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Prevention Agenda 2019-2024: Prevent Chronic Diseases Action Plan

Prevent Chronic Diseases Action Plan (PDF, 1.0MB, 38pp.)

Overview
Focus Area 1. Healthy Eating and Food Security
Focus Area 2. Physical Activity
Focus Area 3. Tobacco Prevention
Focus Area 4. Chronic Disease Preventive Care and Management

Overview

Chronic diseases such as cancer, diabetes, heart disease, stroke, asthma and arthritis are among the leading causes of death, disability and rising health care costs in New York State (NYS). However, chronic diseases are also among the most preventable. Three modifiable risk behaviors - unhealthy eating, lack of physical activity, and tobacco use - are largely responsible for the incidence, severity and adverse outcomes of chronic disease. As such, improving nutrition and food security, increasing physical activity, and preventing tobacco use form the core of the Preventing Chronic Diseases Action Plan. The plan also emphasizes the importance of preventive care and management for chronic diseases, such as screening for cancer, diabetes, and high blood pressure; promoting evidence-based chronic disease management; and improving self-management skills for individuals with chronic diseases.

Some organizations and communities ^1,2 have found the 3-4-50 framework a helpful way to focus interventions on the three behaviors (unhealthy eating, lack of physical activity, and tobacco use) that contribute to four chronic diseases (cancer, heart disease and stroke, type 2 diabetes and chronic lung diseases) that cause over 50 percent of all deaths worldwide.

Additional information about the burden of chronic diseases, underlying risk factors, associated disparities, and social determinants of health can be found at: Link to the burden documents.

Focus Area 1. Healthy Eating and Food Security

Goals

Overarching Goal Reduce obesity and the risk of chronic disease

Goal 1.1 Increase access to healthy and affordable foods and beverages

Goal 1.2 Increase skills and knowledge to support healthy food and beverage choices

Goal 1.3 Increase food security

Objectives: By December 31, 2024

Objective 1.1 Decrease the percentage of children with obesity (among children ages 2-4 years participating in the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC])

Target	13.0%
Baseline	13.7%
Baseline Year	2016
Data Source	PedNSS
Data Level	State (by age, race/ethnicity), county

Objective 1.2 Decrease the percentage of children with obesity (among public school students in NYS exclusive of New York City [NYC])

Target	16.4%
Baseline	17.3%
Baseline Year	2014-16
Data Source	SWSCR
Data Level	State, school district

Objective 1.3 Decrease the percentage of children with obesity (among public school students in NYC)

Target	19.4%
Baseline	20.4%
Baseline Year	2015-16
Data Source	NYC Fitnessgram
Data Level	City, borough

Objective 1.4 Decrease the percentage of adults ages 18 years and older with obesity (among all adults)

Target	24.2%
Baseline	25.5%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.5 Decrease the percentage of adults ages 18 years and older with obesity (among adults with an annual household income of <$25,000)

Target	29.0%
Baseline	30.5%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.6 Decrease the percentage of all adults ages 18 years and older with obesity (among adults living with a disability)

Target	36.2%
Baseline	38.1%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.7 Decrease the percentage of adults who consume one or more sugary drinks per day (among all adults)

Target	22.0%
Baseline	23.2%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.8 Decrease the percentage of adults who consume one or more sugary drinks per day (with an annual household income of <$25,000)

Target	28.5%
Baseline	31.7%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.9 Decrease the percentage of adults who consume less than one fruit and less than one vegetable per day (among all adults)

Target	29.6%
Baseline	31.2%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.10 Decrease the percentage of adults who consume less than one fruit and less than one vegetable per day (among adults who are non-Hispanic black)

Target	39.1%
Baseline	41.2%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.11 Decrease the percentage of adults who consume less than one fruit and less than one vegetable per day (among adults who are Hispanic)

Target	39.1%
Baseline	41.2%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.12 Increase the percentage of adults who buy fresh fruits and vegetables in their neighborhood (among adults who are non-Hispanic black)

Target	90.6%
Baseline	86.3%
Baseline Year	2015
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region)

Objective 1.13 Increase the percentage of adults with perceived food security (among all adults)

Target	80.2%
Baseline	76.4%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.14 Increase the percentage of adults with perceived food security ( among adults with an annual household income of <$25,000)

Target	61.4%
Baseline	55.8%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Interventions

Intervention 1.0.1 Adopt policies and implement practices to reduce (over)consumption of sugary drinks Sugar-sweetened beverages (SSBs) are the largest source of added sugar and an important contributor of calories in the U.S. diet. Several social and environmental factors have been linked to the purchase and consumption of SSBs, and several mechanisms have been proposed to explain the association between SSB consumption and obesity. Research indicates that consumption of SSB is a modifiable behavior and that change in consumption is associated with change in body weight or obesity. There is growing evidence that adopting policies and implementing practices, such as limiting access to SSBs, promoting access to and consumption of more healthful alternatives to SSBs, limiting marketing of SSBs, and implementing differential pricing of SSBs to reduce the relative cost of more healthful beverages, are associated with reductions in the purchase and consumption of SSBs. Local health departments, other agencies, hospitals, businesses, community-based organizations (CBOs) and other stakeholders can collaboratively work to support promising policies, practices and environmental changes.

Evidence and Resources	Evidence base: County Health Rankings and Roadmaps: Sugar Sweetened Beverage Taxes IOM: Preventing Childhood Obesity: Health in the Balance Public Health Law Center: Sickly Sweet: Why the Focus on Sugary Drinks Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis Academy Health: Rapid Evidence Review: How do taxes on sugar-sweetened beverages affect health and health care costs? Cochrane Protocol: Taxation of sugar‐sweetened beverages for reducing their consumption and preventing obesity or other adverse health outcomes Resources: CDC: Community Strategies and Measurements to Prevent Obesity in the United States IOM: Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children CDC: Guide to Strategies for Reducing the Consumption of Sugar-Sweetened Beverages CDC: A Toolkit for Creating Healthy Hospital Environments: Making Healthier Food, Beverage, and Physical Activity Choices ChangeLab Solutions: SSB Restrictions Public Health Law Center: Sugar-Sweetened Beverages
Age Range	All Ages
Social Determinants Addressed	Education Food Security Built Environment
Lead Sectors	Employers, businesses and unions Colleges and Universities Policy makers and elected officials
Contributing Sectors	Governmental Public Health Agencies Media Schools (K-12) CBOs and Human service agencies Urban planning agencies
Intermediate-level Measure Example	Number of entities that adopt policies or implement practices to reduce consumption of sugary drinks. The Healthy Hospital Food, Beverage, and Physical Activity Environment Scans The Healthy Hospital Toolkit Nutrition Environment Measures Survey (NEMS)

Intervention 1.0.2 Quality nutrition (and physical activity) in early learning and child care settings As the obesity epidemic has grown, even the youngest children are affected. The prevalence of young children with obesity or overweight has increased, and for many, this will persist through childhood and adulthood. With the identification of risk factors and obesogenic environments, a growing body of evidence research identifies policy and environmental strategies that support improved nutrition, increased physical activity and reduced screen time to prevent and reduce early childhood overweight and obesity. Local health departments, other agencies, businesses, CBOs and other stakeholders can work with local child care providers to promote and support evidence-based policy and environmental changes.

Evidence and Resources	Evidence base: IOM: Early Childhood Obesity Prevention Policies Caring for Our Children: Preventing Childhood Obesity in Early Care and Education Programs Resources: County Health Rankings & Roadmaps: Nutrition and physical activity interventions in preschool child care Caring for Our Children: Preventing Childhood Obesity in Early Care and Education Programs CDC: The Spectrum of Opportunities Framework for State-level Obesity Prevention Efforts Targeting the Early Care and Education Setting CDC State Obesity Prevention Efforts Targeting Early Care and Education Setting University of North Carolina: Go NAP SACC
Age Range	Children, 6 weeks up to age 6 years
Social Determinants Addressed	Built Environment
Lead Sectors	Policy makers and elected officials Governmental Children's Agencies Child care Centers Day Care Homes
Contributing Sectors	Governmental Public Health Agencies Community or neighborhood residents
Intermediate-level Measure Example	Number of early care and education sites that improve nutrition policies and practices Enrollment data from CACFP The Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC)

Intervention 1.0.3
Worksite nutrition and physical activity programs designed to improve health behaviors and results

Local health departments, hospitals, health centers, businesses, CBOs and other stakeholders can implement wellness programs at their own worksite and work with local worksites to implement nutrition and physical activity interventions as part of a comprehensive worksite wellness program. Recommended components include:

Educating and informing through classes, distributing written information or utilizing educational software.

Conducting activities that target thoughts and social factors to influence behavior change. Examples include individual or group behavioral counseling, skill-building activities, providing rewards, and building support systems among co-workers and family members.

Changing physical or organizational structures that reach the entire workforce and make the healthy choice the easy choice. Examples include changing the options in cafeterias or vending machines; providing more opportunities for physical activity; modifying health insurance benefits; or offering memberships to health clubs.

Evidence and Resources	Evidence base: The Community Guide: Obesity Worksite Programs County Health Rankings & Roadmaps: Worksite Obesity Prevention Interventions Resources: CDC: Workplace Health Model CDC: Tips for Offering Healthier Options and Physical Activity at Workplace Meetings and Events CDC: Creating Healthier Hospital Food, Beverage and Physical Activity Environments CDC: A Step-by Step Guide Using the Healthy Hospital Food, Beverage, and Physical Activity Environment Scans CDC: Workplace Health Promotion CDC: Smart Food Choices: How to Implement Food Service Guidelines in Public Facilities A Report and Recommendations by the Workgroup on Food Procurement Guidelines to the: New York State Council on Food Policy NYC Food Policy: Procurement Standards for Meals and Snacks CSPI: Healthy Meetings CSPI: Healthier Food Choices for Public Places
Age Range	Adolescents (13-21), Adults (21-60), Older Adults (60+)
Social Determinants Addressed	Built Environment Health Care
Lead Sectors	Employers, businesses and unions
Contributing Sectors	Governmental Public Health Agencies Healthcare Delivery system Insurers
Intermediate-level Measure Example	Number of worksites that improve nutrition policies and practices. The CDC Worksite Health ScoreCard Smart Food Choices: How to Implement Food Service Guidelines in Public Facilities-APPENDIX B

Intervention 1.0.4
Multi-component school-based obesity prevention interventions

Local health departments, hospitals, health centers, insurers, businesses, CBOs and other stakeholders can collaborate to work with local school districts and parent-teacher organizations (PTOs) to support policy, and environmental changes that target physical activity and nutrition before, during or after school. Recommended components include:

Increasing the availability of healthier foods and beverages.

Selling healthier snack foods and beverages.

Using strategies to market healthier foods and beverages.

Limiting access to less healthy foods and beverages.

Providing healthy eating learning opportunities.

Creating school meal policies to ensure school breakfasts or lunches meet specific nutrition requirements.

Providing fresh fruits and vegetables to students at lunch and/or snack.

Increasing access to school breakfast.

Participating in Farm to School Programs

Evidence and Resources	Evidence base: The Community Guide: Multicomponent Interventions Increase Availability Healthier Foods and Beverages in Schools The Community Guide: Meal and Fruit and Vegetable Snack Interventions to Increase Healthier Foods and Beverages Provided by Schools County Health Rankings & Roadmaps: Multi-Component School-Based Obesity Prevention Interventions County Health Rankings & Roadmaps: School Breakfast Programs Resources: CDC: School-Based Obesity Prevention Strategies for State Policymakers CDC: Healthy Schools - School Nutrition CDC: Comprehensive Framework for Addressing School Nutrition Environment and Services CDC: School Health Guidelines to Promote Healthy Eating and Physical Activity CDC: Healthy Schools - Parents for Healthy Schools IOM: Nutrition Standards for Foods in Schools: Leading the Way toward Healthier Youth Alliance for Healthier Generation - Schools USDA: School Breakfast Program FRAC: School Breakfast Program Hunger Solution New York's School Breakfast page Farm to School in New York - Resources
Age Range	Children up to age 11, Adolescents (13-21)
Social Determinants Addressed	Education Food Security Community Cohesion
Lead Sectors	Schools (K-12) Policy makers and elected officials Governmental Education Agencies Governmental Agricultural Agencies Agricultural Organizations
Contributing Sectors	Governmental Public Health Agencies Media Community or neighborhood residents CBOs and Human service agencies Transportation agencies
Intermediate-level Measure Example	Number of schools that improve nutrition policies and practices. School Health Index The Wellness School Assessment Tool, WellSAT 2.0 (The WellSAT-i measures implementation, and can be adapted for local use) NYS Education Department, Average Daily Participation for School Meal Participation in NYS schools Hunger Solutions Annual Report, School Breakfast Participation Data: Bridging the Gap, Ending Student Hunger with Breakfast After the Bell

Intervention 1.0.5 Increase the availability fruit and vegetable incentive programs Systematic evidence reviews find that financial incentive programs can increase affordability, access, purchases, and consumption of fruits and vegetables. Incentive programs for the purchase of fruits and vegetables have also been shown to increase sales and use of food assistance benefits (e.g., SNAP or WIC) at farmers' markets. Financial incentives can be a dollar-for-dollar match or a set amount per dollar spent (i.e., $2 for every $5 spent). Local health departments, hospitals, health centers, insurers, businesses, CBOs, hunger prevention advocates and other stakeholders can collaborate with local agencies to increase the availability and/or provide matching funds for low-income persons to purchase healthy foods, especially fresh fruits and vegetables.

Evidence and Resources	Evidence base: County Health Rankings & Roadmaps: Fruit and Vegetable Incentive Programs Pricing strategies to encourage availability, purchase, and consumption of healthy foods and beverages: A systematic review Resources: How to Run a Nutrition Incentive Program: A toolkit for Wholesome Wave's National Nutrition Incentive Network How to Grow Your Nutrition Incentive Program: A toolkit for Wholesome Wave's National Nutrition Incentive Network
Age Range	All ages
Social Determinants Addressed	Food Security
Lead Sectors	Governmental Public Health Agencies Governmental Social Support Agencies Governmental Agricultural Agencies
Contributing Sectors	Healthcare Delivery system CBOs and Human service agencies
Intermediate-level Measure Example	Number of programs that adopt policies and practices to increase consumption of fruits and vegetables. How to Run a Nutrition Incentive Network-PAGE 34, 47, APPENDICES How to Grow Your Nutrition Incentive Program-CHAPTER 5 AND APPENDICES

Intervention 1.0.6
Screen for food insecurity, facilitate and actively support referral

Effective systems for referral are necessary to help individuals and families access services and benefits for which they eligible. Screening for food insecurity in clinical settings has been recommended by several national organizations, as food insecurity can adversely impact a patient's health outcomes. Some studies have shown that screening for food insecurity is feasible and adds minimal time to the appointment. Screening can ensure timely referral to public health nutrition programs such as WIC, SNAP, CACFP and Commodity Supplemental Food Program (CSFP), and, if necessary, local emergency food services. Screening and referral alone, however, may not be sufficient. Successful case studies have included additional information technology (IT), systems and/or staff resources to facilitate connection, application, and enrollment in the appropriate public health nutrition and/or community program(s).

Local hospitals, health centers, businesses, and other stakeholders can partner with CBOs and governmental or private human services organizations to:

Promote and support screening of pediatric patients by healthcare providers, facilitate referral and support active connection to WIC and/or SNAP;

Promote screening of older-adult populations for food insecurity, facilitate referral and support active connection to SNAP; and

Provide IT, systems and/or staff resources to help individuals and families access, connect and enroll in appropriate nutrition and/or community programs to receive the benefits for which they eligible.

Evidence and Resources	Evidence base: Addressing Social Determinants of Health at Well Child Care Visits: A Cluster RCT Clinicians' Perceptions of Screening for Food Insecurity in Suburban Pediatric Practice Screening for social determinants of health in clinical care: Moving from the margins to the mainstream Taking action on the social determinants of health in clinical practice: a framework for health professionals https://www.chcs.org/media/HFCO-Case-Study_080918.pdf Case Study: Hunger Free Colorado: Connecting Vulnerable Patients to Food and Nutrition Resources Resources: AAP, FRAC: Addressing Food Insecurity: A Toolkit for Pediatricians AARP: Implementing Food Security Screening and Referral for Older Patients in Primary Care: A resource Guide and Toolkit FRAC: Free Online Course to Help Health Care Providers Address Senior Hunger Feeding America: Addressing Food Insecurity in Health Care Settings AARP, FRAC: Combating Food Insecurity: Tools for Helping Older Adults Access SNAP Nutrition & Obesity Network: Addressing Food Insecurity: Clinic-to-Community Treatment Models
Age Range	All ages
Social Determinants Addressed	Food Security
Lead Sectors	Healthcare Delivery system CBOs and Human service agencies
Intermediate-level Measure Example	1) Number of health practices that screen for food insecurity and facilitate referrals to supportive services
Additional Intermediate-level Measure Example(s)	2) Percent of eligible New Yorkers participating in SNAP 3) Percent of eligible New Yorkers participating in WIC. USDA Program Data Site: SNAP, WIC, School Lunch NYS OTDA Monthly Caseload Statistics

Focus Area 2. Physical Activity

Goals

Overarching Goal Reduce obesity and the risk of chronic diseases

Goal 2.1 Improve community environments that support active transportation and recreational physical activity for people of all ages and abilities.

Goal 2.2 Promote school, child care and worksite environments that increase physical activity

Goal 2.3 Increase access, for people of all ages and abilities, to indoor and/or outdoor places for physical activity.

Objectives: By December 31, 2024

Objective 1.1 Decrease the percentage of children with obesity (among WIC children ages 2-4 years)

Target	13.0%
Baseline	13.7%
Baseline Year	2016
Data Source	PedNSS
Data Level	State (by age, race/ethnicity), county

Objective 1.2 Decrease the percentage of children with obesity (among public school students in NYS exclusive of NYC)

Target	16.4%
Baseline	17.3%
Baseline Year	2014-16
Data Source	SWSCR
Data Level	State, school district

Objective 1.3 Decrease the percentage of children with obesity (among public school students in NYC)

Target	19.4%
Baseline	20.4%
Baseline Year	2015-16
Data Source	Fitnessgram
Data Level	City, borough

Objective 1.4 Decrease the percentage of adults ages 18 years and older with obesity (among all adults)

Target	24.2%
Baseline	25.5%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.5 Decrease the percentage of adults ages 18 years and older with obesity (among adults with an annual household income of <$25,000)

Target	29.0%
Baseline	30.5%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.6 Decrease the percentage of adults ages 18 years and older with obesity (among adults living with a disability)

Target	36.2%
Baseline	38.1%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income educational attainments, disability and region), county

Objective 1.7 Increase the percentage of adults age 18 years and older who participate in leisure-time physical activity (among all adults)

Target	77.4%
Baseline	73.7%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county

Objective 1.8 Increase the percentage of adults age 18 years and older who participate in leisure-time physical activity (among adults with less than a high school education)

Target	58.7%
Baseline	53.4%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county

Objective 1.9 Increase the percentage of adults age 18 years and older who participate in leisure-time physical activity (among adults with disabilities)

Target	61.8%
Baseline	56.2%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county

Objective 1.10 Increase the percentage of adults age 65 years and older who participate in leisure-time physical activity

Target	75.9%
Baseline	69.0%
Baseline Year	2016
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county

Objective 1.11 Increase the percentage of adults age 18 years and older who meet the aerobic and muscle strengthening physical activity guidelines (among all adults)

Target	21.0%
Baseline	20.0%
Baseline Year	2015
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region)

Objective 1.12 Increase the percentage of adults age 18 years and older who meet the aerobic and muscle strengthening physical activity guidelines (among adults with less than a high school education)

Target	12.0%
Baseline	10.9%
Baseline Year	2015
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region)

Objective 1.13 Increase the percentage of adults age 18 years and older who meet the aerobic and muscle strengthening physical activity guidelines (among adults with disabilities)

Target	10.5%
Baseline	9.5%
Baseline Year	2015
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region)

Objective 1.14 Increase the percentage of adults age 65 years and older who meet the aerobic and muscle strengthening physical activity guidelines

Target	18.0%
Baseline	16.4%
Baseline Year	2015
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region)

Objective 1.15 Increase the percentage of adults age 18 and over who walk or bike to get from one place to another (among all adults)

Target	TBD
Baseline	TBD
Baseline Year	2018
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county

Objective 1.16 Increase the percentage of adults age 18 and over who walk or bike to get from one place to another (among adults with less than a high school education)

Target	TBD
Baseline	TBD
Baseline Year	2018
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county

Objective 1.17 Increase the percentage of adults age 18 and over who walk or bike to get from one place to another (among adults with disabilities)

Target	TBD
Baseline	TBD
Baseline Year	2018
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county

Objective 1.18 Increase the percentage of adults age 65 and over who walk or bike to get from one place to another

Target	TBD
Baseline	TBD
Baseline Year	2018
Data Source	BRFSS
Data Level	State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county

Objective 1.19 Increase the percentage of high school students who were physically active for a total of at least 60 minutes/day on all 7 days (among all high school students)

Target	24.4%
Baseline	23.2%
Baseline Year	2017
Data Source	YRBS
Data Level	State (by sex, grade-level, race/ethnicity)

Objective 1.20 Increase the percentage of high school students who were physically active for a total of at least 60 minutes/day on all 7 days (among black high school students)

Target	18.7%
Baseline	17.0%
Baseline Year	2017
Data Source	YRBS
Data Level	State (by sex, grade-level, race/ethnicity)

Objective 1.21 Increase the percentage of high school students who were physically active for a total of at least 60 minutes/day on all 7 days (among Hispanic high school students)

Target	20.1%
Baseline	18.3%
Baseline Year	2017
Data Source	YRBS
Data Level	State (by sex, grade-level, race/ethnicity)

Interventions

2.1 Improve community environments that support active transportation and recreational physical activity for people of all ages and abilities.

Intervention 2.1.1
Implement a combination of one or more new or improved pedestrian, bicycle, or transit transportation system components (i.e., activity-friendly routes):

Street pattern design and connectivity

Pedestrian infrastructure

Bicycle infrastructure

Public transit infrastructure and access

with new or improved land use or environmental design components (i.e., connecting everyday destinations):

Mixed land use

Increased residential density

Community or neighborhood proximity

Parks and recreational facility access

through comprehensive master/transportation plans or Complete Streets resolutions, policies, or ordinances to connect sidewalks, multi-use paths and trails, bicycle routes, and public transit with homes, early care and education sites, schools, worksites, parks, recreation facilities, and natural or green spaces.

Evidence and Resources	Evidence base: Community Preventive Services Task Force Recommendation for Built Environment Interventions to Increase Physical Activity Resources: Community Guide: Combined Built Environment Approaches The Surgeon General's Call to Action to Promote Walking and Walkable Communities Community Health Inclusion Sustainability Planning Guide Inclusive Community Health Implementation Package (iCHIP)
Age Range	All Ages
Social Determinants Addressed	Economic Stability Transportation Community Cohesion Built Environment
Lead Sectors	Governmental Public Health Agencies
Contributing Sectors	Insurers Media Colleges and Universities Schools (K-12) Community or neighborhood residents CBOs and Human service agencies Policy makers and elected officials Transportation agencies Housing agencies Economic development agencies Natural environment agencies Urban planning agencies
Intermediate-level Measure Example	Number of places that implement new, or improve existing, community planning and transportation interventions that support safe and accessible physical activity

2.2 Promote school, child care and worksite environments that increase physical activity

Intervention 2.2.1 Implement the Centers for Disease Control and Prevention (CDC) Comprehensive School Physical Activity Program in school districts through Local School Wellness Policy Committees aligned with school district educational outcomes; Local School Wellness Policy requirements; School Health Improvement Plans; CDC's Whole School, Whole Community, Whole Child Model; New York State Education Department's Every Student Succeeds Act Plan; School Health Index and Wellness School Assessment Tool (WellSAT) assessments; school staff and teacher professional development and training standards, and with resource or materials support.

Evidence and Resources	Evidence base: Physical Activity: Enhanced School-Based Physical Education Behavioral Interventions that Aim to Reduce Recreational Sedentary Screen Time Among Children Resources: Comprehensive School Physical Activity Programs: A Guide for Schools School Health Guidelines to Promote Healthy Eating and Physical Activity Strategies for Recess in Schools Parents for Healthy Schools WellSAT Physical Activity and Physical Education Items
Age Range	Children up to age 11, Adolescents (13-21)
Social Determinants Addressed	Education Community Cohesion
Lead Sectors	Governmental Public Health Agencies
Contributing Sectors	Media Colleges and Universities Schools (K-12) Community or neighborhood residents CBOs and Human service agencies Policy makers and elected officials Housing agencies Economic development agencies
Intermediate-level Measure Example	Number of schools with Comprehensive School Physical Activity Programs

Intervention 2.2.2 Adopt and implement policies, programs, and best practices that meet QUALITYstars NY standards to provide infants daily opportunities to move freely under adult supervision to explore indoor and outdoor environments, including tummy time when awake; to provide opportunities for toddlers and/or preschoolers to have at least 15 minutes of developmentally appropriate, structured and unstructured, moderate to vigorous physical activity (both inside and outside) for every hour they are in care; and develop policies that limit screen time use of TV/video for children, including that TV/video is never used during nap and meal time or for children birth to age 2. For children ages 2 to 5 there is no more than 30 minutes once a week of high quality educational or movement-based commercial-free programming. Programs should also encourage parental involvement, provide portable play equipment on playgrounds and other play spaces, and provide staff with training in the delivery of structured physical activity sessions and increase the time allocated for such sessions.

Evidence and Resources	Evidence base: Childcare and Preschool Settings (pg.29) Caring for Our Children 3.1.3.1: Active Opportunities for Physical Activity 3.1.3.4: Caregivers'/Teachers' Encouragement of Physical Activity 2.2.0.3: Screen Time/Digital Media Use Resources: CDC Spectrum of Opportunities for Obesity Prevention in the Early Care and Education Setting (ECE) State Obesity Prevention Efforts Targeting the Early Care and Education Setting QUALITYstarsNY Nutrition and Physical Activity Self-Assessment in Childcare Early Care and Education State Indicator Report 2016
Age Range	Infants and Toddlers up to age 5
Social Determinants Addressed	Education Community Cohesion
Lead Sectors	Governmental Public Health Agencies
Contributing Sectors	Media Colleges and Universities Schools (K-12) Community or neighborhood residents CBOs and Human service agencies Housing agencies Economic development agencies
Intermediate-level Measure Example	Number of early care and education sites that improve physical activity policies and practices using an evidence-based assessment tool

Intervention 2.2.3 Implement a combination of worksite-based physical activity policies, programs, or best practices through multi-component worksite physical activity and/or nutrition programs; environmental supports or prompts to encourage walking and/or taking the stairs; or structured walking-based programs focusing on overall physical activity that include goal-setting, activity monitoring, social support, counseling, and health promotion and information messaging.

Evidence and Resources	Evidence base: Physical Activity: Point-of-Decision Prompts to Encourage Use of Stairs Worksite Nutrition and Physical Activity Programs Technology-Supported Multicomponent Coaching or Counseling Interventions - To Reduce Weight Technology-Supported Multicomponent Coaching or Counseling Interventions - To Maintain Weight Loss Resources: CDC Workplace Physical Activity Interventions CDC Worksite Physical Activity Resources CDC Worksite Health Scorecard-Physical Activity Module
Age Range	Adolescents (13-21), Adults (21-60), Older Adults (60+)
Social Determinants Addressed	Economic Stability Health Care
Lead Sectors	Governmental Public Health Agencies
Contributing Sectors	Healthcare Delivery system Employers, businesses and unions Insurers
Intermediate-level Measure Example	Number of worksites that improve physical activity policies and practices using an evidence-based assessment tool

2.3 Increase access, for people of all ages and abilities, to indoor and/or outdoor places for physical activity.

Intervention 2.3.1 Implement and/or promote a combination of community walking, wheeling, or biking programs, Open Streets programs, joint use agreements with schools and community facilities, Safe Routes to School programs, increased park and recreation facility safety and decreased incivilities (i.e., litter, graffiti, dogs off leash, unmaintained equipment), new or upgraded park or facility amenities or universal design features (i.e. playgrounds and structures; walking loops, recreation fields; gymnasiums; pools; outdoor physical activity equipment, fitness stations or zones; skate zones; picnic areas; concessions or food vendors; and pet waste stations); supervised activities or programs combined with onsite marketing, community outreach, and safety education. (Note: Parks can include mini-parks, pocket parks, or parklets; neighborhood parks; community and large urban parks; sports complexes; and natural resource areas.)

Evidence and Resources	Evidence base: Social Support Interventions in Community Settings Community Preventive Services Task Force Recommendation for Built Environment Interventions to Increase Physical Activity The First National Study of Neighborhood Parks Resources: Community Guide: Combined Built Environment Approaches The Surgeon General's Call to Action to Promote Walking and Walkable Communities Community Health Inclusion Sustainability Planning Guide Inclusive Community Health Implementation Package (iCHIP) Parks for Inclusion
Age Range	All Ages
Social Determinants Addressed	Economic Stability Transportation Community Cohesion Natural Environment Built Environment
Lead Sectors	Governmental Public Health Agencies
Contributing Sectors	Insurers Media Colleges and Universities Schools (K-12) Community or neighborhood residents CBOs and Human service agencies Policy makers and elected officials Transportation agencies Housing agencies Economic development agencies Natural environment agencies Urban planning agencies
Intermediate-level Measure Example	Number of indoor and/or outdoor facilities that can be accessed by walking, biking, or wheeling.

Focus Area 3. Tobacco Prevention

Goal 3.1 Prevent initiation of tobacco use

Objectives: By December 31, 2024

3.1.1 Decrease the prevalence of any tobacco use by high school students

Target	19.7%
Baseline	25.4%
Baseline Year	2016
Data Source	NYS YTS
Data Level	State (race/ethniity, gender, grade level, NYC/ROS)

3.1.2 Decrease the prevalence of combustible cigarette use by high school students

Target	3.3%
Baseline	4.3%
Baseline Year	2016
Data Source	NYS YTS
Data Level	State (race/ethniity, gender, grade level, NYC/ROS)

3.1.3 Decrease the prevalence of vaping product use by high school students

Target	15.9%
Baseline	20.6%
Baseline Year	2016
Data Source	NYS YTS
Data Level	State (race/ethniity, gender, grade level, NYC/ROS)

3.1.4 Decrease the prevalence of combustible cigarette use by young adults age 18-24 years

Target	9.1%
Baseline	11.7%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, SES, gender, region), and by county when expanded

3.1.5 Decrease the prevalence of vaping product use by young adults age 18-24 years

Target	7.0%
Baseline	9.1%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, SES, gender, region), and by county when expanded

3.1.6 Increase the number of municipalities that adopt retail environment policies, including those that restrict the density of tobacco retailers, keep the price of tobacco products high, and prohibit the sale of flavored tobacco products

Target	30
Baseline	15
Baseline Year	2018
Data Source	CAT
Data Level	State, municipality

Interventions

3.1.1 Increase Tobacco Control Program Funding to the CDC-Recommended level, to ensure a comprehensive tobacco control program.

Evidence and Resources	Resources: [Best Practices]; 2016 Independent Evaluation Report of the New York Tobacco Control Program https://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm
Age Range	All age groups
Social Determinants Addressed	Health Care Social and Community Context
Lead Sectors	Advocates state government
Intermediate-level Measure Example	Raise program funding to $52 million, approximately 25 percent of recommended full funding.

3.1.2 Use media and health communications to highlight the dangers of tobacco, promote effective tobacco control policies and reshape social norms.

Evidence and Resources	Resources: The Community Guide: The Role of the Media in Promoting and Reducing Tobacco Use https://www.thecommunityguide.org/topic/tobacco
Age Range	All
Social Determinants Addressed	Social and Community Context: Social Cohesion
Lead Sectors	Media State and local health departments
Intermediate-level Measure Example	Evidence of increasing support for effective tobacco control measures that would reduce youth initiation.

3.1.3 Pursue policy action to reduce the impact of tobacco marketing in lower-income and racial/ethnic minority communities, disadvantaged urban neighborhoods and rural areas.

Evidence and Resources	Resources: Public Health Law Center, http://www.publichealthlawcenter.org/sites/default/files/resources/tclc-guide-pos-policy-WashU-2014.pdf
Age Range	Birth — 18, All
Social Determinants Addressed	Neighborhood and Environment: Environmental Conditions
Lead Sectors	Local government
Intermediate-level Measure Example	Evidence of increasing support for effective tobacco control measures that would reduce youth initiation.

3.1.4 Keep the price of tobacco uniformly high by regulating tobacco company practices that reduce the real price of cigarettes through discounts.

Evidence and Resources	Resources: Public Health Law Center http://www.publichealthlawcenter.org/sites/default/files/resources/tclc-guide-pos-policy-WashU-2014.pdf
Age Range	All
Social Determinants Addressed	Neighborhood and Environment: Environmental Conditions
Lead Sectors	Local government
Intermediate-level Measure Example	Evidence of increasing support for effective tobacco control measures that restrict tobacco company practices that decrease the real price of tobacco products through industry discounts.

3.1.5 Decrease the availability of flavored tobacco products including menthol flavors used in combustible and non-combustible tobacco products and flavored liquids including menthol used in electronic vapor products.

Evidence and Resources	Resources: Public Health Law Center http://www.publichealthlawcenter.org/sites/default/files/resources/Regulating-Flavored-Tobacco-Products-2017.pdf
Age Range	Birth — 18, All
Social Determinants Addressed	Neighborhood and Environment: Environmental Conditions
Lead Sectors	local government
Intermediate-level Measure Example	Evidence of increasing support for effective tobacco control measures that would restrict the sale of flavored tobacco products and flavored liquids used in electronic vapor products.

3.1.6 Advocate with media parent companies to eliminate youth exposure to tobacco imagery and tobacco marketing in youth-rated movies.

Evidence and Resources	Resources: University of California, San Francisco, https://smokefreemovies.ucsf.edu/
Age Range	Birth - 18
Social Determinants Addressed	Social Cohesion
Lead Sectors	Entertainment
Intermediate-level Measure Example	Evidence of increasing support for effective tobacco control measures that would eliminate youth exposure to tobacco imagery and marketing in youth-rated movies.

Goal 3.2 Promote tobacco use cessation

Objectives: By December 31, 2024

3.2.1 Increase the percentage of smokers who received assistance from their health care provider to quit smoking by 13.1% from 53.1% (2017) to 60.1%.

Target	60.1%
Baseline	53.1%
Baseline Year	2017
Data Source	NYS ATS
Data Level	State (race/ethniity, gender, SES, NYC/ROS)

3.2.2 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among all adults)

Target	11.0%
Baseline	14.2%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, SES, gender, region), and by county when expanded

3.2.3 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults with income less than $25,000)

Target	15.3%
Baseline	19.8%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, SES, gender, region), and by county when expanded

3.2.4 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults with less than a high school education)

Target	14.9%
Baseline	19.2%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, SES, gender, region), and by county when expanded

3.2.5 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults reporting frequent mental distress)

Target	20.1%
Baseline	26.0%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, SES, gender, region), and by county when expanded

3.2.6 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults who self-identify as LGBT)

Target	14.9%
Baseline	19.3%
Baseline Year	2014-2016 pooled
Data Source	BRFSS
Data Level	state (by race/ethnicity, SES, gender, region), and by county when expanded

3.2.7 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults who are living with any disability)

Target	15.6%
Baseline	20.1%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, SES, gender, region), and by county when expanded

3.2.8 Increase the utilization of smoking cessation benefits (counseling and/or medications) among smokers who are enrolled in any Medicaid* program

Target	26.2%
Baseline	20.5%
Baseline Year	2016
Data Source	Medicaid Program
Data Level	state, NYC/ROS

Interventions

3.2.1 Assist medical and behavioral health care organizations (defined as those organizations focusing on mental health and substance use disorders) and provider groups in establishing policies, procedures and workflows to facilitate the delivery of tobacco dependence treatment, consistent with the Public Health Service Clinical Practice Guidelines, with a focus on Federally Qualified Health Centers, Community Health Centers and behavioral health providers.

Evidence and Resources	Resources: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html https://talktoyourpatients.health.ny.gov/
Age Range	18 years and older
Social Determinants Addressed	Health Care Access to Health Care
Lead Sectors	FQHCs CHC Behavioral Health Clinics Provider Practices
Intermediate-level Measure Example	Health care providers exhibit greater propensity to provide counseling and medications where appropriate to treat tobacco dependence in their patients.

3.2.2 Use health communications and media opportunities to promote the treatment of tobacco dependence by targeting smokers with emotionally evocative and graphic messages to encourage evidence-based quit attempts, to increase awareness of available cessation benefits (especially Medicaid), and to encourage health care provider involvement with additional assistance from the NYS Smokers' Quitline.

Evidence and Resources	Resources: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html https://talktoyourpatients.health.ny.gov/ https://www.nysmokefree.com/
Age Range	18 years and older
Social Determinants Addressed	Health Care Health and Health Care: Access to Health Care
Lead Sectors	State Health Department, local health departments
Intermediate-level Measure Example	Promote and educate smokers about the benefits of evidence-based quitting approaches.

3.2.3 Use health communications targeting health care providers to encourage their involvement in their patients' quit attempts encouraging use of evidence-based quitting, increasing awareness of available cessation benefits (especially Medicaid), and removing barriers to treatment.

Evidence and Resources	Resources: https://talktoyourpatients.health.ny.gov/
Age Range	18 years and older
Social Determinants Addressed	Health Care Health and Health Care: Access to Health Care
Lead Sectors	Health Care Organizations and Providers NYS Smokers' Quitline Community Based Organizations
Intermediate-level Measure Example	Work with departmental health system grantees to promote the delivery of evidence-based cessation services by health care providers.

3.2.4 Promote Medicaid and other health plan coverage benefits for tobacco dependence counseling and medications.

Evidence and Resources	Resources: CDC: https://www.cdc.gov/mmwr/volumes/67/wr/mm6713a3.htm
Age Range	18 years and older
Social Determinants Addressed	Health Care Health and Health Care: Access to Health Care
Lead Sectors	Medicaid Offices County Health Departments
Intermediate-level Measure Example	Increase awareness of Medicaid benefits for tobacco use cessation among Medicaid enrollees and health care providers.

Goal 3.3 Eliminate exposure to secondhand smoke

Objectives: By December 31, 2024

3.3.1 Decrease the percentage of adults (non-smokers) living in multi-unit housing who were exposed to secondhand smoke in their homes

Target	27.2%
Baseline	35.2%
Baseline Year	2017
Data Source	NYS ATS
Data Level	State (race/ethniity, gender, SES, NYC/ROS)

3.3.2 Decrease the percentage of youth (middle and high school students) who were in a room where someone was smoking on at least 1 day in the past 7 days

Target	17.9%
Baseline	23.1%
Baseline Year	2016
Data Source	NYS YTS
Data Level	State (race/ethniity, gender, grade level, NYC/ROS)

3.3.3 Increase the number of multi-unit housing units (focus should be on housing with higher number of units) that adopt a smoke-free policy by 5000 units each year

Target
Baseline
Baseline Year
Data Source	CAT
Data Level	State, municipality

Interventions

3.3.1 Promote smoke-free and aerosol-free (from electronic vapor products) policies in multi-unit housing, including apartment complexes, condominiums and co-ops, especially those that house low-SES residents.

Evidence and Resources	Resources: HUD Smoke Free Public Housing https://www.hud.gov/program_offices/healthy_homes/smokefree
Age Range	All
Social Determinants Addressed	Neighborhood and Environment: Environmental Conditions
Lead Sectors	Housing agencies
Intermediate-level Measure Example	Increase the number of 100% smoke-free public housing units. Increase the proportion of leases that require that smoking policies be transparent.

3.3.2 Increase the number of smoke-free parks, beaches, playgrounds, college and other public spaces.

Evidence and Resources	Resources: Public Health and Tobacco Policy Center http://tobaccopolicycenter.org/tobacco-control/tobacco-free-outdoor-areas/
Age Range	All
Social Determinants Addressed	Neighborhood and Environment: Environmental Conditions
Lead Sectors	Government business educational institutions healthcare institutions
Intermediate-level Measure Example	Increasing support for or actual policies passed that increase the number of smoke-free parks, beaches, playgrounds and other public spaces.

3.3.3 Educate organizational decision makers, conduct community education, and use paid and earned media to increase community knowledge of the dangers of secondhand smoke exposure and secondhand aerosol/emission exposure from electronic vapor products.

Evidence and Resources	Resources: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm
Age Range	All
Social Determinants Addressed	Neighborhood and Environment: Environmental Conditions
Lead Sectors	Business government educational institutions
Intermediate-level Measure Example	Number of times decision makers were educated about secondhand smoke and aerosol/emissions
Additional Intermediate-level Measure Example(s)	Number of community education forums or media campaigns conducted.

Focus Area 4. Chronic Disease Preventive Care and Management

Goal 4.1 Increase cancer screening rates

Objectives: By December 31, 2024

4.1.1 Increase the percentage of women with an annual household income less than $25,000 who receive a breast cancer screening based on most recent guidelines

Target	79.7%
Baseline	75.9%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, gender, and region), and by county

4.1.2 Increase the percentage of women with an annual household income less than $25,000 who receive a cervical cancer screening based on the most recent guidelines

Target	80.0%
Baseline	76.1%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, gender, and region), and by county

4.1.3 Increase the percentage of adults who receive a colorectal cancer screening based on the most recent guidelines (ages 50 to 75 years)

Target	80.0%
Baseline	68.5%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, gender, and region), and by county

4.1.4 Increase the percentage of adults who receive a colorectal cancer screening based on the most recent guidelines (adults with an annual household income less than $25,000)

Target	63.7%
Baseline	60.7%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, gender, and region), and by county

4.1.5 Increase the percentage of adults aged 50-64 who receive a colorectal cancer screening based on the most recent guidelines

Target	66.3%
Baseline	63.1%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by race/ethnicity, gender, and region), and by county

Interventions

4.1.1 Work with health care providers/clinics to put systems in place for patient and provider screening reminders (e.g., letter, postcards, emails, recorded phone messages, electronic health records [EHR] alerts).

Evidence and Resources	Evidence: The Community Guide
Age Range	adults ages 21-75
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system Insurers
Contributing Sectors	Governmental Public Health Agencies
Intermediate-level Measure Example	Number of health systems that implement or improve provider and patient reminder systems Number of patients reached through patient reminder systems Compliance with screening guidelines among patients reached through patient reminder systems/among patients of health systems that adopted systems Provider, clinic or insurer breast, cervical and colorectal cancer screening rates

4.1.2 Conduct one-on-one (by phone or in-person) and group education (presentation or other interactive session in a church, home, senior center or other setting).

Evidence and Resources	Evidence: The Community Guide
Age Range	adults ages 21-75
Social Determinants Addressed	Education
Lead Sectors	Governmental Public Health Agencies Healthcare Delivery system CBOs and Human service agencies
Contributing Sectors	Employers, businesses and unions Insurers Community or neighborhood residents
Intermediate-level Measure Example	Number of individuals reached through one-on-one or group education that were referred to health providers for cancer screening Change in knowledge and awareness of need for cancer screening among individuals reached through one-on-one or group education Compliance with screening guidelines among individuals that were reached through one-on-one or group education

4.1.3 Use small media such as videos, printed materials (letters, brochures, newsletters) and health communications to build public awareness and demand.

Evidence and Resources	Evidence: The Community Guide
Age Range	adults ages 21-75
Social Determinants Addressed	Education
Lead Sectors	Governmental Public Health Agencies Healthcare Delivery system Insurers CBOs and Human service agencies
Contributing Sectors	Employers, businesses and unions
Intermediate-level Measure Example	Number and type of locations where materials were distributed Change in knowledge and awareness of need for cancer screening among groups reached through small media dissemination

4.1.4 Work with clinical providers to assess how many of their patients receive screening services and provide them feedback on their performance (Provider Assessment and Feedback).

Evidence and Resources	Evidence: The Community Guide
Age Range	adults ages 21-75
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system Insurers
Contributing Sectors	Governmental Public Health Agencies
Intermediate-level Measure Example	Number of health systems or providers that adopt or improve provider assessment and feedback systems for cancer screening Provider or clinic-level breast, cervical, and colorectal cancer screening rates

4.1.5 Remove structural barriers to cancer screening such as providing flexible clinic hours, offering cancer screening in non-clinical settings (mobile mammography vans, flu clinics), offering on-site translation, transportation, patient navigation and other administrative services and working with employers to provide employees with paid leave or the option to use flex time for cancer screenings.

Evidence and Resources	Evidence: The Community Guide
Age Range	adults ages 21-75
Social Determinants Addressed	Transportation Health Care
Lead Sectors	Governmental Public Health Agencies Healthcare Delivery system Employers, businesses and unions CBOs and Human service agencies Transportation agencies
Intermediate-level Measure Example	Number of organizations that adopt practices and policies that reduce structural barriers to cancer screening

4.1.6 Ensure continued access to health insurance to reduce economic barriers to screening.

Evidence and Resources	Evidence: The Community Guide
Age Range	adults ages 21-64
Social Determinants Addressed	Economic Stability Health Care
Lead Sectors	Governmental Public Health Agencies Healthcare Delivery system Employers, businesses and unions Insurers CBOs and Human service agencies Policy makers and elected officials
Intermediate-level Measure Example	Change in the percent of NYS population that has health insurance coverage

Goal 4.2 Increase early detection of cardiovascular disease, diabetes, prediabetes and obesity

Objectives: By December 31, 2024

4.2.1 Increase the percentage of adults 45+ who had a test for high blood sugar or diabetes within the past three years by 5%

Target	71.7%
Baseline	68.3%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by gender, income, and region), and by county

4.2.2 Increase the percentage of low-income (<$25,000) adults 45+ who had a test for high blood sugar or diabetes within the past three years by 5%

Target	67.4%
Baseline	64.2%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by gender, income, and region), and by county

4.2.3 Increase the percentage of children and adolescents ages 3 -17 years with an outpatient visit with a primary care provider or OB/GYN practitioner during the measurement year who received appropriate assessment for weight status during the measurement year by 5%

Target	80.6% [HMO]; 80.6% [MMC]
Baseline	77% [HMO]; 77% [MMC]
Baseline Year	2016
Data Source	QARR
Data Level	state (by health plan)

Interventions

4.2.1 Promote strategies that improve the detection of undiagnosed hypertension in health systems.

Evidence and Resources	Resources: Million Hearts
Age Range	Adult, with a focus over 45 years
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system Insurers
Contributing Sectors	Governmental Public Health Agencies
Intermediate-level Measure Example	number of health systems with policies/practices to identify patients with undiagnosed HTN number/percentage of patients served by health systems with policies/practices in place number of patients identified with undiagnosed HTN

4.2.2 Promote testing for prediabetes and risk for future diabetes in asymptomatic people in adults of any age with obesity and overweight (BMI 25 kg/m2 or 23 kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes, including first degree relative with diabetes, high risk race/ethnicity, and history of cardiovascular disease. Promote testing for all other patients beginning at 45 years of age. Promote repeat testing at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.

Evidence and Resources	Resources: https://www.cdc.gov/sixeighteen/diabetes/index.htm http://clinical.diabetesjournals.org/content/36/1/14
Age Range	Adult, with a focus over 45 years
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system Insurers
Contributing Sectors	Governmental Public Health Agencies
Intermediate-level Measure Example	number of health systems with policies/practices to identify patients with diabetes or prediabetes number/percentage of patients served by health systems with policies/practices in place number of patients identified with diabetes/prediabetes

Goal 4.3 Promote evidence-based care to prevent and manage chronic diseases including asthma, arthritis, cardiovascular disease, diabetes and prediabetes and obesity

Objectives: By December 31, 2024

4.3.1 Decrease the percentage of adult members with diabetes whose most recent HbA1c level indicated poor control (>9%)

Target	26.6% [HMO]; 31.4% [MMC]
Baseline	28% [HMO]; 33% [MMC]
Baseline Year	2016
Data Source	QARR
Data Level	state (by health plan, age, race/ethnicity)

4.3.2 Decrease the percentage of adult Black Medicaid members with diabetes whose most recent HbA1c level indicated poor control (>9%)

Target	38.0%
Baseline	40.0%
Baseline Year	2016
Data Source	QARR
Data Level	state (by health plan)

4.3.3 Decrease the percentage of adult Medicaid members aged 18-44 with diabetes whose most recent HbA1c level indicated poor control (>9%)

Target	39.0%
Baseline	41.0%
Baseline Year	2016
Data Source	QARR
Data Level	state (by health plan)

4.3.4 Increase the percentage of adult members who had hypertension whose blood pressure was adequately controlled during the measurement year

Target	66.2% [HMO]; 65.1% [MMC]
Baseline	63% [HMO]; 62% [MMC]
Baseline Year	2016
Data Source	QARR
Data Level	state (by health plan, age, race/ethnicity)

4.3.5 Increase the percentage of adult Black Medicaid members who had hypertension whose blood pressure was adequately controlled during the measurement year

Target	56.7%
Baseline	54.0%
Baseline Year	2016
Data Source	QARR
Data Level	state (by health plan)

4.3.6 Increase the percentage of adult Medicaid members 18-44 who had hypertension whose blood pressure was adequately controlled during the measurement year

Target	52.5%
Baseline	50.0%
Baseline Year	2016
Data Source	QARR
Data Level	state (by health plan)

4.3.7 Decrease the Asthma ED visit rate per 10,000 for those aged 0-4, 0-17, and all age groups

Target	0-4: 175.8; 0-17: 131.1; all: 73.0
Baseline	0-4: 185.1; 0-17: 138.0; all: 76.8
Baseline Year	2016
Data Source	SPARCS
Data Level	Statewide; County

4.3.8 Decrease the Asthma hospitalization rate per 10,000 for those aged 0-4, 0-17, and all age groups

Target	0-4: 38.6; 0-17: 21.2; all: 9.6
Baseline	0-4: 42.9; 0-17: 23.5; all: 10.7
Baseline Year	2016
Data Source	SPARCS
Data Level	Statewide; County

4.3.9 Increase the percentage of members (ages 5-64) who were identified as having persistent asthma and were dispensed appropriate asthma controller medications for at least 50% of the treatment period during the measurement year

Target	5-18: 59%; 19-64: 75%
Baseline	5-18: 54%; 19-64: 68%
Baseline Year	2016
Data Source	QARR
Data Level	Statewide; health plan; county

4.3.10 Increase the percentage of members (ages 5-64), who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year

Target	5-18: 69%; 19-64: 62%
Baseline	5-18: 63%; 19-64: 56%
Baseline Year	2016
Data Source	QARR
Data Level	Statewide; health plan; county

4.3.11 Increase the percentage of adults with HTN who are currently taking medicine to manage their high blood pressure

Target	80.70%
Baseline	76.9%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by gender, race/ethnicity, income and region), and by county

4.3.12 Increase the percentage of adults with arthritis who have been told by their doctor or health professional to be physically active/exercise to help with arthritis or joint symptoms by 5%

Target	66.6%
Baseline	63.4%
Baseline Year	2015
Data Source	BRFSS
Data Level	state (by gender, age, region)

Interventions

4.3.1 Promote a team-based approach (which may include pharmacist, community health worker, registered dietitian, podiatrist, and other health workers) to chronic disease care to improve health outcomes.

Evidence and Resources	Resources: Million Hearts CDC Best Practice Guide for CVD
Age Range	All ages
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system
Contributing Sectors	Governmental Public Health Agencies Insurers
Intermediate-level Measure Example	number of health systems that implement policies/practices to promote team-based care number/percentage of patients in health systems with policies/practices in place

4.3.2 Promote evidence-based medical management in accordance with national guidelines.

Evidence and Resources	Resources: Cardiovascular Disease: 2017 Hypertension Guidelines , 2013 Cholesterol Guidelines Chronic Kidney Disease: https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf https://www.ahajournals.org/doi/abs/10.1161/01.cir.0000437738.63853.7a Diabetes: https://professional.diabetes.org/content-page/standards-medical-care-diabetes http://www.nyspma.org/aws/NYSPMA/pt/sp/diabetes Asthma: https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma
Age Range	All ages
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system
Contributing Sectors	Governmental Public Health Agencies Insurers
Intermediate-level Measure Example	number of health systems that implement policies/practices to promote guideline-concordant chronic disease care number/percentage of patients in health systems with policies/practices in place

4.3.3 Promote the use of Health Information Technology for: Measurement, Registry Development, Patient Alerts, Bi-Directional Referrals, Reporting.

Evidence and Resources	Resources: Merit-Based Incentive Payment System (MIPS)
Age Range	All ages
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system
Contributing Sectors	Governmental Public Health Agencies Insurers
Intermediate-level Measure Example	number of providers using a registry to identify patients with a chronic condition number/percentage of health systems with certified EHRs number/percentage of health systems with connections to a Qualified Entity number/percentage of patients served by health systems with a certified EHR and/or QE connected health system

4.3.4 Promote strategies that improve access and adherence to medications and devices.

Evidence and Resources	Resources: Cardiovascular: CDC 6/18 Intervention Asthma: https://www.cdc.gov/sixeighteen/asthma/index.htm
Age Range	All ages
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system
Contributing Sectors	Governmental Public Health Agencies Insurers
Intermediate-level Measure Example	number of health systems that implement policies/practices to encourage self-management behaviors, including adherence to medication number of health systems that include pharmacists as members of the care team number/percentage of patients served by health systems with policies/practices related to self-management behaviors, including adherence to medication #number of patients identified with a self-management plan

4.3.5 Promote referral of patients with prediabetes to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program to achieve and maintain 5% to 7% loss of initial body weight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week.

Evidence and Resources	Resources: http://clinical.diabetesjournals.org/content/36/1/14
Age Range	Adults, including those over 65 years old.
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system
Contributing Sectors	Governmental Public Health Agencies Insurers CBOs and Human service agencies
Intermediate-level Measure Example	number of health systems that have policies/practices for identifying and referring patients to National DPP programs number of National DPP programs in community settings number of patients referred to National DPP number of patients who participate in National DPP percentage of patients who complete National DPP

4.3.6 Counsel and refer patients with arthritis to increase physical activity, including participation in arthritis-appropriate evidence-based interventions and walking.

Evidence and Resources	Resources: https://www.cdc.gov/mmwr/volumes/67/wr/mm6717a2.htm?s_cid=mm6717a2
Age Range	Adults with arthritis, including those over 65 years old.
Social Determinants Addressed	Health Care
Lead Sectors	Healthcare Delivery system
Contributing Sectors	Governmental Public Health Agencies Employers, businesses and unions Insurers Media Colleges and Universities Community or neighborhood residents CBOs and Human service agencies Policy makers and elected officials Transportation agencies Housing agencies Natural environment agencies Urban planning agencies
Intermediate-level Measure Example	number of health systems that have policies/practices for identifying and counseling patients with arthritis on PA number patient with arthritis identified and counseled number of patients referred to evidence-based walking programs number evidence-based walking programs in the community number of patients who participate in programs/% who complete

Goal 4.4 In the community setting, improve self-management skills for individuals with chronic diseases, including asthma, arthritis, cardiovascular disease, diabetes and prediabetes and obesity

Objectives: By December 31, 2024

4.4.1 Increase the percentage of adults with chronic conditions (arthritis, asthma, CVD, diabetes, CKD, cancer) who have taken a course or class to learn how to manage their condition

Target	10.60%
Baseline	10.1%
Baseline Year	2016
Data Source	BRFSS
Data Level	state (by gender, age, race/ethnicity, income), and by county

4.4.2 Increase the percentage of children (0-17) and adults (18+) with asthma who were ever given an asthma action plan by a doctor or health professional by 10% in both groups

Target	0-17: 53.1%; 18+: 26.6%
Baseline	0-17: 48.3%; 18+: 24.21%
Baseline Year	2011-2013 (0-17); 2014 (18+)
Data Source	BRFSS Asthma Call-Back Survey
Data Level	State

Interventions

4.4.1 Expand access to home-based multi-trigger, multicomponent visits by licensed professionals or qualified lay health workers to provide targeted, intensive asthma self-management education and to reduce home asthma triggers for individuals whose asthma is not well-controlled with NAEPP Guidelines' medical management and asthma self-management education (ASME).

Evidence and Resources	Resources: https://www.cdc.gov/sixeighteen/asthma/index.htm https://www.thecommunityguide.org/findings/asthma-home-based-multi-trigger-multicomponent-environmental-interventions-children-and https://www.epa.gov/sites/production/files/2018-05/documents/asthma_home_environment_checklist.pdf
Age Range	All, with focus on ages 0-17
Social Determinants Addressed	Housing Health Care
Lead Sectors	CBOs and Human service agencies
Contributing Sectors	Governmental Public Health Agencies Employers, businesses and unions Insurers Media Colleges and Universities Community or neighborhood residents Policy makers and elected officials Transportation agencies Housing agencies Economic development agencies
Intermediate-level Measure Example	number of providers trained on NAEPP Guidelines including ASME and home-based interventions number of health systems that have policies/practices for referring patients with asthma to home-based services number of patients referred to home-based services

4.4.2 Expand access to evidence-based self-management interventions for individuals with chronic disease (arthritis, asthma, cardiovascular disease, diabetes, prediabetes, and obesity) whose condition(s) is not well-controlled with guidelines-based medical management alone.

Evidence and Resources	Resources: Arthritis: http://www.ymca.net/enhancefitness https://www.selfmanagementresource.com/programs/small-group/chronic-disease-self-management/ Asthma: https://www.cdc.gov/sixeighteen/asthma/index.htm Cardiovascular Disease: Million Hearts Self-Measured BP Diabetes: http://care.diabetesjournals.org/content/41/Supplement_1/S38
Age Range	All, including those over 65 years old and children age 0-17 for asthma only
Social Determinants Addressed	Health Care
Lead Sectors	CBOs and Human service agencies
Contributing Sectors	Governmental Public Health Agencies Employers, businesses and unions Insurers Colleges and Universities Community or neighborhood residents Policy makers and elected officials Transportation agencies Housing agencies Economic development agencies
Intermediate-level Measure Example	number of health systems that have policies/practices for identifying and referring patients to evidence-based self-management education (EBSMPs) programs number and type of EBSMP programs in community settings number patients referred to EBSMP number of patients who participate in EBSMP percentage of patients who complete EBSMP number of schools using the NYSDOH Guide for Asthma Management in Schools

4.4.3 Expand access to the National Diabetes Prevention Program (National DPP), a lifestyle change program for preventing type 2 diabetes.

Evidence and Resources	Resources: https://www.cdc.gov/sixeighteen/diabetes/index.htm
Age Range	Adults, including those over 65 years old.
Social Determinants Addressed	Health Care
Lead Sectors	CBOs and Human service agencies
Contributing Sectors	Governmental Public Health Agencies Employers, businesses and unions Insurers Community or neighborhood residents
Intermediate-level Measure Example	number of health systems that have policies/practices for identifying and referring patients to National DPP programs number of National DPP programs in community settings number patients referred to National DPP number of patients who participate in National DPP percentage of patients who complete National DPP

Department of Health

Prevention Agenda 2019-2024: Prevent Chronic Diseases Action Plan

Table of Contents

Overview

Focus Area 1. Healthy Eating and Food Security

Goals

Overarching Goal Reduce obesity and the risk of chronic disease

Goal 1.1 Increase access to healthy and affordable foods and beverages

Goal 1.2 Increase skills and knowledge to support healthy food and beverage choices

Goal 1.3 Increase food security

Objectives: By December 31, 2024

Objective 1.1 Decrease the percentage of children with obesity (among children ages 2-4 years participating in the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC])

Objective 1.2 Decrease the percentage of children with obesity (among public school students in NYS exclusive of New York City [NYC])

Objective 1.3 Decrease the percentage of children with obesity (among public school students in NYC)

Objective 1.4 Decrease the percentage of adults ages 18 years and older with obesity (among all adults)

Objective 1.5 Decrease the percentage of adults ages 18 years and older with obesity (among adults with an annual household income of <$25,000)

Objective 1.6 Decrease the percentage of all adults ages 18 years and older with obesity (among adults living with a disability)

Objective 1.7 Decrease the percentage of adults who consume one or more sugary drinks per day (among all adults)

Objective 1.8 Decrease the percentage of adults who consume one or more sugary drinks per day (with an annual household income of <$25,000)

Objective 1.9 Decrease the percentage of adults who consume less than one fruit and less than one vegetable per day (among all adults)

Objective 1.10 Decrease the percentage of adults who consume less than one fruit and less than one vegetable per day (among adults who are non-Hispanic black)

Objective 1.11 Decrease the percentage of adults who consume less than one fruit and less than one vegetable per day (among adults who are Hispanic)

Objective 1.12 Increase the percentage of adults who buy fresh fruits and vegetables in their neighborhood (among adults who are non-Hispanic black)

Objective 1.13 Increase the percentage of adults with perceived food security (among all adults)

Objective 1.14 Increase the percentage of adults with perceived food security ( among adults with an annual household income of <$25,000)

Interventions

Focus Area 2. Physical Activity

Goals

Overarching Goal Reduce obesity and the risk of chronic diseases

Goal 2.1 Improve community environments that support active transportation and recreational physical activity for people of all ages and abilities.

Goal 2.2 Promote school, child care and worksite environments that increase physical activity

Goal 2.3 Increase access, for people of all ages and abilities, to indoor and/or outdoor places for physical activity.

Objectives: By December 31, 2024

Objective 1.1 Decrease the percentage of children with obesity (among WIC children ages 2-4 years)

Objective 1.2 Decrease the percentage of children with obesity (among public school students in NYS exclusive of NYC)

Objective 1.3 Decrease the percentage of children with obesity (among public school students in NYC)

Objective 1.4 Decrease the percentage of adults ages 18 years and older with obesity (among all adults)

Objective 1.5 Decrease the percentage of adults ages 18 years and older with obesity (among adults with an annual household income of <$25,000)

Objective 1.6 Decrease the percentage of adults ages 18 years and older with obesity (among adults living with a disability)

Objective 1.7 Increase the percentage of adults age 18 years and older who participate in leisure-time physical activity (among all adults)

Objective 1.8 Increase the percentage of adults age 18 years and older who participate in leisure-time physical activity (among adults with less than a high school education)

Objective 1.9 Increase the percentage of adults age 18 years and older who participate in leisure-time physical activity (among adults with disabilities)

Objective 1.10 Increase the percentage of adults age 65 years and older who participate in leisure-time physical activity

Objective 1.11 Increase the percentage of adults age 18 years and older who meet the aerobic and muscle strengthening physical activity guidelines (among all adults)

Objective 1.12 Increase the percentage of adults age 18 years and older who meet the aerobic and muscle strengthening physical activity guidelines (among adults with less than a high school education)

Objective 1.13 Increase the percentage of adults age 18 years and older who meet the aerobic and muscle strengthening physical activity guidelines (among adults with disabilities)

Objective 1.14 Increase the percentage of adults age 65 years and older who meet the aerobic and muscle strengthening physical activity guidelines

Objective 1.15 Increase the percentage of adults age 18 and over who walk or bike to get from one place to another (among all adults)

Objective 1.16 Increase the percentage of adults age 18 and over who walk or bike to get from one place to another (among adults with less than a high school education)

Objective 1.17 Increase the percentage of adults age 18 and over who walk or bike to get from one place to another (among adults with disabilities)

Objective 1.18 Increase the percentage of adults age 65 and over who walk or bike to get from one place to another

Objective 1.19 Increase the percentage of high school students who were physically active for a total of at least 60 minutes/day on all 7 days (among all high school students)

Objective 1.20 Increase the percentage of high school students who were physically active for a total of at least 60 minutes/day on all 7 days (among black high school students)

Objective 1.21 Increase the percentage of high school students who were physically active for a total of at least 60 minutes/day on all 7 days (among Hispanic high school students)

Interventions

Focus Area 3. Tobacco Prevention

Goal 3.1 Prevent initiation of tobacco use

Objectives: By December 31, 2024

3.1.1 Decrease the prevalence of any tobacco use by high school students

3.1.2 Decrease the prevalence of combustible cigarette use by high school students

3.1.3 Decrease the prevalence of vaping product use by high school students

3.1.4 Decrease the prevalence of combustible cigarette use by young adults age 18-24 years

3.1.5 Decrease the prevalence of vaping product use by young adults age 18-24 years

3.1.6 Increase the number of municipalities that adopt retail environment policies, including those that restrict the density of tobacco retailers, keep the price of tobacco products high, and prohibit the sale of flavored tobacco products

Interventions

3.1.1 Increase Tobacco Control Program Funding to the CDC-Recommended level, to ensure a comprehensive tobacco control program.

3.1.2 Use media and health communications to highlight the dangers of tobacco, promote effective tobacco control policies and reshape social norms.

3.1.3 Pursue policy action to reduce the impact of tobacco marketing in lower-income and racial/ethnic minority communities, disadvantaged urban neighborhoods and rural areas.

3.1.4 Keep the price of tobacco uniformly high by regulating tobacco company practices that reduce the real price of cigarettes through discounts.

3.1.5 Decrease the availability of flavored tobacco products including menthol flavors used in combustible and non-combustible tobacco products and flavored liquids including menthol used in electronic vapor products.

3.1.6 Advocate with media parent companies to eliminate youth exposure to tobacco imagery and tobacco marketing in youth-rated movies.

Goal 3.2 Promote tobacco use cessation

Objectives: By December 31, 2024

3.2.1 Increase the percentage of smokers who received assistance from their health care provider to quit smoking by 13.1% from 53.1% (2017) to 60.1%.

3.2.2 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among all adults)

3.2.3 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults with income less than $25,000)

3.2.4 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults with less than a high school education)

3.2.5 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults reporting frequent mental distress)

3.2.6 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults who self-identify as LGBT)

3.2.7 Decrease the prevalence of cigarette smoking by adults ages 18 years and older (among adults who are living with any disability)