Chronic Disease Directors Research Articles

Annual Survey of State and Territorial Chronic Disease Prevention and Health Promotion Capacity and Organizational Development Needs—United States, 2023

Objective: The National Association of Chronic Disease Directors (NACDD) is a nonprofit organization that supports state and territorial chronic disease prevention and health promotion efforts through capacity building and technical assistance. Each year, NACDD surveys health department leaders who oversee chronic disease prevention and health promotion (hereafter, Chronic Disease Directors). We have previously used the annual survey results to inform strategic planning and resource allocation but have not historically published key findings in the peer-reviewed literature. In this paper, we report on NACDD’s 2023 survey outcomes and place those findings into the broader public health policy context. Design: State Chronic Disease Directors completed a survey about their organizational capacity and development needs. Responses were summarized in aggregate and by jurisdiction size. Results: State chronic disease units have varied staffing and responsibilities, but most address diabetes, cardiovascular diseases, and cancer screening and prevention. Chronic Disease Directors generally reported strong or improving capacity in most practice areas but ranked workforce development lower. Staffing increased slightly during 2023 compared with the 2020 baseline (median of 1.3 and 1.1 employees per 100 000 jurisdiction population, respectively). However, Chronic Disease Directors expressed ongoing concerns about turnover, hiring, and training of inexperienced staff, as well as about funding limitations and uncertainty. Looking forward to 2024, many Chronic Disease Directors expressed intentions to focus on supporting their workforce with training and development opportunities and addressing health equity. Conclusions: During this period of pandemic recovery, turnover, hiring, and training—particularly of the many new public health staff—remain key areas of concern for many chronic disease units. Continued stabilization of public health funding and increased prioritization of organizational capacity development—particularly workforce development, chronic disease data systems, and tools for addressing health equity—could help ensure chronic disease units can better address current and emerging challenges in chronic disease prevention and health promotion.

Abstract B091: Listen, Empower, Co-Create: Conducting listening sessions to create tailored messages about colorectal health for American Indian communities

Abstract Background We conducted Listening Sessions using a modified version of boot camp translation (BCT), a validated community engaged approach, to engage American Indian community members in the Great Plains and the Pacific Northwest to develop culturally and locally relevant colorectal cancer (CRC) screening messages and materials. Methods CRC is one of the leading causes of cancer death in the US and disproportionally affects American Indian adults. Routine CRC screening leads to earlier diagnosis and prolonged survival from the disease. In partnership with Great Plains Tribal Leaders Health Board (GPTLHB), South Puget Intertribal Planning Agency (SPIPA), and National Association of Chronic Disease Directors, we used a modified BCT approach to obtain feedback from tribal communities to create CRC screening messages and materials. To make the BCT process more meaningful for our partner communities, we reframed the BCT sessions by referring to them as Listening Sessions. The Listening Session engagement process was designed to help community leaders and champions learn about local barriers and gaps in care (listen), share health information in a collaborative way (empower), and develop messages and materials that resonate with and motivate community members to take control of their health (co-create). Eligible tribal community members from GPTLHB and SPIPA were between the ages of 45-75 and able to participate in three Listening Session meetings (one five-hour in-person meeting including expert presentations, brainstorming opportunities, and interactive small group sessions, and two follow-up virtual sessions (one-hour each) to refine messages and materials). Results Common Themes. Both groups emphasized the importance of using a multigenerational approach by including grandchildren and Elders in the messages and materials. Additionally, they highlighted the need for materials to be relatable and culturally relevant by incorporating local cultural imagery and traditions and multigenerational family support .Differing Themes. The GPTLHB findings focused specifically on including Lakota words to reinforce cultural identity, using visuals for colon health education, and incorporating details about healing traditions. The SPIPA findings recommended highlighting intertribal milestones like the canoe journey and incorporating water as a symbol of spiritual healing. Materials and Dissemination Methods. Preferred materials and channels for dissemination were: 1) fact sheets, posters, and visual stories to be distributed in-clinic or at community events, 2) animated videos for CRC screening education to be shown in clinic, 3) live action videos with community member CRC stories to be shown in clinic. Final materials will be available here: www.KPCHR-engage.org Conclusion We conducted Listening Sessions to incorporate participant feedback to develop CRC screening messages and materials and identified preferred dissemination channels for tribal communities in the Great Plains and Pacific Northwest. Citation Format: Jamie Thompson, Jennifer Rivelli, Priyanka Gautom, LaToya Brave Heart, Jamie Nikander, Lorrie Graaf, Gloria Coronado. Listen, Empower, Co-Create: Conducting listening sessions to create tailored messages about colorectal health for American Indian communities [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B091.

Abstract A044: Creating culturally relevant colorectal cancer screening messages and materials for tribal communities in the Great Plains

Abstract Introductory sentences indicating the purposes of the study: We applied a modified version of boot camp translation (BCT), a validated community participatory approach, to engage tribal community members in the Great Plains to develop culturally and locally relevant colorectal cancer (CRC) screening messages and materials. Brief description of pertinent experimental procedures: CRC is one of the leading causes of cancer death in the United States and disproportionally affects American Indian adults, especially American Indians living in the Great Plains. Routine CRC screening leads to earlier diagnosis and prolonged survival from the disease. However, American Indian adults are less likely to be up to date on CRC screening than White adults, highlighting the need to increase CRC screening within this community. In partnership with the Great Plains Tribal Leaders Health Board and the National Association of Chronic Disease Directors, we used a modified BCT approach to elicit feedback from tribal community members to create messages and materials that motivate tribal members to get screened for CRC. To make the BCT process more meaningful for our partner communities, we reframed the BCT sessions by referring to them as listening sessions. Eligible tribal community members recruited were between the ages of 45-75 and agreed to participate in all three listening sessions over a two-month period. The sessions consist of one five-hour in-person gathering in Rapid City, South Dakota, and two one-hour follow-up video-conferencing calls. The in-person session included a cultural presentation of Lakota teachings by a local hoop dancer, CRC education by an expert in CRC research, a presentation by local leaders on interventions to increase community access to CRC screening, and discussions on CRC knowledge, beliefs, barriers to screening, and messages/materials to help increase screening. The follow-up sessions, scheduled to occur in the summer of 2023, will gather feedback on draft materials and messages. Summary of the new unpublished data: A total of 38 adults participated in the first listening session. The key themes emphasized the importance of: 1) including Lakota words in the messages/materials as language is tied to cultural identity, 2) creating messaging/materials that are relatable, address local barriers, and include resources and cultural imagery, 3) applying a multigenerational approach to screening education in the messages and materials, 4) including cultural details about healing traditions, and 5) using visuals for colon health education and screening education. The participants suggested using videos in clinics, radio ads, visual stories, brochures, and text messages as the primary channels to disseminate the messages/materials. Statement of conclusions: We successfully used a modified BCT approach to incorporate participant feedback to develop CRC screening messages and materials and identified preferred dissemination channels for the Great Plains tribal communities. Final materials will be showcased. Citation Format: Priyanka Gautom, Jamie H. Thompson, Jennifer S. Rivelli, Senait R. Tadesse, Richard Mousseau, LaToya Brave Heart, Kelley LeBeaux, Derrick Molash, Lorrie Graaf, Dawn Wiatrek, Gloria D. Coronado. Creating culturally relevant colorectal cancer screening messages and materials for tribal communities in the Great Plains [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A044.

COGNITIVE DECLINE PUBLIC HEALTH SURVEILLANCE: EXPERT-GUIDED COLLABORATION FOR BRFSS MODULE REVISION

Abstract The Behavioral Risk Factor Surveillance System (BRFSS) Cognitive Decline Module collects population level data on subjective cognitive decline (SCD) — self-reported difficulties in thinking or memory — which can be one of the earliest warning signs of dementia. Originally devised in 2009, the module undergoes periodic revision to ensure it remains current, the data collected are actionable, and to encourage uptake of the module by state health agencies. In 2021, the Alzheimer’s Association and the Centers for Disease Control and Prevention’s Alzheimer’s Disease Program formed an expert workgroup to examine the ongoing value and relevance of the module and propose any improvements. Workgroup members included researchers, chronic disease directors, epidemiologists, survey methodologists, policy analysts, and BRFSS coordinators. Using a consensus-building process, the workgroup utilized pre-meeting worksheets to identify areas of agreement and disagreement which informed key debates during subsequent meetings. Among many factors, the workgroup assessed the existing module for accuracy and utility. Discussion centered on aligning language and concepts contained within the module’s questions with current scientific research on SCD and how to accurately and adequately assess the associated burden SCD imposes. People living with cognitive impairment were consulted during the revision process to ensure phrasing reflected their lived experience. The result was a consensus set of suggested revisions to the Cognitive Decline Module, submitted to CDC for review and approval. The robust process, involving a variety of stakeholders and perspectives, can serve as an efficient and effective model for ensuring the longevity and usefulness of population health surveillance.

A roadmap toward equitable, coordinated, quality reproductive care for women with chronic conditions.

A roadmap toward equitable, coordinated, quality reproductive care for women with chronic conditions.

The power of partnerships: state public health department multisector collaborations in major chronic disease programme areas in the United States

BackgroundMultisector collaboration between state public health departments (SHDs) and diverse community partners is increasingly recognized as important for promoting positive public health outcomes, addressing social determinants of health, and reducing health inequalities. This study investigates collaborations between SHDs in the United States and different types of organizations addressing chronic disease in and outside of the health sector.MethodsSHD employees were randomly selected from the National Association of Chronic Disease Directors membership list for participation in an online survey. Participants were asked about their primary chronic disease work unit (cancer, obesity, tobacco, diabetes, cardiovascular disease, and others), as well as their work unit collaborations (exchange of information/cooperation in activities) with organizations in health and non-health sectors. As a measure of the different organizations SHDs collaborated with in health and non-health sectors, a collaboration heterogeneity score for each programme area was calculated. One-way analysis of variance (ANOVA) with Tukey’s post hoc tests were used to assess differences in collaborator heterogeneity between programme areas.ResultsA total of 574 participants were surveyed. Results indicated that the cancer programme area, along with diabetes and cardiovascular disease, had significantly less collaboration heterogeneity with organizations outside of the health sector compared to the obesity and tobacco programme areas.ConclusionsWhile collaborations with health sector organizations are commonly reported, public health departments can increase collaboration with sectors outside of health to more fully address chronic disease prevention.

Integrating Alzheimer's Messages into Chronic Disease Programs

The number of people in the United States with dementia is increasing, with nearly six million people living with Alzheimer’s disease and related dementias. It is the fifth leading cause of death for those aged ≥65 years. Over 95% of people with dementia have another comorbid chronic condition. The Healthy Brain Initiative’s State and Local Public Health Partnerships to Address Dementia: The 2018-2023 Road Map notes that public health agencies should raise awareness of the link between brain health and physical health, and specifically calls out tobacco prevention and control, cardiovascular health management diabetes prevention and management, obesity prevention and control, and injury prevention as intervention points. The National Association of Chronic Disease Directors developed brain health messages targeted to reduce risk for cognitive decline through the prevention and control of comorbid chronic conditions. These messages can be leveraged for public health action by integrating them into existing chronic disease programs.

Overcoming difficult conversations: Training medical professionals to discuss mental health with cancer survivors.

e19155 Background: Cancer survivors have overcome a significant health challenge, and now face the physical, social and emotional effects of surviving cancer. These psychosocial side-effects are often not addressed in the clinic due to time constraints, false perceptions of reimbursement and discomfort toward the subject from both the patient and medial professional. The National Association of Chronic Disease Directors, along with the Centers for Disease Control and Prevention and Kognito Solutions have developed a series of conversation simulations led by virtual human, digital characters to help medical professionals practice these patient interactions. Methods: The simulation was developed after an extensive literature review and interviews with cancer survivors and 12 professionals in oncology and primary care. Scripts were developed that included hundreds of conversation pathways for providers to choose from. Scripts were tested by subject matter experts in clinical psychology, oncology and survivorship. Three video interviews with survivors were included along with a didactic teaching segment to provide instruction to medical professionals participating in the simulation. Results: The resulting learning experience is a self-guided conversation pathway where the medical professional chooses responses to the virtual cancer survivor’s questions guiding the survivor toward a discussion focused on distress. The simulation offers feedback and suggests conversational improvements throughout the process. The simulation is now complete and freely available online. Full rollout and dissemination including CME credits will begin in March. To date,197 distinct users have engaged in the simulation. Users self-reported the simulation was high quality and resulted in them listening more, asking more open-ended questions, and discussing mental health issues routinely with patients. Conclusions: This innovative approach to learning offers an interactive and highly engaging way to practice difficult discussions with patients. Increasing the quality and frequency of mental health screenings with cancer survivors will empower survivors and improve their adherence to other health behaviors reducing the risk of recurrence. Increased use of the simulation after the national rollout will allow a more robust evaluation of future impact on patient mental health and changes in medical practice.

The Association Between Evidence-Based Decision Making and Accreditation of State Health Departments.

To assess the association between evidence-based decision making, including implementation of evidence-based interventions (EBIs), with accreditation of state health departments through the Public Health Accreditation Board (PHAB). This was a cross-sectional, electronic survey of state health department practitioners. We utilized a survey instrument focused on evidence-based public health, de-implementation, and sustainability of public health programs. Survey questions were organized into 6 domains: (1) demographic information; (2) individual-level skills; (3) decision making on programs ending; (4) decision making on programs continuing; (5) organization/agency capacity; and (6) external influences. The targeted practitioners were randomly selected from the 3000-person membership of National Association of Chronic Disease Directors and program manager lists from key Centers for Disease Control and Prevention-supported programs in cancer and cancer risk factors. The final target audience for the survey totaled 1329 practitioners, representing all 50 states. The main outcome measures included the strength of association between a state's PHAB accreditation status and variables related to evidence-based public health and use of EBIs that fell within the individual participant skills, organization/agency capacity, and external influences domains. We received 643 valid responses (response rate = 48.4%), representing all 50 states, with 35 states being PHAB accredited. There was a statistically significant association between PHAB accreditation and state health department use of quality improvement processes (P = .002), leadership plans to implement EBIs (P = .009), and leadership reactions to EBI implementation issues (P = .004). Respondents from PHAB-accredited states were significantly more likely than participants from nonaccredited states to report greater engagement with legislators and governors regarding EBIs and 14% less likely to report the inappropriate termination of programs in their work unit (P = .05). The importance of accreditation relates to both internally focused functions and externally focused activities, especially regarding policy-related impact.

Practitioner perspectives on building capacity for evidence-based public health in state health departments in the United States: a qualitative case study

BackgroundPublic health agencies are responsible for implementing effective, evidence-based public health programs and policies to reduce the burden of chronic diseases. Evidence-based public health can be facilitated by modifiable administrative evidence-based practices (A-EBPs) (e.g., workforce development, organizational climate), yet little is known about how practitioners view A-EBPs. Thus, the purpose of this qualitative study was to understand state health department practitioners’ perceptions about how A-EBPs are implemented and what facilitators and barriers exist to using A-EBPs.MethodsChronic disease prevention and health promotion program staff who were members of the National Association of Chronic Disease Directors were recruited to participate in telephone interviews using a snowball sampling technique. Interviews were transcribed verbatim, and transcripts were analyzed using a common codebook and the a priori method in NVivo.ResultsTwenty seven interviews were conducted with practitioners in four states (5–8 interviews per state). All practitioners felt that their work unit culture is positive and that leadership encouraged and expected staff to use evidence-based processes. Participants discussed the provision of trainings and technical assistance as key to workforce development and how leaders communicate their expectations. Access to evidence, partnerships, and funding restrictions were the most commonly discussed barriers to the use of A-EBPs and EBDM.ConclusionsResults of this study highlight practitioners’ perspectives on promoting evidence-based public health in their departments. Findings can inform the development and refinement of resources to improve A-EBP use and organizational and leadership capacity of state health departments.

Core Competencies for Chronic Disease Prevention Practice.

Chronic disease prevention practice is an important specialization within public health and health care that connects chronic conditions, causes, prevention tactics, and population-based health promotion modalities. Required competencies for successful chronic disease prevention and health promotion encompass leadership, epidemiology, program practice, and evaluation, among others. In 2007, the National Association of Chronic Disease Directors (NACDD) developed and codified the Core Chronic Disease Prevention Competencies (Competencies), a standard set of competencies for professionals in chronic disease prevention and control. NACDD also devised support tools to assist individuals and managers in increasing capacity and opportunities for member growth, thereby benefitting the agencies they serve. In revisiting the Competencies in 2015 through 2018, the NACDD Professional Development Committee reviewed uses, conducted member surveys, polled NACDD councils, and produced recommendations. The goal of this process was to recognize rapid changes in the environments, practices, and characteristics that affect chronic disease prevention, both at the population level and for individual groups at risk during the past 10 years. In addition, opportunities existed to benefit from the changes in technology that have increased demands on health professionals, who as a result have had to adapt to these changes. We worked with the NACDD Learning and Professional Development Committee and reviewed learning offerings, other related competency sets, and tools for performance assessment. The results of the review include a final set of Competencies and subcompetencies, a guide to using the competencies, and a fully integrated interactive assessment tool used by individuals, managers, and teams. Going forward, NACDD’s strategic focus includes a regular review of the Competencies and building chronic disease learning assets.

Application of Geographic Information Systems to Address Chronic Disease Priorities: Experiences in State and Local Health Departments.

Application of Geographic Information Systems to Address Chronic Disease Priorities: Experiences in State and Local Health Departments.

Moving the Needle on Action Around Evidence-Based Screening for Hereditary Conditions: Preparing State Chronic Disease Directors to Advance Precision Public Health.

Moving the Needle on Action Around Evidence-Based Screening for Hereditary Conditions: Preparing State Chronic Disease Directors to Advance Precision Public Health.

Adjusting the Equity Lens: Gaps in Addressing Health Equity in State Chronic Disease Prevention.

Purpose: Chronic diseases cause a significant proportion of mortality and morbidity in the United States, although risk factors and prevalence rates vary by population subgroups. State chronic disease prevention practitioners are positioned to address these issues, yet little is known about how health equity is being incorporated into their work. The purpose of this study was to explore perceptions of health equity in a sample of state chronic disease practitioners.Methods: Participants were selected in conjunction with a related evaluation of the National Association of Chronic Disease Directors (NACDD) capacity-building and evidence-based efforts. Four states were chosen for study based on variance in capacity. Directors in each of the states were interviewed and using snowball sampling, 8–12 practitioner interviews were conducted in each state, digitally audio recorded and transcribed. Using a comparative coding technique, themes and analyses were developed.Results: Comments from the practitioners fell into three main and inter-related categories. First, they discussed the varying degrees of integration of health equity in their work. The second theme was collaboration and the importance of working within and outside of departments, as well as with the community. The third theme related to measurement and the need for better data that can be used to garner support and measure impact.Conclusion: Chronic disease practitioners can play an important role in achieving health equity. Integrating this work more fully into chronic disease prevention and health promotion, developing strategic partnerships, tracking efforts, and measuring impact will improve practice and ultimately population health.

Cancer Prevention During Early Adulthood: Highlights From a Meeting of Experts

Using a life course approach, the Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control and the National Association of Chronic Disease Directors co-hosted a 2-day meeting with 15 multidisciplinary experts to consider evidence linking factors in early adulthood to subsequent cancer risk and strategies for putting that evidence into practice to reduce cancer incidence. This paper provides an overview of key themes from those meeting discussions, drawing attention to the influence that early adulthood can have on lifetime cancer risk and potential strategies for intervention during this phase of life. A number of social, behavioral, and environmental factors during early adulthood influence cancer risk, including dietary patterns, physical inactivity, medical conditions (e.g., obesity, diabetes, viral infections), circadian rhythm disruption, chronic stress, and targeted marketing of cancer-causing products (e.g., tobacco, alcohol). Suggestions for translating research into practice are framed in the context of the four strategic directions of the National Prevention Strategy: building healthy and safe community environments; expanding quality preventive services in clinical and community settings; empowering people to make healthy choices; and eliminating health disparities. Promising strategies for prevention among young adults include collaborating with a variety of community sectors as well as mobilizing young adults to serve as advocates for change. Young adults are a heterogeneous demographic group, and targeted efforts are needed to address the unique needs of population subgroups that are often underserved and under-represented in research studies.

A Customizable Model for Chronic Disease Coordination: Lessons Learned From the Coordinated Chronic Disease Program.

In 2012, the Centers for Disease Control and Prevention provided funding and technical assistance to all states and territories to implement the Coordinated Chronic Disease Program, marking the first time that all state health departments had federal resources to coordinate chronic disease prevention and control programs. This article describes lessons learned from this initiative and identifies key elements of a coordinated approach. We analyzed 80 programmatic documents from 21 states and conducted semistructured interviews with 7 chronic disease directors. Six overarching themes emerged: 1) focused agenda, 2) identification of functions, 3) comprehensive planning, 4) collaborative leadership and expertise, 5) managed resources, and 6) relationship building. These elements supported 4 essential activities: 1) evidence-based interventions, 2) strategic use of staff, 3) consistent communication, and 4) strong program infrastructure. On the basis of these elements and activities, we propose a conceptual model that frames overarching concepts, skills, and strategies needed to coordinate state chronic disease prevention and control programs.

National Survey of Training Needs Reported by Public Health Professionals in Chronic Disease Programs in State, Territorial, and Local Governments

In 2009, the National Association of Chronic Disease Directors published desirable competencies for professionals in public health chronic disease programs. Assessing the training needs of these professionals is an important step toward providing appropriate training programs in chronic disease prevention and control competencies. Conduct a survey of the chronic disease workforce in state and local health departments to identify professional training needs. We conducted a cross-sectional survey of state, territorial, and local public health professionals who work in chronic disease programs to identify their self-reported training needs, using the membership lists of 3 professional organizations that included practitioners in chronic disease public health programs. The survey was national, used a convenience sample, and was conducted in 2011. The survey was developed using an algorithm to select anonymous participants from the membership lists of the National Association of Chronic Disease Directors, the Directors for Health Promotion and Education, and the National Association of County & City Health Officials. The survey included questions about professional background, chronic disease activities, confidence about skills, and needs for training. The survey had 567 responses (38% response ratio). The majority of the respondents were female, non-Hispanic white, and 40 years or older. Respondents were not confident of their skills in health economics (38%) and technology and data management (23%). The most requested training topics were assessing the effects of policies, laws, and regulations (70%) and health economics (66%). This survey included local, territorial, and state public health professionals who work in chronic disease programs. These reported training needs in quantitative measurement methods and policy-related topics suggest key subjects for future training and education curricula.

Technical Assistance From State Health Departments for Communities Engaged in Policy, Systems, and Environmental Change: The ACHIEVE Program

IntroductionThis study assessed the value of technical assistance provided by state health department expert advisors and by the staff of the National Association of Chronic Disease Directors (NACDD) to community groups that participated in the Action Communities for Health, Innovation, and Environmental Change (ACHIEVE) Program, a CDC-funded health promotion program.MethodsWe analyzed quantitative and qualitative data reported by community project coordinators to assess the nature and value of technical assistance provided by expert advisors and NACDD staff and the usefulness of ACHIEVE resources in the development and implementation of community action plans. A grounded theory approach was used to analyze and categorize phrases in text data provided by community coordinators. Open coding placed conceptual labels on text phrases. Frequency distributions of the quantitative data are described and discussed.ResultsThe most valuable technical assistance and program support resources were those determined to be in the interpersonal domain (ie, interactions with state expert advisors, NACDD staff, and peer-to-peer support). The most valuable technical assistance events were action institutes, coaches’ meetings, webinars, and technical assistance conference calls.ConclusionThis analysis suggests that ACHIEVE communities valued the management and training assistance provided by expert advisors and NACDD staff. State health department expert advisors provided technical guidance and support, including such skills or knowledge-based services as best-practice strategies, review and discussion of community assessment data, sustainability planning, and identification of possible funding opportunities. NACDD staff led development and implementation of technical assistance events.

Health departments in a brave New World.

The number of people at risk for chronic diseases is increasing, and methods for reducing risk and promoting health are becoming more complex. Demands of changing political and social environments, as well as economic and demographic trends, are forcing state and local health departments to reassess what is most important and make judicious choices that will yield the greatest gains. Health departments cannot afford to squander time and resources on ineffective programs and policies; to maintain their relevance, they must adopt a public health agenda that is both ambitious and grounded in science. The mission of health departments is the same today as it was in the 1800s: to ensure conditions in which people can be healthy. As essential players in the nation’s public health system, health departments are operating in the best of times and the worst of times. On the one hand, prevention is getting more attention, and new cross-sector collaborations to embed health in all policies can affect upstream health determinants and push the clinical care system toward more effective, efficient, and equitable care. On the other hand, resources are tight, additional budget cuts loom, and public health is caught up in the larger issues of increasing political polarization and distrust of government. Aligning health with community and economic development can help mitigate these problems. Working with partners from different sectors is essential in reshaping commercial and government policies and practices that drive poor population health (1). State and local health departments must capitalize on opportunities that now exist to transform the way they do business. Improving the health of Americans requires improvement of population health at multiple levels. The momentum of health care reform and the increased support for prevention must be harnessed. A coordinated approach to prevent chronic diseases and promote health is now supported by new funding provided by the Centers for Disease Control and Prevention (CDC). State public health chronic disease prevention and control programs, especially those that focus on common risk factors such as poor nutrition, low levels of physical activity, and tobacco use, have demonstrated the potential benefits of an integrated model and are a key link to improving our nation’s health (2). State chronic disease directors must expand the effects of local and community-based health programs through coordination and dissemination of evidence-based interventions. Strong leadership from state health directors can reinvent the way health departments operate and stimulate the public health system to be more effective. We offer 3 priority areas where action can lead to real change in health department programs and practices. Concerted efforts in these areas could substantially improve the health of Americans.

Counselor Demographics, Ageist Attitudes, and Multicultural Counseling Competence Among Counselors and Counselor Trainees

The purpose of this study was to understand the relationship among counselors' self reported multicultural counseling competence and their attitudes of the geriatric population. A statistically significant negative correlation was found between participants' attitudes of the geriatric population and their self-reported multicultural counseling competence. Implications for training and practice are provided. ********** Approximately 75 million individuals who were born between 1946 and 1964 encompass the Baby Boom population (Goldstein & Damon, 1993). In the year 2011, these individuals began entering the geriatric population. As the Baby Boom population ages, the geriatric population, which includes those 65 years and older, will grow to be the largest cohort in history. By 2000, 35 million individuals composed the geriatric population (Gist & Hetzel, 2004), and researchers expect this cohort to continue to grow to include 21% of the U.S. population--or 76.4 million individuals--by 2030 (Van Gerpen, Johnson, & Winstead, 1999). With the rapid increase of the geriatric population, greater attention to mental illness, elder abuse, and other psychosocial factors (e.g., ageism) within the population is likely, as counselors may be treating more of these individuals. The purpose of this article is to review these salient characteristics for working with this population and to explore the relationship between two constructs indicating counselor competency in multicultural counseling and attitudes toward the geriatric population. MENTAL HEALTH AND PSYCHOSOCIAL CONSIDERATIONS Mental Health Considerations There are many mental health considerations counselors must be aware of when counseling individuals of the geriatric population. Dementia, depression, and suicide are prevalent within this population. Dementia such as Alzheimer's disease is extremely prevalent during older adulthood and may be the most prevalent mental illness in older adults (Zank, 1998). Overall, 5% of adults over the age of 65 years are diagnosed with dementia and 10% are diagnosed with Alzheimer's disease (Spira & Edelstein, 2007; Zank, 1998). In addition, individuals over the age of 80 years are diagnosed with dementia at a rate of 20%, and more than half of individuals over the age of 85 years are diagnosed with Alzheimer's disease. Currently, in the United States, 4 million people are living with Alzheimer's disease (Spira & Edelstein, 2007). These individuals often have progressive memory loss; language disruption; agitation; and personality, emotional, and behavior changes (Abraham, 2005). Depression can lead to impairments in mental, physical, and social functioning for this population (Centers for Disease Control and Prevention [CDC] & National Association of Chronic Disease Directors [NACDD], 2009). Overall, 2.5% of older adults meet the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) criteria for depression or dysthymic disorder. However, 27% of older adults have symptoms of depression but do not meet the full criteria for the disorder. Older adults must often face the death of friends as well as partners, and, therefore, bereavement becomes a focus of older adulthood. Because of this, elders may experience increased depression. In addition, depression may also be exacerbated by illness and accidents, such as hip fractures or heart disease (U.S. Department of Health and Human Services [USDHHS], 2000). For instance, 12% of older individuals who are hospitalized for illness and accidents such as these develop depression. In addition, elders in nursing homes are particularly inclined to develop depression because 15% to 25% of these individuals develop symptoms of the mental health illness (USDHHS, 2000). Suicide also greatly affects individuals of the geriatric population. Overall, 13 individuals 65 years and older commit suicide each day in the United States (Walsh, Currier, Shah, Lyness, & Friedman, 2008). …