Four Domains of Chronic Disease Prevention

Attachment B: The Four Domains of Chronic Disease Prevention

The Four Domains of Chronic
Disease Prevention

Working Toward Healthy People in Healthy Communities
Modern efforts to prevent disease, help people
lead healthier lives, and end health disparities
must include a focus on chronic diseases.
Chronic diseases—heart disease and stroke,
diabetes, cancer, chronic lung diseases, and
others—account for most deaths in the United
States and globally.
Chronic diseases and conditions are the major drivers of sickness, disability,
and health care costs in the nation.

Common Risk Factors
Much of the chronic disease burden is attributable to a short list of key risk
factors; most US adults have more than one of these risk factors:
Š High blood pressure.
Š Tobacco use and exposure to secondhand smoke.
Š Obesity (high body mass index).
Š Physical inactivity.
Š Excessive alcohol use.
Š Diets low in fruits and vegetables.
Š Diets high in sodium and saturated fats.

The Chronic Disease Prevention System
Just as most chronic diseases are caused or made worse by many of the
same risk factors, they can be prevented or lessened by many of the
same strategies and interventions. The risk factors for chronic disease
can and must be addressed at two levels: the individual level (including
health care interventions) and the population level (including policies and
environments that promote health). Working at both levels is essential.
To optimize public health’s efficiency and effectiveness, the Centers for
Disease Control and Prevention (CDC) recommends coordinating chronic
disease prevention efforts in four key domains:
1. Epidemiology and surveillance—to monitor trends and track progress.
2. Environmental approaches—to promote health and support healthy
behaviors.
3. Health care system interventions—to improve the effective delivery and
use of clinical and other high-value preventive services.
4. Community programs linked to clinical services—to improve and
sustain management of chronic conditions.
The four domains help organize and focus the effective work the public
health community has been doing for many years. At the same time, they
help concentrate efforts to strengthen programs and build expertise to
address gaps in services. Finally, they help government agencies, state and
local grantees, and diverse public and private partners find new ways to
work together and support each other’s efforts.

National Center for Chronic Disease Prevention and Health Promotion
Office of the Director
CS253404-A

Fast Facts
CDC works to prevent chronic
diseases and their risk factors
through four domains: epidemiology and surveillance,
environmental approaches, health
care system interventions, and
community-clinical links.
Š Epidemiology and surveillance
refers to systems that are used to
track chronic diseases and their
risk factors.
Š Environmental approaches
refers to changes in policies and
physical surroundings to make the
healthy choice the easy choice.
Š Health care system
interventions refers to
improvements in care that allow
doctors to diagnose chronic
diseases earlier and to manage
them better.
Š Community programs linked to
clinical services refers to those
that help patients prevent and
manage their chronic diseases,
with guidance from their doctor.

The four domains focus on strategies that
Š Collectively address the behaviors and other risk factors that can cause
chronic diseases.
Š Work to simultaneously prevent and control multiple diseases and
conditions.
Š Reach more people by strengthening systems and environments to
support health.
Š Link community and health care efforts to prevent and control disease.
In sum, the four domains highlight shared strategies and opportunities to
make real health improvements across a range of diseases, conditions, and risk
factors to improve the health and quality of life of millions of Americans.
This coordinated approach to preventing chronic diseases and promoting
health can help achieve NCCDPHP’s vision of healthy people in healthy
communities.

Domain 1 : Epidemiology and Surveillance
Epidemiology and surveillance provide essential data to define and prioritize
public health problems, identify populations most affected, guide solutions,
and monitor progress. Insights can be used to educate decision makers and
the public about
Š The high rates of death and disability and the high health care costs
associated with chronic diseases.
Š Actions being taken by the public health community and its partners to
prevent and control chronic diseases.
Š Successes in preventing and controlling chronic diseases.
Š Unmet needs and priorities in addressing chronic diseases.

Epidemiology and Surveillance in Action
Š Track chronic diseases and their risk factors and share the information in
easy-to-use formats. Ensure coordination among multiple data systems,
including behavioral risk factor surveys (e.g., the Behavioral Risk Factor
Surveillance System), birth and death certificates (from the National Vital
Statistics System), registries of cancer cases and deaths (e.g., the National
Program of Cancer Registries), and health care data (e.g., from Medicare
data sets).
Š Monitor social and environmental factors that influence health, as well as
policies that affect chronic diseases, such as those related to smoke-free
air, access to healthy foods, and community water fluoridation.
Š Conduct surveillance of health care preventive services, such as cancer
screening, the “ABCS” of heart disease and stroke prevention (Aspirin
use, Blood pressure and Cholesterol control, and Smoking cessation),
and measures of diabetes control (e.g., hemoglobin A1C) and obesity
(e.g., body mass index).
Š Leverage health information technology to improve efficiency and
timeliness of public health surveillance (e.g., use new US meaningful-use
standards to speed reporting to state cancer registries).

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Improving community
conditions to support
healthy behaviors and
promote effective
management of chronic
conditions will deliver:

Healthier students to
schools
Š

Healthier workers to
businesses and employers
Š

A healthier population to
the health care system

Healthier People
Lower Health Care Costs

Domain 2: Environmental Approaches
Environmental approaches promote health and support healthy behaviors across
the nation, in states and communities, and in settings such as schools, child care
programs, work sites, and businesses. Approaches that change the environment
reach more people, are more cost efficient, and are more likely to have a lasting
effect on population health.

Environmental Approaches in Action
Š Policies that change the context and make healthy lifestyles easier:
» Comprehensive smoke-free air laws that cover all workplaces, restaurants, and
bars, protecting nonsmokers from secondhand tobacco smoke.
» Bans on flavored cigarettes, to make smoking less attractive to youth.
» Bans on artificial trans fats, eliminating a cardiotoxin from the food supply.
» Increases in the number of community water systems that have the best level
of fluoride to prevent cavities.
» Price increases for unhealthy products (e.g., tobacco, alcohol, and high-calorie,
low-nutrition foods and drinks) to reflect the medical and societal costs of their use.

Š Changes to social and physical environments that make healthy choices easier,
safer, cheaper, and more convenient:
» Community design that encourages walking and biking.
» More schools that offer more high-quality physical education, and child care
programs that follow national physical activity standards.
» More access to healthy foods and beverages (e.g., full-service groceries and
farmers markets in underserved areas, healthier menu items in restaurants).

Domain 3: Health Care System Interventions
Health care system interventions increase the use and improve the quality of
clinical and other preventive services. These services prevent or enable early
detection of disease, reduce risk factors, and manage complications. Interventions
that increase access to and build demand for quality preventive services, such as
the National Breast and Cervical Cancer Early Detection Program, also reduce
population health disparities.

Health Care System Interventions in Action
Š The Affordable Care Act, US meaningful-use regulations, and other health reform
efforts offer opportunities to speed progress by creating ways to
»
»
»
»
»

Expand population coverage.
Require coverage of effective clinical preventive services.
Improve the organization of and payment for care.
Involve a larger number and broader range of health professionals in delivering care.
Increase use of health information technology and tools (e.g., reminders and clinical
decision support).
» Increase measurement and reporting of successes and shortfalls.

Š Governmental and community public health organizations can foster better
health system use through approaches that
» Define high-impact services and priorities.
» Conduct surveillance of high-priority health outcomes.
» Remove barriers to access to help ensure delivery of care to hardest-to-reach
populations.

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Domain 4: Community Programs Linked to
Clinical Services
Strategies that link community and clinical services help ensure that people with or
at high risk of chronic diseases have access to the resources they need to prevent or
manage these diseases.
In turn, people can improve their quality of life, delay the onset or progression of
disease, avoid complications, and reduce the need for more health care. Improved
links between the community and clinical settings offer community delivery of
proven programs, to which patients may be referred by a clinician, with third-party
payments to community organizations and lay providers.

Community-Clinical Links in Action
Š Increase the use of effective community interventions—such as chronic disease
self-management programs, the National Diabetes Prevention Program, and
smoking cessation services—by making them widely available, ensuring that
doctors refer their patients to them, and helping to ensure that they are covered
by health insurance.
Š Link existing public health services, such as tobacco quitlines, to health care
systems.
Š Establish partnerships with hospitals and health care providers to improve
community and population health through use of community benefit
investments and advocacy.
Š Encourage a broader spectrum of health care workers—including pharmacists,
patient navigators, and community health workers—to help people manage
their own health.
Š Use education and outreach to more fully engage the public in its own health
care.

For more information, contact
Centers for Disease Control
and Prevention
National Center for Chronic
Disease Prevention and
Health Promotion
1-800-CDC-INFO (232-4636);
TTY: 1-888-232-6348
Contact CDC-INFO

CDC’s Chronic Disease Prevention System
WHAT WE DO

• Provide leadership and technical assistance
• Monitor chronic diseases, conditions, and
risk factors
• Conduct and translate research and evaluation
to enhance prevention
• Engage in health communication
• Develop sound public health policies
• Implement prevention strategies

WHY WE DO IT

HOW WE DO IT  THE FOUR DOMAINS
EPIDEMIOLOGY AND SURVEILLANCE
Provide data and conduct research to guide, prioritize,
deliver, and monitor programs and population health

WHO WE WORK WITH

ENVIRONMENTAL APPROACHES
Make healthy behaviors easier and more convenient for
more people

WHERE WE DO IT

HEALTH CARE SYSTEM INTERVENTIONS
Improve delivery and use of quality clinical services to
prevent disease, detect diseases early, and manage risk
factors

• State, tribal, territorial, and local governments
• National, state, and local nongovernmental
organizations
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Communities
Workplaces
Schools and academic institutions
Health care settings
Child care settings
Faith organizations
Homes

COMMUNITY-CLINICAL LINKS
Ensure that people with or at high risk of chronic diseases
have access to quality community resources to best manage
their conditions

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Healthier environments
Healthier behaviors
Greater health equity
Increased productivity
Lower health care costs
Increased life expectancy
Improved quality of life

WHAT WE ACHIEVE
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Less tobacco use
Less obesity
Less heart disease and stroke
Less cancer
Less diabetes
Less arthritis
More physical activity
Better nutrition
Better oral health
Healthier mothers and babies
Healthier kids