • Beaglehole, R., R. Bonita, R. Horton, et al. 2011. Priority actions for the non-communicable disease crisis. Lancet 377.9775: 1438–1447.

    DOI: 10.1016/S0140-6736(11)60393-0Save Citation »Export Citation »E-mail Citation »

    A 2011 UN meeting on noncommunicable diseases describes the need to mobilize countries to engage in a global movement “against premature death and preventable morbidity and disability.” Priorities include leadership, prevention, treatment, international cooperation, monitoring and accountability, and delivery of five priority interventions—namely tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. Available online by subscription.

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    • Centers for Disease Control and Prevention. 2011. Chronic Disease: At a Glance Reports.

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      The CDC comprehensively lists documents related to alcohol abuse, arthritis, cancer, diabetes, heart disease and stroke, obesity, epilepsy, and tobacco use. CDC efforts targeted at disease control include healthy communities, prevention research centers, preventive health and health services block grants, and school health programs. The CDC provides information regarding racial and ethnic gaps in chronic disease control and community approaches to reducing disparities.

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      • Clark, N. M. 2003. Management of chronic disease by patients. Annual Review of Public Health 24:289–313.

        DOI: 10.1146/annurev.publhealth.24.100901.141021Save Citation »Export Citation »E-mail Citation »

        Management of a disease by the patient is central to control of its effects. Interventions can produce positive outcomes, including monitoring of a condition, fewer symptoms, enhanced physical and psychosocial functioning, and reduced health-care use. Successful programs are theory based. Self-regulation is a promising framework for program development. Gaps in understanding and improving disease management by patients are described. Available online for purchase or by subscription.

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        • Geneau, R., D. Stuckler, S. Stachenko, et al. 2010. Raising the priority of preventing chronic diseases: A political process. Lancet 376.9753: 1689–1698.

          DOI: 10.1016/S0140-6736(10)61414-6Save Citation »Export Citation »E-mail Citation »

          Employs an “adapted political process model” to identify strategies for increased political support for chronic disease control and involvement of development agencies. Recommendations are: (1) emphasize social determinants of disease and interrelations among chronic disease, poverty, and development; (2) mobilize resources through a cooperation and inclusion approach to development and equitably distribute resources on the basis of avoidable mortality; and (3) merge strategic and political opportunities. Available online by subscription.

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          • “Noncommunicable disease control.” 2002. In Encyclopedia of public health. Vol. 3. Edited by Lester Breslow, 814–822. New York: Macmillan Reference.

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            This entry provides concepts and details related to six priority topics in chronic disease control. These are: the ascendency of noncommunicable diseases as a worldwide health threat; the modifiable and nonmodifiable causes and means to prevent chronic disease; the environmental exposures found generally around the globe; the needed areas for research; and projection of trends and needs in the future. Available online.

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            • Slonim, A., F. C. Wheeler, K. M. Quinlan, and S. M. Smith. 2010. Designing competencies for chronic disease practice. Preventing Chronic Disease 7.2: A44.

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              This article describes the outcome of a work group of the US National Association of Chronic Disease Directors convened to develop competencies required of professionals who practice chronic disease prevention and control. Concept mapping was used with existing public health competency statements to identify interrelationships among skills and knowledge required for leading and managing state chronic disease programs. Seven competency areas were highlighted.

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              • US Department of Health and Human Services. 2010. Multiple chronic conditions: A strategic framework. Washington, DC: US Department of Health and Human Services.

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                This document produced at the behest of the US secretary of health and human services is the first to delineate the problem of comorbidities. The report underlines the fact that little is known and even less done to assist people with multiple conditions despite their significant growth in number and associated medical cost. It calls for new perspectives and actions in prevention and management of comorbidities by individuals, clinicians, and health systems.

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                • World Health Organization. 2010. Discussion paper: Regional high-level consultation in the European Region on the prevention and control of noncommunicable diseases. Geneva, Switzerland: World Health Organization.

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                  In May 2010 the UN General Assembly passed a resolution calling for the 2011 high-level meeting with heads of state and governments to consider prevention and control of chronic noncommunicable diseases. This report describes the historic step that recognized the dominance of chronic disease as the cause of premature death and morbidity worldwide. The report was written to support decision making in member states regarding how to combat noncommunicable diseases.

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                  Textbooks

                  Several textbooks describe the most current thinking regarding chronic disease prevention and control. These works cover basic concepts from epidemiology to the context for disease management to specific mental or physical health interventions to the quality and equity of preventive and treatment services. Remington and Brownson 2010 and Larsen and Lubkin 2009 provide in-depth discussions of the epidemiology of noncommunicable diseases. Newman, et al. 2008 and Sperry 2009 focus on psychosocial and behavioral interventions thought to be promising in supporting disease management. Institute of Medicine 2001 constitutes a sentinel document in tying the impact of chronic disease to inequities in care.

                  • Institute of Medicine, Committee on Health Care in America. 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

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                    The IOM calls for a fundamental change in the delivery of health care to reduce disparities in outcomes across different populations. A framework of patient-clinician relationships for achieving better alignment between incentives and quality of care as well as steps to promote evidence-based practice and enhance clinical information systems are discussed. Also discussed are causes of the quality gap and deficient elements of existing health-care systems.

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                    • Larsen, P. D., and I. M. Lubkin. 2009. Chronic illness: Impact and intervention. Sundbury, MA: Jones and Bartlett.

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                      Focuses on those aspects of chronic illness with the greatest impact on individuals and families. Suggests that professionals can improve their ability to help patients manage their conditions and demands of daily life. Covers social, psychological, ethical, and financial factors in coping with chronic disease. Highlights organizational and health system factors that contribute to poor chronic disease outcomes.

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                      • Newman, S., E. Steed, and K. Mulligan. 2008. Chronic physical illness: Self-management and behavioural interventions. London: Open Univ. Press.

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                        Provides an overview of the state of the art of self-management in chronic illness. Touches on the conceptual underpinnings of interventions. Examines issues related to the delivery of interventions. Different chronic conditions are described by international experts regarding efficacy and effectiveness of existing interventions. A section provides ideas for future directions in research and practice.

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                        • Remington, P. L., and R. C. Brownson. 2010. Chronic disease epidemiology and control. 3d ed. Washington, DC: American Public Health Association.

                          DOI: 10.2105/9780875531922Save Citation »Export Citation »E-mail Citation »

                          A compendium of the experience of diverse public health professionals. Targets a varied professional audience. Overviews the “life course” of the major chronic diseases from the upstream social and environmental determinants to behavioral risk factors. Categories of the chronic disease continuum are provided: public health approaches, selected disease risk factors, major chronic conditions, major chronic diseases. First edition published in 1998.

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                          • Sperry, L. 2009. Treatment of chronic medical conditions: Cognitive-behavioral therapy strategies and integrative treatment protocols. Washington, DC: American Psychological Association.

                            DOI: 10.1037/11850-000Save Citation »Export Citation »E-mail Citation »

                            One of the challenges in chronic disease control is reintegrating psychological and physical health in the way that treatment and management are conceptualized. This text is a comprehensive guide to providing integrated care related to the most common chronic conditions. It emphasizes cognitive and behavioral therapies and their appropriateness for combining with general health care. It is targeted toward health-care professionals in clinical practice.

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                            Journals

                            Although many disease-specific journals are available for those seeking information about particular chronic conditions, only a handful focus more generally on chronic disease. These works look at broader issues of context, care delivery, and prevention. For continuous updates on the epidemiology of chronic disease, the Morbidity and Mortality Weekly Report is the prime source for the United States. For a public health perspective, Preventing Chronic Disease and the Annual Review of Public Health are major references. For clinically oriented priorities in chronic disease management, Chronic Illness, Chronic Diseases in Canada, and Therapeutic Advances in Chronic Disease provide salient information and perspectives.

                            • Annual Review of Public Health.

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                              This journal annually recruits experts to review a public health field of importance and to provide a new or emerging perspective regarding it. Key developments in epidemiology, biostatistics, environmental and occupational health, social environments, health behavior, health services, and public health practice are routinely included. A large numbers of articles have direct relevance to prevention and management of chronic conditions and policies and practices conducive to control.

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                              • Chronic Diseases in Canada.

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                                Chronic Disease in Canada (CDIC) is a quarterly scientific journal focusing on evidence relevant to control and prevention of noncommunicable diseases. It is a blend of peer-reviewed articles from epidemiology, public and community health programs, behavioral science, and health services and economics. Most articles relate to chronic conditions in Canada, but most are also highly relevant to prevention and control in the United States and other countries.

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                                • Chronic Illness.

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                                  Chronic Illness is among the leading peer-reviewed journals for those who study, work with, manage, or experience chronic illness. It integrates academic and clinical perspectives and those of people living with long-term medical conditions. Chronic Illness publishes original research, reviews, discussions of topical issues, case studies, and meeting reports.

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                                  • Morbidity and Mortality Weekly Report.

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                                    The Morbidity and Mortality Weekly Report (MMWR) is produced by the CDC and is the agency’s primary way to present timely, reliable, authoritative, accurate, and objective public health data and recommendations based on them. The majority of MMWR’s articles concern the chronic diseases, including the prevalence of conditions, the subgroups of the population most affected, descriptions of efforts to prevent and control conditions, and recommendations for further research.

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                                    • Preventing Chronic Disease: Public Health Research, Practice, and Policy.

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                                      Preventing Chronic Disease (PCD) is a peer-reviewed electronic journal produced by the National Center for Chronic Disease Prevention and Health Promotion of the CDC. Its focus is the interface among public health research, practice, and policy. Special interests include the impact of chronic illness on quality of life, morbidity, and mortality across the life span.

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                                      • Therapeutic Advances in Chronic Disease.

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                                        A source of information regarding drug treatments for the major chronic conditions. Includes expert opinion reviews, narrative reviews, and analyses of clinical guidelines. A focus is results of drug or drug class efficacy. Provides guidance on drugs that are best for a condition and when they are most effective. It is an important primer for understanding the clinical bases for management of chronic disease.

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                                        Evidence-Based Practice Guidelines

                                        Several authors and organizations have provided recommendations for using evidence-based programs and principles in efforts to prevent and manage chronic disease. These are available from several countries, including the United States, Australia, and Canada. Evidence has generally been generated through review of rigorous research related to both processes and outcomes of disease control efforts and can range from clinical recommendations to national, regional, and local procedures and practices. More attention to, and demand for, evidence before adopting practices has led to a larger portfolio of effective interventions. Successful translation and dissemination of practices into new and/or different venues remains a challenge. For an international perspective, Zwar, et al. 2006 and the Health Council of Canada 2009 provide a review and specific case studies. For the US point of view, Briss, et al. 2004 presents an overview of CDC priorities for practice.

                                        • Briss, P. A., R. C. Brownson, J. E. Fielding, and S. Zaza. 2004. Developing and using the guide to community preventive services: Lessons learned about evidence-based public health. Annual Review of Public Health 25:281–302.

                                          DOI: 10.1146/annurev.publhealth.25.050503.153933Save Citation »Export Citation »E-mail Citation »

                                          Developed by an independent task force led by the CDC. Makes recommendations given evidence for interventions and strategies to control chronic disease. Features identification of promising interventions that deserve further study. The guide has been continually updated and has appeared electronically and in various publications and provides an objective evidence-based resource for guiding public health decision making.

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                                          • Health Council of Canada. 2009. Getting it right: Case studies of effective management of chronic disease using primary health care teams. Toronto: Health Council of Canada.

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                                            Intended to be a practical guide for primary health care for translating research findings into action. Elements of success in five case studies are discussed regarding effective leadership—clinical and administrative, roles of team members, coordination of service providers, philosophies and shared values of team-based care, electronic health and medical record support systems, patient-centered programs and support services, and self-assessment and self-management tools.

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                                            • Zwar, N., M. Harris, R. Griffiths, M. Roland, S. Dennis, G. Powell Davies, and I. Hasan. 2006. A systematic review of chronic disease management. Sydney: Research Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, Univ. of New South Wales.

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                                              Provides a definition of chronic disease management in primary health care in New South Wales and compares Australia with North America and Europe. Describes models of chronic disease management and key outcomes of models applied in various settings and assessment strategies. Efficiency and innovation of models are provided. Facilitating factors and barriers to effective, evidence-based interventions in primary care are examined.

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                                              Disparities

                                              In chronic disease, as with most health problems, disparity in outcomes across subgroups of the population is significant. Negative outcomes are most apparent among economically or socially disadvantaged people. Agreement is general in the field of public health that disparity is an indicator of an ineffective health system and of a failure to both attend to the determinants of health and look for root causes. A number of recent articles and reports have examined gaps in outcome and the attendant factors. Freedman, et al. 2011, Seligman and Schillinger 2010, and Fogel 2004 provide social-economic explanations for disparities in health outcomes. Halle, et al. 2009, Agency for Healthcare Research and Quality 2010, and the Centers for Disease Control and Prevention 2009, from the US perspective, discuss priorities for changing care that are expected to reduce disparities in outcomes in chronic disease control.

                                              • Agency for Healthcare Research and Quality. 2010. Highlights from the national healthcare quality and disparities reports. Rockville, MD: Agency for Healthcare Research and Quality.

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                                                Describes progress and opportunities for reducing health-care disparities. Six dimensions of quality linked to reductions in gaps in outcome are identified: effectiveness of care, patient safety, timeliness of care, patient centeredness, efficiency, and access to care. Three factors guide these reports as they pertain to health-care quality and disparities: (1) status in the United States, (2) change over time, and (3) greatest needs for improvement.

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                                                • Centers for Disease Control and Prevention. 2009. Chronic Disease Prevention and Health Promotion: Health Equity.

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                                                  This resource describes the goals of the CDC’s National Center for Chronic Disease Prevention and Health Promotion. Central among these is achieving health equity by eliminating health disparities and achieving optimal health for all Americans. The indicators of health inequities are described as differences in length of life, quality of life, rates of disease, disability and death, severity of disease, and access to treatment.

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                                                  • Fogel, R. W. 2004. Changes in the disparities in chronic disease during the course of the twentieth century. NBER Working Paper 10311. Cambridge, MA: National Bureau of Economic Research.

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                                                    Chronic conditions in later life are influenced by exposures at early ages, including in utero. Differences in age-specific prevalence for chronic disease relate to changes in levels of environmental hazard exposure and improvements in influential factors (e.g., nutrition). Synergism of these factors contributes to reduction in population inequalities related to income, body size, and life expectancy. Findings underscore the importance of environmental factors in chronic disease onset.

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                                                    • Freedman, V. A., I. B. Grafova, and J. Rogowski. 2011. Neighborhoods and chronic disease onset in later life. American Journal of Public Health 101.1: 79–86.

                                                      DOI: 10.2105/AJPH.2009.178640Save Citation »Export Citation »E-mail Citation »

                                                      Reports a study of associations between the built-up social and economic environments and the onset of heart disease, hypertension, stroke, diabetes, cancer, and arthritis in adults over the age of 55. Illustrates the significant effect that living in more economically disadvantaged areas and those areas with higher crime rates has on heart disease and cancer. Neighborhood stressors are shown to be associated with increased incidence of chronic disease.

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                                                      • Halle, Michael, Caya B. Lewis, and Meena Seshamani. 2009. Health disparities: A case for closing the gap. Washington, DC: Department of Health and Human Services.

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                                                        Affirms that eliminating disparities constitutes a public health priority: despite consistent increases in health-care spending, disparities persist; illustrates that low-income Americans and racial/ethnic minorities experience higher rates of disease, fewer treatment options, and reduced access to care; notes that increasing unemployment leads to gaps in outcomes. Posits options to reducing disparities: making health care affordable, protecting patients’ choice, investments in prevention, and assuring quality of care.

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                                                        • Seligman, H. K., and D. Schillinger. 2010. Hunger and socioeconomic disparities in chronic disease. New England Journal of Medicine 363:6–9.

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                                                          This report uses diabetes to illustrate that, even after adjustment for social and economic factors, adults living with the most severe levels of food insecurity have more than twice the risk of chronic disease and are more likely to have poor glycemic control than adults who have access to healthful foods. Findings underscore the role of community contextual factors on negative chronic disease outcomes.

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