OBJECTIVE: Immunization quality improvement (QI) interventions are rarely tested as multicomponent interventions within the context of a theoretical framework proven to improve outcomes. Our goal was to study a comprehensive QI program to increase immunization rates for underserved children that relied on recommendations from the Centers for Disease Control and Prevention's Task Force on Community Preventive Services and the framework of the Chronic Care Model. METHODS: QI activities occurred from September 2007 to May 2008 at 6 health centers serving a low-income, minority population in Washington, DC. Interventions included family reminders, education, expanding immunization access, reminders and feedback for providers, and coordination of activities with community stakeholders. We determined project effectiveness in improving the 4:3:1:3:3:1:3 vaccination series (4 diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 measles-mumps-rubella vaccine, 3 Haemophilus influenzae type b vaccines, 3 hepatitis B vaccines, 1 varicella vaccine, and three 7-valent pneumococcal conjugate vaccines) compliance. RESULTS: We found a 16% increase in immunization rates overall and a 14% increase in on-time immunization by 24 months of age. Improvement was achieved at all 6 health centers and maintained beyond 18 months. CONCLUSION: We were able to implement a comprehensive immunization QI program that was sustainable over time.

As public health practitioners from the National Asthma Control Program (NACP) of the Centers for Disease Control and Prevention, we read the essay "From Evidence-Based Medicine to Evidence-Based Health: the Example of Asthma" (1) with great interest. We agree with the authors' hypothesis that evidence-based clinical medicine must be supplemented by asthma self-management support "that extends beyond the clinic" and "by interventions that change elements of the environment in which patients live." As the authors note, this concept is not new. Indeed, it underlies the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (2). | A recent article (3) describes remarkable progress not only in understanding the pathophysiology of asthma and in producing new medications for its control but also in a public health response "to support patient- and community-level interventions and to assess the effect of the environment on asthma." The NACP has greatly expanded population-level asthma surveillance of asthma prevalence, illness, and death (4). The NACP also supports 34 states, Washington, DC, and Puerto Rico "to build and sustain programs that translate evidence-based practice into interventions." Furthermore, the Task Force on Community Preventive Services recently conducted and published a systematic review of the effectiveness of home-based, multi-trigger, multicomponent interventions in improving asthma control (5). The NACP is working through state asthma programs to implement those interventions. | Much work remains to be done to achieve evidence-based health (as defined by Moskowitz and Bodenheimer), particularly among racial/ethnic minorities, who have a disparately high prevalence of and morbidity from asthma. The authors note 3 necessary actions: linking clinical teams with community resources to address asthma triggers in housing, advocating for better housing and cleaner air, and convincing insurers to reimburse for essential educational and community health services. We suggest that these actions, although necessary, are not sufficient to decrease the burden of asthma at a population level.

The Task Force on Community Preventive Services recommends the use of dram shop liability laws, on the basis of strong evidence of effectiveness in preventing and reducing alcohol-related harms. The Task Force found insufficient evidence to determine the effectiveness of overservice law enforcement initiatives as a means to reduce excessive alcohol consumption and related harms, because too few studies were identified and findings were inconsistent.

Asthma, a common chronic respiratory disease and major source of morbidity in the U.S., affects more than 20 million Americans, can substantially reduce quality of life, and has more than doubled in prevalence since 1980.1 Asthma is also a major cause of hospital use1 and results in very high direct and indirect costs (over $32.7 billion in healthcare costs spent annually when adjusted to 2007 U.S. dollars).2 In 2001, asthma was ranked the 25th leading cause of disability-adjusted life-years (DALYs) lost worldwide3 and is a leading cause of school absences for U.S. children.4 | Asthma is inextricably linked with the home environment and occupant health. Conditions in the home environment must be addressed to treat asthma adequately.5, 6 | The recommendations presented below are based on findings from the accompanying systematic review of home-based, multi-trigger, multicomponent environmental interventions to reduce asthma morbidity, published in this supplement.7 The findings on economic efficiency are from a systematic review of economic evaluations of such interventions, also in this supplement.8

This case study examines the translation of evidence on the effectiveness of laws to reduce the blood alcohol concentration (BAC) of drivers into policy. It was reconstructed through discussions among individuals involved in the processes as well as a review of documentation and feedback on oral presentations. The Centers for Disease Control and Prevention collaborated extensively with federal and non-federal partners and stakeholders in conducting a rigorous systematic review, using the processes of the Guide to Community Preventive Services to evaluate the body of empirical evidence on 0.08% BAC laws. The timely dissemination of the findings and related policy recommendations-made by the independent Task Force on Community Preventive Services-to Congress very likely contributed to the inclusion of strong incentives to States to adopt 0.08 BAC laws by October 2003. Subsequent dissemination to partners and stakeholders informed decision-making about support for state legislative and policy action. This case study suggests the value of: clearly outlining the relationships between health problems, interventions and outcomes; systematically assessing and synthesizing the evidence; using a credible group and rigorous process to assess the evidence; having an impartial body make specific policy recommendations on the basis of the evidence; being ready to capitalize in briefly opening policy windows; engaging key partners and stakeholders throughout the production and dissemination of the evidence and recommendations; undertaking personalized, targeted and compelling dissemination of the evidence and recommendations; involving multiple stakeholders in encouraging uptake and adherence of policy recommendations; and addressing sustainability. These lessons learned may help others working to translate evidence into policy.

In 2000, the Guide to Community Preventive Services (Community Guide) completed a systematic review of the effectiveness of various approaches to increasing physical activity including informational, behavioral and social, and environmental and policy approaches. Among these approaches was the use of signs placed by elevators and escalators to encourage stair use. This approach was found to be effective based on sufficient evidence. Over the past 5 years the body of evidence of this intervention has increased substantially, warranting an updated review. This update was conducted on 16 peer-reviewed studies (including the six studies in the previous systematic review), which met specified quality criteria and included evaluation outcomes of interest. These studies evaluated two interventions: point-of-decision prompts to increase stair use and enhancements to stairs or stairwells (e.g., painting walls, laying carpet, adding artwork, playing music) when combined with point-of-decision prompts to increase stair use. This latter intervention was not included in the original systematic review. According to the Community Guide rules of evidence, there is strong evidence that point-of-decision prompts are effective in increasing the use of stairs. There is insufficient evidence, due to an inadequate number of studies, to determine whether or not enhancements to stairs or stairwells are an effective addition to point-of-decision prompts. This article describes the rationale for these systematic reviews, along with information about the review process and the resulting conclusions. Additional information about applicability, other effects, and barriers to implementation is also provided.

Overweight and obesity remain major health concerns in the U.S. and elsewhere. Obesity increases the risk of many diseases and health conditions including coronary heart disease, type 2 diabetes, a range of cancers (e.g., endometrial, breast, and colon), hypertension, dyslipidemia (e.g., high total cholesterol or high levels of triglycerides), stroke, liver and gallbladder disease, sleep apnea and respiratory problems, osteoarthritis, and gynecologic problems (abnormal menses, infertility). While regular physical activity improves aerobic capacity, muscular strength, body agility and coordination, and metabolic functioning, and is associated with enhanced health and reduced risk for all-cause mortality, maintaining energy balance (defined as the balance between energy taken in and energy expended) is also important in achieving and maintaining a healthy weight and overall health.1, 2, 3, 4 | One way to increase energy expenditure, and improve energy balance, is to incorporate small bouts of physical activity into daily routines.3 According to the CDC, environmental and policy interventions to promote physical activity are important because they can benefit all people exposed to the environment rather than focusing on changing physical activity behavior one person at a time. The use of point-of-decision prompts (PODP) to increase the use of stairwells is one intervention of this type.5

Over the past 25 years, the number of organizations and companies offering a health promotion program for their employees at the worksite has increased dramatically; by 1990, 81% of worksites and by 2000, nearly 90% of all workplaces with at least 50 employees offered their employees some type of health promotion program.1, 2 There are several reasons why health promotion in U.S. work settings has become increasingly common. The top five health conditions (heart disease, cancers, cerebrovascular disease, chronic lower respiratory disease, and unintentional injuries) are responsive to intervention; American adults spend increasing hours at work; and poor employee health results in substantial financial and productivity costs to employers. | In comparison to nonworksite environments, the worksite provides a number of advantages for health promotion: (1) the potential for intervention exposure because of a large and rather stable population; (2) the potential for adequate or enhanced promotion of, recruitment for, and participation in programs; and (3) the potential for social support networks and peer influences among coworkers as reinforcement of efforts.3

BACKGROUND: Many health behaviors and physiologic indicators can be used to estimate one's likelihood of illness or premature death. Methods have been developed to assess this risk, most notably the use of a health-risk assessment or biometric screening tool. This report provides recommendations on the effectiveness of interventions that use an Assessment of Health Risks with Feedback (AHRF) when used alone or as part of a broader worksite health promotion program to improve the health of employees. EVIDENCE ACQUISITION: The Guide to Community Preventive Services' methods for systematic reviews were used to evaluate the effectiveness of AHRF when used alone and when used in combination with other intervention components. Effectiveness was assessed on the basis of changes in health behaviors and physiologic estimates, but was also informed by changes in risk estimates, healthcare service use, and worker productivity. EVIDENCE SYNTHESIS: The review team identified strong evidence of effectiveness of AHRF when used with health education with or without other intervention components for five outcomes. There is sufficient evidence of effectiveness for four additional outcomes assessed. There is insufficient evidence to determine effectiveness for others such as changes in body composition and fruit and vegetable intake. The team also found insufficient evidence to determine the effectiveness of AHRF when implemented alone. CONCLUSIONS: The results of these reviews indicate that AHRF is useful as a gateway intervention to a broader worksite health promotion program that includes health education lasting > or =1 hour or repeating multiple times during 1 year, and that may include an array of health promotion activities. These reviews form the basis of the recommendations by the Task Force on Community Preventive Services presented elsewhere in this supplement.

The density of alcohol outlets in communities may be regulated to reduce excessive alcohol consumption and related harms. Studies directly assessing the control of outlet density as a means of controlling excessive alcohol consumption and related harms do not exist, but assessments of related phenomena are indicative. To assess the effects of outlet density on alcohol-related harms, primary evidence was used from interrupted time-series studies of outlet density; studies of the privatization of alcohol sales, alcohol bans, and changes in license arrangements-all of which affected outlet density. Most of the studies included in this review found that greater outlet density is associated with increased alcohol consumption and related harms, including medical harms, injury, crime, and violence. Primary evidence was supported by secondary evidence from correlational studies. The regulation of alcohol outlet density may be a useful public health tool for the reduction of excessive alcohol consumption and related harms.

Obesity is now recognized as a major health problem with substantial direct and indirect costs to individuals and the U.S. healthcare system. In workplaces over the past century, economic and industrial innovations have reduced the number of workers in primary industries (e.g., agriculture, fishing, mining, or forestry); increased automation and labor-saving devices in production industries; and produced large increases in the proportion of people engaged in sedentary industries. Many workers are sedentary, with easy access to energy-dense (i.e., “empty-calorie”) foods and beverages. Epidemiologic studies of characteristics of working conditions and worker overweight or obesity have shown associations between long work hours, shift work, and job stress and increases in BMI.1 The association between excess body weight and risk for a range of occupational conditions—including injury, asthma, musculoskeletal disorders, immune response, neurotoxicity, stress, cardiovascular disease, and cancer—has been described elsewhere.1 | More than 30% of the U.S. adult population is obese, and a link has been established between obesity and cardiovascular disease, hypertension, dyslipidemia, type 2 diabetes, stroke, osteoarthritis, and some cancers.2, 3 Estimates of aggregate overweight- and obesity-attributable medical spending in the U.S. in 1998 were as high as $78.5 billion ($92.6 billion in 2002 dollars) or 9.1% of the total annual medical expenditure.4 Given the tremendous costs, policymakers, health administrators, and employee wellness program directors need to take action by supporting evidence-based physical activity and nutrition programs that can help reduce the burden of obesity on the U.S. healthcare system. In the workplace, obesity affects costs associated with absenteeism, sick leave, disability, injuries, and healthcare claims.5 Programs and policies that improve worker health and ultimately reduce healthcare costs are of great importance to employers.6 Although extant reviews, both qualitative7, 8, 9, 10 and quantitative,11, 12, 13 have yielded mixed results on the effectiveness of worksite programs in reducing overweight and obesity among workers, these reviews investigated multiple health risk outcomes and did not attempt to quantify program impacts on weight as a summary measure of effect across the bodies of evidence reviewed.

A systematic review was conducted to determine the effectiveness and economic efficiency of multicomponent programs with community mobilization for reducing alcohol-impaired driving. The review was conducted for the Guide to Community Preventive Services (Community Guide). Six studies of programs qualified for the review. Programs addressed a wide range of alcohol-related concerns in addition to alcohol-impaired driving. The programs used various crash-related outcomes to measure their effectiveness. Two studies examined fatal crashes and reported declines of 9% and 42%; one study examined injury crashes and reported a decline of 10%; another study examined crashes among young drivers aged 16-20 years and reported a decline of 45%; and one study examined single-vehicle late-night and weekend crashes among young male drivers and reported no change. The sixth study examined injury crashes among underage drivers and reported small net reductions. Because the actual numbers of crashes were not reported, percentage change could not be calculated. According to Community Guide rules of evidence, the studies reviewed here provided strong evidence that carefully planned, well-executed multicomponent programs, when implemented in conjunction with community mobilization efforts, are effective in reducing alcohol-related crashes. Three studies reported economic evidence that suggests that such programs produce cost savings. The multicomponent programs generally included a combination of efforts to limit access to alcohol (particularly among youth), responsible beverage service training, sobriety checkpoints or other well-defined enforcement efforts, public education, and media advocacy designed to gain the support of both policymakers and the general public for reducing alcohol-impaired driving.

This report presents the results of a systematic review of the effectiveness of worksite nutrition and physical activity programs to promote healthy weight among employees. These results form the basis for the recommendation by the Task Force on Community Preventive Services on the use of these interventions. Weight-related outcomes, including weight in pounds or kilograms, BMI, and percentage body fat were used to assess effectiveness of these programs. This review found that worksite nutrition and physical activity programs achieve modest improvements in employee weight status at the 6-12-month follow-up. A pooled effect estimate of -2.8 pounds (95% CI=-4.6, -1.0) was found based on nine RCTs, and a decrease in BMI of -0.5 (95% CI=-0.8, -0.2) was found based on six RCTs. The findings appear to be applicable to both male and female employees, across a range of worksite settings. Most of the studies combined informational and behavioral strategies to influence diet and physical activity; fewer studies modified the work environment (e.g., cafeteria, exercise facilities) to promote healthy choices. Information about other effects, barriers to implementation, cost and cost effectiveness of interventions, and research gaps are also presented in this article. The findings of this systematic review can help inform decisions of employers, planners, researchers, and other public health decision makers.