Notes from the Field
Submissions to Notes from the Field (500 to 1000 words, preferably without references, tables, or figures) should be sent to Hugh H. Tdsonr MD, Editor, AJPH Notes from the Field, ESP Dimision, Burroughs Weilcome Co, 3030 Comwalli Road, Research Tnangle Parl, NC 27709. T7is colwnn presents infonmation on newsworthy public health programs andproject experiences at the comnunity leveL Further infonnation should be soughtfrom the author(s) listed at the end of each article.
Controlling Cardiovascular Disease: The Role of the Local Health Department Cardiovascular disease (CVD) is the leading cause of death, illness, disability, and medical costs in the United States.1 Systematic prevention and control of modifiable CVD risk factors (i.e., cigarette smoking, hypertension, high blood cholesterol, physical inactivity, obesity, and diabetes) are important public health priorities for the nation, as reflected in recent year 2000 objectives2 and model standards for state and local action.3 Local health departments are the front line of public health4 and are responsible for delivering the majority of public health services. Traditionally, local health departments have been active in communicable disease control, sanitation, laboratory services, matemal and child health, and vital statistics.5 However, the control of many communicable diseases, combined with the growing importance of chronic diseases such as CVD, suggests that local health departments' priorities should be expanded to include more CVD control activities. 1414 Amencan Journal of Public Health
We recently began a project to reduce the prevalence ofCVD risk factors in Missouri (population 5 117 073). A key component of this project is the involvement of local health departments in program planning and local coalition development. Long-term project goals are to build the capacity of local health departments to control CVD and to develop an intervention model for use elsewhere. To raise local conscousness about the need to refocus cardiovascular activities at the community level and to underscore the value of coalition building, we undertook a survey of CVD control knowledge and activities among local health departments in Missouri. We used data from this survey and other data to develop six local CVD control coalitions.
Locl Heath Depxulmt Suwey The survey, which included 119 city, county, and district health departments ("local health departments"), was conducted by mail from June through August 1990. The six-page instrument contained 11 questions, many of which had multiple parts. Most questions were closed-ended and were standardized from other surveys.6,7 With two separate mailings, we achieved a 95% response rate (113 responses). Most surveys were completed by a health department administrator/nonnurse (56%), a community health nurse (20%), or an administrator/nurse (19%o). The major areas covered in the survey were
* Relative importance of various diseases * Knowledge of CVD risk factors * Health department activity levels in various health care services * Possible barriers to CVD control in the local setting
Answers to questions pertaiing to activity levels in various health care services were ranked on five-point scales: numerical values of 0, 1, 2, 3, and 4 were assigned to the response options "none," "low," "medium," "high," and "very high," respectively. Mean activity scores were then calculated by summing the values and dividing by the total number of respondents for each item. Cardiovascular disease was viewed as the most important health issue in terms of morbidity and mortality in the population. Other chronic diseases (cancer, diabetes, and chronic lung disease) also were viewed as having major health impacts on the population. Of the 10 health issues examined, homicide and suicide ranked lowest in importance. Respondents were generally knowledgeable about the major risk factors for CVD. Hypertension, cigarette smoking, and obesity were considered the three most important riskfactors for CVD. High blood cholesterol was rated as the fifth most important risk factor, with a considerably lower ranking than the two other major risk factors for CVD (i.e., hypertension and cigarette smoking1). Among activities related to CVD prevention and control, only hypertension screening received a high activity score. Nutrition education was ranked relatively high, although much of this activity probably occus in Women, Infants, and Clildren programning and is not seen as targeted directly toward CVD control. Among other major CVD risk factor control strategies, cholesterol screening and tobacco cessation counseling received only medium to low activity scores. The mean activity scores of various health services were as follows:
* Immunizations, 3.7 * Child health services, 3.3 October 1992, Vol. 82, No. 10
Notes fm the Fied
* Hypertension screening, 3.1 * Nutrition education, 2.7 * Family planning, 2.0 * Cholesterol screening, 1.6 * AIDS prevention, 1.5 * Tobacco cessation counseling, 1.4 * Physical exams, 1.4
Ninety-five percent of those surveyed believed that CVD prevention and screening activities should be increased in their areas. Individual patient education was cited as the most effective method for increasing CVD control efforts (it was considered to have a "large effect" by 60% of the respondents). Other CVD control methods cited as having a large effect were * School-based education (54%) * Work-site programs (42%) * Mass media (28%) * Physician education (25%)
Several important constraints on CVD control efforts were identified. Sixty percent of the respondents strongly agreed with the statement that the lack of financial reimbursement lessens the likelihood of tobacco, diet, and physical activity counseling in the local health department setting. Forty-five percent strongly agreed that these counseling activities require more time than is currently available. Finally, 22% of the respondents strongly agreed that the lack of technical training in risk reduction activities is a sig-
nificant barrier. Overall, our survey findings showed that although local health department respondents were well aware of the importance of CVD control, their level of activity in this area was relatively low. The results also suggested that respondents typically preferred more traditional oneto-one CVD educational methods and considered other proven strategies8 (e.g., community-wide efforts) to be less effective. The major barriers to CVD risk reduction activities in the local health department setting included deficiencies in reimbursement, time, and technical training. These issues have been raised by others.5,7 Cost- and time-effective risk reduction techniques exist for CVD control. For example, in the area of smoking cessation, numerous studies have shown that minimal advice from health professionals has a substantial effect on smoking reduction among patients.9 Although there were clearly identified constraints, it was gratifying to note that 95% of our respondents October 1992, Vol. 82, No. 10
acknowledged the need for increased CVD control activities at the local level.
Local CVD Conmi Coalitns The survey underscored the need for a new strategy at the local level, one that broadens the focus of programming beyond the agency to the larger community. The Missouri Department of Health has undertaken an approach that has involved the development of a CVD control coalition in each of six southeast Missouri counties. These counties were chosen for intervention on the basis of a review of their mortality data,10 the need to address issues raised in the survey, and qualitative factors such as interest among the local health departments in the area. This region of the state also has relatively large economially disadvantaged and minority populations. The development of these coalitions is being guided by the principles of the Centers for Disease Control's Planned Approach to Community Health program,11 which includes the processes of community mobilization, community diagnosis, community intervention, and evaluation. The coalitions are addressing modifiable risk factors for CVD portrayed in the survey, including high blood pressure, high blood cholesterol, physical inactivity, and smoldng. To develop these CVD control coalitions, it was essential for local health departments to shift from a one-to-one counseling model of CVD control to a community-wide approach. To begin this process, broad-based, local health
department-coordinated coalitions were developed. These coalitions included diverse groups such as lay leaders, voluntary health agencies, local medical societies, university extension departments, city officials, chambers of commerce, the media, religious leaders, and the National Association for the Advancement of Colored People. The local mass media were used to raise community interest and awareness. To help alleviate the survey-identified concern that CVD control activities are limited by a lack of staff time and financial incentives, several measures were taken. The first step was to hire a full-time project coordinator, stationed in southeast Missouri, to coordinate all local coalition activities. In addition, small contracts (an average of $5000 each) were awarded to each of six county health departments to support the coalitions. The applications for these awards were devel-
oped by the coalitions in cooperation with the local health departments. The approximate annual direct cost of this program is $60 000. Considerable in-kind support is also being provided by various individuals and groups represented in the coalitions. For example, in one community, the mayor provided free transportation to persons attending exercise classes. Both outcome and process evaluations of the coalitions are being conducted. Long-term outcomes are being monitored with CVD mortality data, although measurable mortality changes are expected to take S to 10 years. Additional outcome evaluation of the local projects is being accomplished through a special behavioral risk factor survey, which initially involved interviews with 1006 local residents at baseline10 and will be repeated periodically. Process is being evaluated on many levels. The most straightforward indicator of successful process may be that community-level action has begun. Other examples of process measures include the following: * Number of CVD control programs conducted by local coalitions * Number of participants in local coalition activities * Percentage of high-risk individuals (economically disadvantaged and
minorities) participating * Intervention characteristics that result in increased participation of high-risk individuals * Level of CVD knowledge and activity among local health departments
The Missouri experience demonstrates that the conduct of a survey that helps portray the extent of need and the opportunity for change can be a valuable ingredient in broadened community involvement in CVD control. In Missouri, we have active and productive community coalitions as evidence of the usefulness of a baseline survey. Prevention and control of CVD is a key objective at national, state, and local levels.23 We believe that local health departmentcoordinated programs such as ours are effective strategies for achieving this important objective. O Ross Brownson, PhD Carol Smith, MSPH
NIhsa Jorge, MPH Cynthia Dean, BS MaPA Lane DeP,
American Joumal of Public Health 1415
Notes fom the Fidd
The authors are with the Missouri Department of Health, Division of Chronic Disease Prevention and Health Promotion, Columbia, MO. Requests for reprints should be sent to Ross Brownson, PhD, Division of Chronic Disease Prevention and Health Promotion, Missouri Department of Health, 201 Business Loop 70 W, Columbia, MO 65203. Copies of the survey instrument and materials being used in the community coalitions are available from Dr. Brownson.
Acknowledgents This project was funded in part by Centers for Disease Control contract U58/CCU700950. The authors are grateful for the technical assistance of Richard Lasco of the Centers for Disease Control.
References 1. 1991 Heart Facts. Dallas, TX: American Heart Association, National Center; 1991. 2. HealhyPeople2(X): NationalHealthPmmotion and Disease Prevention. Washington, DC: US Dept of Health and Human Services; 1990. PHS publication 017-00100473-1. 3. Healhy Communities 2000(: Model Standards. Guidelines for Cormmity Attainmentofthe Year2000 NationalHealth Objectives. Washington, DC: American Public Health Association; 1991. 4. Institute of Medicine, Committee for the Study of the Future of Public Health. The Future ofPubic Health. Washington, DC: National Academy Press; 1988. 5. Brumback CL, Christalds G. Local health department activities in heart disease control. JPublic Health Poliy. 1980;3:64-82. 6. Schucker B, Wittes JT, Cutler JA, et al. Change in physician perspective on cholesterol and heart disease. JAMA. 1987;258: 3521-3526. 7. Davis JR, Brownson RC, Simms SG, Kern TG. Cancer control and public health in Missouri: a time for action. Missoui MeL
1990;87:82-85. 8. Farquhar JW, Fortmann SP, Flora JA, et al. Effects of communitywide education on cardiovascular disease risk factors. The Stanford Five-City Project. JAMA 1990; 264:359-365. 9. The Health Consequences of SmoAdng: Cancer. A Report of the Surgeon GeneraL Rockville, Md: Public Health Service, Office on Smoldng and Health; 1982. DHHS publication PHS 82-50179. 10. Brownson RC, Smith CA, Jorge NE, DePrima LT, Dean CG, Cates RW. The role of data-driven planning and coalition development in preventing cardiovascular disease. Public Health Rep. 1992;107:3237. 11. Planned Approach to Commnity Health. Coordinator Guidwe. Atlanta, Ga: Centers for Disease Control Public Health Service; 1990.
1416 American Journal of Public Health
Implementing the Veterans Administration's No-Smoking Policy In December 1988, Veterans Administration (VA) officials announced that VA medical centers were becoming smokefree. In late January 1989, the Director of the West Haven VA Medical Center hospital (a 530-bed facility located in West Haven, Connecticut, population 55 000) appointed a task force to make recommendations for implementing this policy by April 1, 1989. Because absolute policies such as this one require changes in attitudes as well as in behavior, the first action of the Task Force was to argue that 2 months was not enough time to prepare our employees and patients to make such a drastic change. A new target date of July 4, 1989, was agreed upon. In agreeing to change the target date, the hospital director demonstrated to the VA community his intention to be guided by the task force. Second, the task force announced the impending change in the hospital's weekly newsletter. Predictably, smokers and staff responsible for smoking patients reacted with worry and fear. The need for time to address their concerns was a major reason a later deadline for implementation was sought. The next step was to write a smoking policy. The task force consisted of the associate medical center director, the chief of personnel, a clinical nurse specialist (C.B.), a long-term care head nurse, a psychologist and ex-smoker (M.C.J.), a current smoker who was a union leader and alcohol counselor, a VA police officer, and a public relations person. Additionally, the task force consulted ward chiefs on the long-stay units, both medical and psychiatric. The written policy banned smokingby all employees, inpatients, outpatients, visitors, and volunteers in all medical center buildings. Psychiatry units were allowed to designate smoking areas for patients restricted to the wards. Our plans were announced in local newspapers. Ashtrays and signs announcing the change were placed at all entances to the medical center. A large sign counting the days until July 4was placed in the courtyard. The rationale for the new policy was published in the quarterly West Haven V4-
sin Tisraonaleincludedthegowingevidence that passive smoking is dangerous, our responsibility for role-modeling healthy behaviors, and the fact that no other non-
medical druguse, exceptforcaffeine, iscondoned in this setting. The Federal Women's Program offered a lunchtime seminar of speakers, induding two physicians, with the goal of clarifing the new policy and the reasons forit. A letter from the hospital director to all employees asked for full commitment to providing the healthiest environment for all. All supeivisors and diredors of clinical services were asked diecy by the hospital diector to support the change. Publicity for smoldng cessation classes was inased, and individual and group one-time sessions designed to assist smokers in getting through a workday with minimal smoking were offered. The authors consulted with staff on ways to reduce anxiety on the units among staff as well as patients. All actions taken by the task force were aimed at promoting a smoke-free environment, not at getting uninterested individuals to quit smocing On July 4, 1989, members of the task force-armed with baskets of chewing gum, cinnamon sticks, and hard candy (including sugar-free candy)-visited all areas of the medical center, offering encouragement and ensuring that all smokers knew the new regulations. Only two negative incidents were reported. In the ensuing weeks, some patients and staff requested more of these token handouts. From July 4, 1989, until January 7, 1991, the policy remained the same and was largely observed. Within about 1 month, one no longer came upon people smoking in the halls or stairwells. Some noncompliance occurred at night on the wards and among a very few staff with private offices. It was a purposeful decision of the task force to encourage compliance through the gradual development of norms, rather than through formal enforcement. One hundred percent compliancewas never expected. Rather, ourgoal was to establish a healthier environment in which to work and heal. In January 1990 the hospital newsletter encouraged employees to contact the task force to say how they were coping with the no-smoking policy. Only three responses were received, all from individuals who found the policy burdensome. The VA police have reported receiving two complaints from patients who wanted to smoke. We would recommend that other hospitals attempting this transition fonnally survey the impact of the change on their employees. In July 1990, the VA Central O>ffice announced that all VA medical centers October 1992, Vol. 82, No. 10
Notes fom the Field were to go entirely smoke-free in the near future; only outdoor smoking was to be allowed. Eventually, January 7,1991, was set as the target date. In preparation for this day, our psychiatly units, which had housed smoking rooms for restricted patients, elected to go smoke-free on December 17, 1990. On January 7,1991, our medical center went entirely smoke-free. We expect no significant difficulties, but an enforcement plan has been outlined. For repeated violations, staff are disciplined as for any other repeated infraction; outpatients are warned and then fined; and inpatients are warned and then discharged from the hospital (if it is clinically safe to discharge
them). Direct costs for a successful transition to a smoke-free environment included the purchase of "goodies" for employees who smoked, to support them during a difficult time, and the building of
October 1992, Vol. 82, No. 10
outdoor shelters for smokers. Indirect costs were in the form of staff planning and counseling. From the beginning, we have attempted to reshape the norms of our medical center, rather than to focus on formal discipline. Service chiefs have been asked by the hospital director to assist their supervisors in role-modeling compliance with the policy and in taking responsibility to remind those they see violating the policy. Early on, the clinical executive board was informed of the impending changes, and members of the board were held accountable for the compliance oftheir units and employees. It seems apparent that the care with which we prepared our population was critical to the success of our transition. Equally important was the fact that we kept the focus on the hospital environment rather than on smokers. No attempts were ever made to persuade smokers to quit or to chastise them for a "bad habit."
Rather, all written messages and public activities of the task force were meant to offer smokers support and understanding for the difficult changes they were being required to make, and nonsmokers were asked to be supportive and understanding as well. Our focus was on developing a nonpunitive environment in which the important contnbution ofsmokers who were asked to change long-term habitswould be recognized. [1 Chil Bevino, RNV, MSN Mary Casey Jacob, PhD Cheryl Bevvino is with the West Haven Veterans Affairs Medical Center, West Haven, Conn. Mary Casey Jacob is with the Departments of Psychiatry and Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, Conn. Requests for reprints should be sent to Cheryl Bewino, RN, MSN, Nursing Service, West Haven Veterans Affairs Medical Center, West Haven, C(T 06032. Copies of the materials used in the policy implementation can be obtained from the authors.
American Journal of Public Health 1417
Submissions to Notes from the Field (500 to 1000 words, preferably without references, tables, or figures) should be sent to Hugh H. Tdsonr MD, Editor, AJPH Notes from the Field, ESP Dimision, Burroughs Weilcome Co, 3030 Comwalli Road, Research Tnangle Parl, NC 27709. T7is colwnn presents infonmation on newsworthy public health programs andproject experiences at the comnunity leveL Further infonnation should be soughtfrom the author(s) listed at the end of each article.
Controlling Cardiovascular Disease: The Role of the Local Health Department Cardiovascular disease (CVD) is the leading cause of death, illness, disability, and medical costs in the United States.1 Systematic prevention and control of modifiable CVD risk factors (i.e., cigarette smoking, hypertension, high blood cholesterol, physical inactivity, obesity, and diabetes) are important public health priorities for the nation, as reflected in recent year 2000 objectives2 and model standards for state and local action.3 Local health departments are the front line of public health4 and are responsible for delivering the majority of public health services. Traditionally, local health departments have been active in communicable disease control, sanitation, laboratory services, matemal and child health, and vital statistics.5 However, the control of many communicable diseases, combined with the growing importance of chronic diseases such as CVD, suggests that local health departments' priorities should be expanded to include more CVD control activities. 1414 Amencan Journal of Public Health
We recently began a project to reduce the prevalence ofCVD risk factors in Missouri (population 5 117 073). A key component of this project is the involvement of local health departments in program planning and local coalition development. Long-term project goals are to build the capacity of local health departments to control CVD and to develop an intervention model for use elsewhere. To raise local conscousness about the need to refocus cardiovascular activities at the community level and to underscore the value of coalition building, we undertook a survey of CVD control knowledge and activities among local health departments in Missouri. We used data from this survey and other data to develop six local CVD control coalitions.
Locl Heath Depxulmt Suwey The survey, which included 119 city, county, and district health departments ("local health departments"), was conducted by mail from June through August 1990. The six-page instrument contained 11 questions, many of which had multiple parts. Most questions were closed-ended and were standardized from other surveys.6,7 With two separate mailings, we achieved a 95% response rate (113 responses). Most surveys were completed by a health department administrator/nonnurse (56%), a community health nurse (20%), or an administrator/nurse (19%o). The major areas covered in the survey were
* Relative importance of various diseases * Knowledge of CVD risk factors * Health department activity levels in various health care services * Possible barriers to CVD control in the local setting
Answers to questions pertaiing to activity levels in various health care services were ranked on five-point scales: numerical values of 0, 1, 2, 3, and 4 were assigned to the response options "none," "low," "medium," "high," and "very high," respectively. Mean activity scores were then calculated by summing the values and dividing by the total number of respondents for each item. Cardiovascular disease was viewed as the most important health issue in terms of morbidity and mortality in the population. Other chronic diseases (cancer, diabetes, and chronic lung disease) also were viewed as having major health impacts on the population. Of the 10 health issues examined, homicide and suicide ranked lowest in importance. Respondents were generally knowledgeable about the major risk factors for CVD. Hypertension, cigarette smoking, and obesity were considered the three most important riskfactors for CVD. High blood cholesterol was rated as the fifth most important risk factor, with a considerably lower ranking than the two other major risk factors for CVD (i.e., hypertension and cigarette smoking1). Among activities related to CVD prevention and control, only hypertension screening received a high activity score. Nutrition education was ranked relatively high, although much of this activity probably occus in Women, Infants, and Clildren programning and is not seen as targeted directly toward CVD control. Among other major CVD risk factor control strategies, cholesterol screening and tobacco cessation counseling received only medium to low activity scores. The mean activity scores of various health services were as follows:
* Immunizations, 3.7 * Child health services, 3.3 October 1992, Vol. 82, No. 10
Notes fm the Fied
* Hypertension screening, 3.1 * Nutrition education, 2.7 * Family planning, 2.0 * Cholesterol screening, 1.6 * AIDS prevention, 1.5 * Tobacco cessation counseling, 1.4 * Physical exams, 1.4
Ninety-five percent of those surveyed believed that CVD prevention and screening activities should be increased in their areas. Individual patient education was cited as the most effective method for increasing CVD control efforts (it was considered to have a "large effect" by 60% of the respondents). Other CVD control methods cited as having a large effect were * School-based education (54%) * Work-site programs (42%) * Mass media (28%) * Physician education (25%)
Several important constraints on CVD control efforts were identified. Sixty percent of the respondents strongly agreed with the statement that the lack of financial reimbursement lessens the likelihood of tobacco, diet, and physical activity counseling in the local health department setting. Forty-five percent strongly agreed that these counseling activities require more time than is currently available. Finally, 22% of the respondents strongly agreed that the lack of technical training in risk reduction activities is a sig-
nificant barrier. Overall, our survey findings showed that although local health department respondents were well aware of the importance of CVD control, their level of activity in this area was relatively low. The results also suggested that respondents typically preferred more traditional oneto-one CVD educational methods and considered other proven strategies8 (e.g., community-wide efforts) to be less effective. The major barriers to CVD risk reduction activities in the local health department setting included deficiencies in reimbursement, time, and technical training. These issues have been raised by others.5,7 Cost- and time-effective risk reduction techniques exist for CVD control. For example, in the area of smoking cessation, numerous studies have shown that minimal advice from health professionals has a substantial effect on smoking reduction among patients.9 Although there were clearly identified constraints, it was gratifying to note that 95% of our respondents October 1992, Vol. 82, No. 10
acknowledged the need for increased CVD control activities at the local level.
Local CVD Conmi Coalitns The survey underscored the need for a new strategy at the local level, one that broadens the focus of programming beyond the agency to the larger community. The Missouri Department of Health has undertaken an approach that has involved the development of a CVD control coalition in each of six southeast Missouri counties. These counties were chosen for intervention on the basis of a review of their mortality data,10 the need to address issues raised in the survey, and qualitative factors such as interest among the local health departments in the area. This region of the state also has relatively large economially disadvantaged and minority populations. The development of these coalitions is being guided by the principles of the Centers for Disease Control's Planned Approach to Community Health program,11 which includes the processes of community mobilization, community diagnosis, community intervention, and evaluation. The coalitions are addressing modifiable risk factors for CVD portrayed in the survey, including high blood pressure, high blood cholesterol, physical inactivity, and smoldng. To develop these CVD control coalitions, it was essential for local health departments to shift from a one-to-one counseling model of CVD control to a community-wide approach. To begin this process, broad-based, local health
department-coordinated coalitions were developed. These coalitions included diverse groups such as lay leaders, voluntary health agencies, local medical societies, university extension departments, city officials, chambers of commerce, the media, religious leaders, and the National Association for the Advancement of Colored People. The local mass media were used to raise community interest and awareness. To help alleviate the survey-identified concern that CVD control activities are limited by a lack of staff time and financial incentives, several measures were taken. The first step was to hire a full-time project coordinator, stationed in southeast Missouri, to coordinate all local coalition activities. In addition, small contracts (an average of $5000 each) were awarded to each of six county health departments to support the coalitions. The applications for these awards were devel-
oped by the coalitions in cooperation with the local health departments. The approximate annual direct cost of this program is $60 000. Considerable in-kind support is also being provided by various individuals and groups represented in the coalitions. For example, in one community, the mayor provided free transportation to persons attending exercise classes. Both outcome and process evaluations of the coalitions are being conducted. Long-term outcomes are being monitored with CVD mortality data, although measurable mortality changes are expected to take S to 10 years. Additional outcome evaluation of the local projects is being accomplished through a special behavioral risk factor survey, which initially involved interviews with 1006 local residents at baseline10 and will be repeated periodically. Process is being evaluated on many levels. The most straightforward indicator of successful process may be that community-level action has begun. Other examples of process measures include the following: * Number of CVD control programs conducted by local coalitions * Number of participants in local coalition activities * Percentage of high-risk individuals (economically disadvantaged and
minorities) participating * Intervention characteristics that result in increased participation of high-risk individuals * Level of CVD knowledge and activity among local health departments
The Missouri experience demonstrates that the conduct of a survey that helps portray the extent of need and the opportunity for change can be a valuable ingredient in broadened community involvement in CVD control. In Missouri, we have active and productive community coalitions as evidence of the usefulness of a baseline survey. Prevention and control of CVD is a key objective at national, state, and local levels.23 We believe that local health departmentcoordinated programs such as ours are effective strategies for achieving this important objective. O Ross Brownson, PhD Carol Smith, MSPH
NIhsa Jorge, MPH Cynthia Dean, BS MaPA Lane DeP,
American Joumal of Public Health 1415
Notes fom the Fidd
The authors are with the Missouri Department of Health, Division of Chronic Disease Prevention and Health Promotion, Columbia, MO. Requests for reprints should be sent to Ross Brownson, PhD, Division of Chronic Disease Prevention and Health Promotion, Missouri Department of Health, 201 Business Loop 70 W, Columbia, MO 65203. Copies of the survey instrument and materials being used in the community coalitions are available from Dr. Brownson.
Acknowledgents This project was funded in part by Centers for Disease Control contract U58/CCU700950. The authors are grateful for the technical assistance of Richard Lasco of the Centers for Disease Control.
References 1. 1991 Heart Facts. Dallas, TX: American Heart Association, National Center; 1991. 2. HealhyPeople2(X): NationalHealthPmmotion and Disease Prevention. Washington, DC: US Dept of Health and Human Services; 1990. PHS publication 017-00100473-1. 3. Healhy Communities 2000(: Model Standards. Guidelines for Cormmity Attainmentofthe Year2000 NationalHealth Objectives. Washington, DC: American Public Health Association; 1991. 4. Institute of Medicine, Committee for the Study of the Future of Public Health. The Future ofPubic Health. Washington, DC: National Academy Press; 1988. 5. Brumback CL, Christalds G. Local health department activities in heart disease control. JPublic Health Poliy. 1980;3:64-82. 6. Schucker B, Wittes JT, Cutler JA, et al. Change in physician perspective on cholesterol and heart disease. JAMA. 1987;258: 3521-3526. 7. Davis JR, Brownson RC, Simms SG, Kern TG. Cancer control and public health in Missouri: a time for action. Missoui MeL
1990;87:82-85. 8. Farquhar JW, Fortmann SP, Flora JA, et al. Effects of communitywide education on cardiovascular disease risk factors. The Stanford Five-City Project. JAMA 1990; 264:359-365. 9. The Health Consequences of SmoAdng: Cancer. A Report of the Surgeon GeneraL Rockville, Md: Public Health Service, Office on Smoldng and Health; 1982. DHHS publication PHS 82-50179. 10. Brownson RC, Smith CA, Jorge NE, DePrima LT, Dean CG, Cates RW. The role of data-driven planning and coalition development in preventing cardiovascular disease. Public Health Rep. 1992;107:3237. 11. Planned Approach to Commnity Health. Coordinator Guidwe. Atlanta, Ga: Centers for Disease Control Public Health Service; 1990.
1416 American Journal of Public Health
Implementing the Veterans Administration's No-Smoking Policy In December 1988, Veterans Administration (VA) officials announced that VA medical centers were becoming smokefree. In late January 1989, the Director of the West Haven VA Medical Center hospital (a 530-bed facility located in West Haven, Connecticut, population 55 000) appointed a task force to make recommendations for implementing this policy by April 1, 1989. Because absolute policies such as this one require changes in attitudes as well as in behavior, the first action of the Task Force was to argue that 2 months was not enough time to prepare our employees and patients to make such a drastic change. A new target date of July 4, 1989, was agreed upon. In agreeing to change the target date, the hospital director demonstrated to the VA community his intention to be guided by the task force. Second, the task force announced the impending change in the hospital's weekly newsletter. Predictably, smokers and staff responsible for smoking patients reacted with worry and fear. The need for time to address their concerns was a major reason a later deadline for implementation was sought. The next step was to write a smoking policy. The task force consisted of the associate medical center director, the chief of personnel, a clinical nurse specialist (C.B.), a long-term care head nurse, a psychologist and ex-smoker (M.C.J.), a current smoker who was a union leader and alcohol counselor, a VA police officer, and a public relations person. Additionally, the task force consulted ward chiefs on the long-stay units, both medical and psychiatric. The written policy banned smokingby all employees, inpatients, outpatients, visitors, and volunteers in all medical center buildings. Psychiatry units were allowed to designate smoking areas for patients restricted to the wards. Our plans were announced in local newspapers. Ashtrays and signs announcing the change were placed at all entances to the medical center. A large sign counting the days until July 4was placed in the courtyard. The rationale for the new policy was published in the quarterly West Haven V4-
sin Tisraonaleincludedthegowingevidence that passive smoking is dangerous, our responsibility for role-modeling healthy behaviors, and the fact that no other non-
medical druguse, exceptforcaffeine, iscondoned in this setting. The Federal Women's Program offered a lunchtime seminar of speakers, induding two physicians, with the goal of clarifing the new policy and the reasons forit. A letter from the hospital director to all employees asked for full commitment to providing the healthiest environment for all. All supeivisors and diredors of clinical services were asked diecy by the hospital diector to support the change. Publicity for smoldng cessation classes was inased, and individual and group one-time sessions designed to assist smokers in getting through a workday with minimal smoking were offered. The authors consulted with staff on ways to reduce anxiety on the units among staff as well as patients. All actions taken by the task force were aimed at promoting a smoke-free environment, not at getting uninterested individuals to quit smocing On July 4, 1989, members of the task force-armed with baskets of chewing gum, cinnamon sticks, and hard candy (including sugar-free candy)-visited all areas of the medical center, offering encouragement and ensuring that all smokers knew the new regulations. Only two negative incidents were reported. In the ensuing weeks, some patients and staff requested more of these token handouts. From July 4, 1989, until January 7, 1991, the policy remained the same and was largely observed. Within about 1 month, one no longer came upon people smoking in the halls or stairwells. Some noncompliance occurred at night on the wards and among a very few staff with private offices. It was a purposeful decision of the task force to encourage compliance through the gradual development of norms, rather than through formal enforcement. One hundred percent compliancewas never expected. Rather, ourgoal was to establish a healthier environment in which to work and heal. In January 1990 the hospital newsletter encouraged employees to contact the task force to say how they were coping with the no-smoking policy. Only three responses were received, all from individuals who found the policy burdensome. The VA police have reported receiving two complaints from patients who wanted to smoke. We would recommend that other hospitals attempting this transition fonnally survey the impact of the change on their employees. In July 1990, the VA Central O>ffice announced that all VA medical centers October 1992, Vol. 82, No. 10
Notes fom the Field were to go entirely smoke-free in the near future; only outdoor smoking was to be allowed. Eventually, January 7,1991, was set as the target date. In preparation for this day, our psychiatly units, which had housed smoking rooms for restricted patients, elected to go smoke-free on December 17, 1990. On January 7,1991, our medical center went entirely smoke-free. We expect no significant difficulties, but an enforcement plan has been outlined. For repeated violations, staff are disciplined as for any other repeated infraction; outpatients are warned and then fined; and inpatients are warned and then discharged from the hospital (if it is clinically safe to discharge
them). Direct costs for a successful transition to a smoke-free environment included the purchase of "goodies" for employees who smoked, to support them during a difficult time, and the building of
October 1992, Vol. 82, No. 10
outdoor shelters for smokers. Indirect costs were in the form of staff planning and counseling. From the beginning, we have attempted to reshape the norms of our medical center, rather than to focus on formal discipline. Service chiefs have been asked by the hospital director to assist their supervisors in role-modeling compliance with the policy and in taking responsibility to remind those they see violating the policy. Early on, the clinical executive board was informed of the impending changes, and members of the board were held accountable for the compliance oftheir units and employees. It seems apparent that the care with which we prepared our population was critical to the success of our transition. Equally important was the fact that we kept the focus on the hospital environment rather than on smokers. No attempts were ever made to persuade smokers to quit or to chastise them for a "bad habit."
Rather, all written messages and public activities of the task force were meant to offer smokers support and understanding for the difficult changes they were being required to make, and nonsmokers were asked to be supportive and understanding as well. Our focus was on developing a nonpunitive environment in which the important contnbution ofsmokers who were asked to change long-term habitswould be recognized. [1 Chil Bevino, RNV, MSN Mary Casey Jacob, PhD Cheryl Bevvino is with the West Haven Veterans Affairs Medical Center, West Haven, Conn. Mary Casey Jacob is with the Departments of Psychiatry and Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, Conn. Requests for reprints should be sent to Cheryl Bewino, RN, MSN, Nursing Service, West Haven Veterans Affairs Medical Center, West Haven, C(T 06032. Copies of the materials used in the policy implementation can be obtained from the authors.
American Journal of Public Health 1417
