Annual Performance Plan and Report

Topics on this page: Goal 3. Objective D | Table of Related Performance Measures | Analysis of Results | Plans for the Future | Objective Progress Update Summary

Goal 3. Objective D: Promote prevention and wellness across the lifespan

HHS is focusing on creating environments that promote healthy behaviors to prevent chronic diseases and health conditions including tobacco use, being overweight or obese, and mental and substance use disorders. These conditions result in the most deaths, disability, and substantial human and fiscal costs for Americans. HHS works to promote prevention and wellness across its programs, with CDC identified as the Nation’s principal prevention agency. CDC‘s goals for chronic disease prevention and health promotion include reducing the onset of chronic health conditions; improving health equity; accelerating the translation of scientific finding into community practice; and promoting social, environmental, and systems approaches that support healthy living.

Across HHS agencies including ACF, ACL, AHRQ, CDC, FDA, HRSA, IHS, NIH, OASH and SAMHSA contribute to prevention and wellness. For example, FDA has committed to increasing compliance with tobacco products regulations. IHS is striving to reduce heart disease among American Indian and Alaska Native patients. The Office of the Secretary led this Objective’s assessment as a part of the Strategic Review.

Objective 3.D Table of Related Performance Measures

Reduce the annual adult combustible tobacco consumption in the United States (cigarette equivalents per capita) (Lead Agency - OASH; Measure ID - 1.5)

Reduce the proportion of adults (aged 18 and over) who are current cigarette smokers. (Lead Agency - CDC; Measure ID - 4.6.3)

Reduce the proportion of adolescents (grade 9 through 12) who are current cigarette smokers. (Lead Agency - CDC; Measure ID - 4.6.5)

The total number of tobacco compliance check inspections of retail establishments in states under contract. (Lead Agency - FDA; Measure ID - 280005)

Decrease underage drinking as measured by an increase in the percent of SPF SIG (Strategic Prevention Framework State Incentive Grant) states that show a decrease in 30-day use of alcohol for individuals 12 - 20 years old (Lead Agency - SAMHSA; Measure ID - 2.3.21)

Increase the number of calls answered by the suicide hotline (Lead Agency - SAMHSA; Measure ID - 2.3.61)

Increase the percentage of adults with severe mental illness receiving homeless support services who report positive functioning at 6 month follow-up (Lead Agency - SAMHSA; Measure ID - 3.4.02)

Increase the percentage of Early Head Start children completing all medical screenings. (Lead Agency - ACF; Measure ID - 3.6LT and 3B)

American Indian and Alaska Native patients, 22 and older, with Coronary Heart Disease are assessed for five cardiovascular disease (CVD) risk factors. (Lead Agency - IHS; Measure ID - 30)

Analysis of Results

Smoking, and second hand smoke, kills an estimated 480,000 people in the U.S. each year. For every smoker who dies from a smoking-attributable disease, another 30 live with a serious smoking-related disease. Smoking costs the U.S. $133 billion in direct medical costs and more than $156 billion in lost productivity each year. An estimated 88 million nonsmoking Americans are exposed to secondhand smoke, which causes an estimated 7,330 lung cancer deaths and more than 33,900 heart disease deaths in nonsmoking adults each year. The Department’s comprehensive tobacco control strategy,Ending the Epidemic – A Tobacco Control Strategic Action Plan, is designed to mobilize HHS’s expertise and resources in support of proven, pragmatic, achievable actions that can be aggressively implemented at the federal, state, and community levels to reduce the incidence of smoking. HHS experienced challenges in the first year of this new Priority Goal. The annual adult combustible tobacco consumption in the United States failed to meet the target of 1,259 cigarette equivalents per capita in FY 2013.

However, HHS did make positive progress in other related measures.  Two complementary efforts by the CDC also target smoking reduction in two populations, adults (18 and over) and adolescents (grade 9 – 12).  The percentage of current adult smokers decreased to 17.8 percent in FY 2013, exceeding the target.  The FY 2013 result for teen smokers (15.7%) represents the lowest teen smoking rate ever recorded with the Youth Risk Behavior Surveillance System (YRBSS) since data collection began in 1991.  Because YRBSS data is only available every other year, CDC sought to glean data in the interim years with data from the National Youth Tobacco Survey (NYTS).  NYTS data tracked closely with YRBSS data until FY 2012 results showed an unacceptable variance.  Therefore, the YRBSS will once again be the sole data source for CDC reporting of teen smoking rates as of FY 2014.  FDA’s fights adolescent smoking with its program to conduct compliance checks to assure that retailers refuse sales of tobacco to adolescents under the age of 18.  In FY 2014, under contracts with 45 states and territories, FDA conducted 124,296 compliance check inspections of retail establishments, substantially exceeding its target.  Although this was a much higher number than expected, it reflects the high level of variability inherent in this goal requiring the estimation of the number of compliance checks that each state will be able to conduct.

Underage drinking has been linked to a number of mental and physical health problems. The Strategic Prevention Framework State Incentive Grant (SPF SIG) program, managed by SAMHSA, provides funding to states, federally recognized tribes, and U.S. territories to support local communities in preventing the onset and progression of substance abuse and substance abuse-related problems including underage drinking. Targets have been exceeded each year. For FY 2013, 76 percent of the states in the program reduced their rates of underage drinking. This represents a decline from the previous year, possibly in part because Virginia was suppressed from the result due to low precision of data. This measure is being retired as an APP/R measure and discontinued in FY 2015.

Another significant cause of early death in the U.S. is suicide. The National Center for Health Statistics (CDC) reported in 2013 there were 41,149 suicides, ranking as the 10th leading cause of death among persons ages 10 years and older nationally. The National Suicide Prevention Lifeline (Lifeline), sponsored by SAMHSA, routes callers from anywhere in the U.S. to the closest certified crisis center within Lifeline’s network of more than 150 centers. Trained counselors provide crisis counseling, link callers to emergency services, and offer behavioral health referrals. SAMHSA has increased efforts to promote Lifeline broadly to the public, in order to enhance awareness of this resource. The success of this outreach effort is reflected in the 1,308,825 calls answered in FY 2014, an increase of almost 250,000 over the previous year. Targets have been exceeded each year.

In addition to suicide prevention, SAMHSA works through multiple programs to support those adults who may be severely mentally ill and homeless.  A significant portion of persons who are chronically homeless have mental and/or substance use disorders.  Grants under the Homelessness Prevention and Housing Programs initiative are awarded to organizations that assist severely mentally ill adults who are homeless or at risk of becoming homeless in gaining access to sustainable permanent housing, treatment, and recovery support.  A measure of the performance of these grantees is the self-reported sense of positive functioning by the individual 6 months after beginning to receive homeless support services.  In FY 2014, 66 percent reported improved functioning, exceeding the target.  This was a result of a combination of factors including, but not limited to, grantees engaging and providing services to the population of focus in collaboration with community consortia, improved reporting, and support to grantees via technical assistance on housing, evidence based practices and other relevant topics.

ACF, through the Early Head Start program, aims to promote prevention and wellness early in the life span. For the 2013-2014 program year, 83.1 percent of Early Head Start program children completed medical screenings expected for their age, missing the target of 93 percent. The Early Head Start program underwent a large expansion under the American Recovery and Reinvestment Act, which resulted in expanded enrollment and many new programs. However, in the FY 2013-2014 program year, many Head Start and Early Head Start programs were still experiencing the effects of cuts from sequestration. Depending on when during the year programs are funded, some programs experienced the impact of sequestration during the FY 2012-2013 program year while others experienced the most of the impact from the reductions during the FY 2013-2014 program year. Data from the FY 2014 Program Information Report shows that relative to the prior year, Head Start had fewer staff, teachers and volunteers, which compromises the program's ability to support families in a range of areas, including supporting them in their efforts to complete medical screenings.

HHS manages a number of programs to reduce health disparities for minorities, including prevention and wellness. Modifying the following risk factors offers the greatest potential for reducing CVD morbidity, disability, and mortality: high blood pressure, high cholesterol, smoking tobacco, excessive body weight, and physical activity. IHS seeks to address these risk factors in patients 22 and older diagnosed with coronary heart disease by assessing all five of these risk factors. In FY 2014 the target was 51 percent of coronary heart disease patients receiving all 5 assessments, a substantial increase over the previous year, and the result was 52.3 percent, exceeding that target.

Plans for the Future

In FY 2015 and beyond the Department will continue its efforts coordinated across a number of agencies to reduce smoking among all ages and populations. The annual adult combustible tobacco consumption measure is a new Priority Goal for FY 2014–2015 and HHS continues its commitment to reducing tobacco consumption through 2015. The focus of this goal was changed from cigarettes to combustible tobacco due to consumer preferences shifting to other products such as cigars and cigarillos. The FDA contributes to this cause by contracting with 45 states and territories to conduct tobacco regulation compliance check inspections of retail establishments. Although the FY 2013 result was a much higher number than expected, it reflects the high level of variability inherent in this goalthat requires estimating the number of compliance checks that each state will be able to conduct. In addition, some of expiring contracts will need to be renewed in the next year to continue these efforts. Most states are expected to renew, however there are always factors that may prohibit them from doing so. Accordingly, the FY 2014 and FY 2015 targets consider these challenges but have still been increased.

The CDC will continue to support the National Tobacco Control Program (NTCP) in 50 states and the District of Columbia, eight territories/jurisdictions, eight tribal support centers, and six national networks. NTCP grants support evidence-based efforts by state, tribal and territorial health department to prevent initiation of tobacco use among young adults, promote tobacco use cessation, eliminate exposure to secondhand smoke, and identify and eliminate tobacco-related disparities. It will also provide national leadership for a comprehensive, broad-based approach to reducing tobacco use which involves: preventing young people from starting to smoke; eliminating exposure to secondhand smoke; promoting quitting; and, identifying and eliminating disparities in tobacco use among population groups. These are some of the efforts the CDC will employ to meet the future target for reduction of adolescent and adult smoking.

The SPF SIG program is eliminated in FY 2015 and grantees are being transitioned to the Partnerships for Success program.

The suicide hotline (Lifeline) has seen a yearly increase in calls answered, a trend that SAMHSA projects to continue.  During FY 2013, SAMHSA awarded a new 3-year cooperative agreement with a continued focus on serving callers in distress, as well as expanding capacity of the Crisis Chat service for individuals seeking help online.  The growth in average quarterly Lifeline calls can likely be attributed to the following: continued outreach and marketing of the National Suicide Prevention Lifeline service; wide distribution of the Lifeline number by third party organizations seeking to provide their clients with a 24/7 emergency resources; heavy promotion of the Lifeline through social media outreach on Facebook and other social media sites; and significant marketing and outreach to veterans of the Veterans Crisis Line, which also uses the 1-800-273-TALK (8255) Lifeline number.  These efforts are expected to increase the number of calls answered in FY 2015 and 2016.

Through different initiatives and approaches, SAMHSA will continue to support those adults who may be severely mentally ill and/or struggling with other behavioral health issues while facing or being at risk of homelessness.  SAMHSA expects to maintain performance in FY 2015 and 2016.

Despite the challenges to the Early Head Start program described above, ACF aims to achieve a target rate of 93 percent in FY 2015 and FY 2016. The Office of Head Start is in the process of developing a toolkit for programs to assist them in the tailored use of an online, web-based Well Visit Planner, which is a free online pre-visit planning tool designed to engage parents in planning for and partnering more fully in their child’s well visit. Studies continue to show gaps in the quality of well-child care. Improving care means improving communication and partnerships with parents and meeting the unique needs and priorities of each child and family.

The CVD Risk Assessment measure logic used in the IHS measure addressing coronary heart disease in American Indian and Alaska Native populations was revised in FY 2013.  Performance for this program is expected to decline in FY 2015 and then increase in FY 2016 from continued efforts by IHS to promote the Million Hearts Initiative at the regional and local levels.

Objective Progress Update Summary

HHS demonstrated progress toward this objective as shown by the representative performance measures described in the HHS Annual Performance Plan and Report. Further evidence of progress is described below.

• ACL's Administration on Aging (AoA) developed a graduated set of criteria for evidence-based interventions.  The goal has been for all OAA Title III-D activities to move toward the highest-level criteria.  Beginning in October 2016, Title III-D funds will only be used on health promotion programs that meet AoA’s highest-level criteria.  Several states targeted having 100 percent of their Title III-D funding for programs meeting the highest-level criteria by 2015.  As of March 2014, two states (Florida and Georgia) have certified that they are using 100 percent of their Title III-D funds for programs meeting only the highest-level criteria.
• In 2012, the CDC's Tips I campaign generated 365,194 calls (207,519 additional calls and a 132 percent increase) to 1-800-QUIT NOW compared to corresponding weeks in 2011, resulting in an estimated 1.6 million new quit attempts among U.S. adult smokers.  More than 200,000 Americans had quit smoking immediately following the three-month campaign, of which more than 100,000 will likely quit permanently.  A preliminary analysis of the Tips II campaign's impact showed that calls to the national quitline increased by 75 percent, and the number of unique visitors to the campaign website increased almost 40-fold.  In 2014, CDC launched Tips III in two phases. The first nine week phase (February 3—April 6) generated more than 250 news stories in print, broadcast, and online media, reaching an audience of more than 276 million people and generating over $230,000 in advertising value. A second nine week broadcast was launched on July 7.
• The HRSA Health Center Program promotes prevention and wellness through education, counseling, and treatment. Tobacco use, the most preventable cause of death and disease in the United States, is a key focus of these efforts. The most recent national data (2012) show that among health center patients age 18 years and older who are tobacco users, 57.6 percent have received cessation advice or medication (compared to 52.7 percent in 2011).
• An evaluation was conducted of the SAMHSA Minority AIDS Initiative-Targeted Capacity Expansion Program for Substance Abuse Treatment and HIV/AIDS Services grants. The proportion of program participants across the different target populations that increased HIV knowledge from baseline to exit increased by 10.9 percentage points. Increases in HIV knowledge was most common among adolescent participants ages 12-17 years with 13.2 percent increasing HIV knowledge from baseline to exit. Black, Latina and Hispanic women showed the next highest increases with 11.4 and 12.2 percent of participants increasing HIV knowledge from baseline to exit, respectively.

The Department is continuing to support and execute the programs contributing to this objective, monitoring progress, performance, and program integrity while adjusting to any budgetary constraints or changes to programmatic demands.