The Arizona
Chronic Disease Plan
An Integrated Model For
Promoting Healthy Communities

“
ii

Alone we
can do so little;
together we can
do so much.

”

– Helen Keller

i

Chronic disease accounts for seven out of the 10 leading causes of death in Arizona and is the most
common and preventable of all health problems. During the 20th Century, our citizens saw the focus of
public health shift dramatically from the communicable diseases that were so prevalent during the early
part of the century to chronic disease as the primary cause of mortality and morbidity. Diseases such as
heart disease, cancer, lung disease, and stroke rank highest on the list as the four leading causes of death
for Arizonans.
The Arizona Chronic Disease Plan: An Integrated Model for Promoting Healthy Communities is the
culmination of a collaborative effort among members of the Chronic Disease Team who worked to
combine the elements of six comprehensive disease-specific categorical plans into a cohesive and
integrated model. It is an innovative and cutting-edge approach that promotes collective thinking and
problem solving in addressing common elements of the disease-specific and primary risk factor
categories. This plan represents the Arizona Department of Health Services’ efforts to view chronic
disease from a more comprehensive and integrated perspective.
The Arizona Chronic Disease Plan is not meant to be the final answer; rather it is a beginning in the
department’s ongoing commitment to reducing the impact of chronic disease in our state and, thereby,
enhancing the quality of life for our citizens.

Susan Gerard
Director
Arizona Department of Health Services

The Arizona Chronic Disease Plan

Letter From Our Director

Dear Arizona Residents:

ii
Acknowledgments

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

II. E x e c u t i v e S u m m a r y
III. I n t r o d u c t i o n

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Vision for the Arizona Chronic Disease Plan:
An Integrated Model for Promoting Healthy Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
ADHS Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Chronic Disease Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Definition of Chronic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Comprehensive Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Case for an Integrated Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Timeframe for the Arizona Chronic Disease Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

IV. T h e P l a n

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

The Burden of Chronic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
The Need for an Arizona Chronic Disease Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Health Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
The Cost of “Not Taking Action” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
How This Plan is Different . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Purpose of the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
How to Use This Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Description of the Categorical Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

V. I n t e g r a t i o n

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Healthy Lifestyles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Priorities for Chronic Disease Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Implementing an Integrated Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
State Level Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Community Level Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
Summary Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

VI. A p p e n d i c e s
A.
B.
C.
D.
E.
F.
G.
H.

Ta b l e o f C o n t e n t s

I.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

Sample Matrices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Tobacco Tax Statute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Healthy Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
Priority Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Programs and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77
Culturally and Linguistically Appropriate Services Standards . . . . . . . . . . . . . . . . . . . . . . . . . .85
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

The Arizona Chronic Disease Plan

1

Courtesy of Heard Museum

I

Chronic Disease Team

Primary Author

We would like to thank the members of the Chronic

Janet Bourbouse

Disease Team for their dedication and commitment to

Arizona Department of Health Services

the development of this plan. Their willingness to

Reviewers

give of their time, energy, and expertise represents

Acknowledgements

Acknowledgements

Chronic Disease Team

the true spirit of teamwork.

Trust Commission

Consultants
Sincere gratitude to our technical consultants, Randy

We would like to thank the members of the Tobacco
Revenue Use, Spending, and Tracking (TRUST)
Commission for supporting the development of The

Kirkendall (Partnership for Prevention) and Tom
Kean (Strategic Health Concepts) for their insight,
direction, and support throughout the project.

Arizona Chronic Disease Plan: An Integrated Model
for Promoting Healthy Communities.

The Arizona Chronic Disease Plan

3

II
Executive Summary

Executive Summary
Chronic disease accounts for seven out of the 10 leading causes
of death in the state of Arizona.1 This plan is intended to
provide state level agencies, communities, health care providers,
funding agencies, organizations, 2) The AzCD Plan will be used as a vehicle for
establishing partnerships with local communities
policy and decision makers,
and organizations to develop programs to address
and consumers direction and
the burden of chronic disease.
support in creating a system of care that proactively

3)

priorities for a portion of the Arizona Tobacco Tax

treatment of chronic disease in Arizona. It is hoped

and Health Care Fund – Health Education

the framework presented will encourage the

Account. The funding priorities will address

development of partnerships to promote a

prevention and early detection of the four leading

comprehensive and integrated approach to reducing

disease-related causes of death, i.e., heart disease,

mortality and morbidity due to chronic disease.

Vision for The Arizona
Chronic Disease Plan:
An Integrated Model for
Promoting Healthy Communities
1)

The AzCD Plan will be used to establish funding
5

addresses the prevention, early detection and

cancer, lung disease (chronic obstructive
pulmonary disease or COPD), and stroke.
4)

The AzCD Plan provides a framework for
leveraging resources and exploring other funding
streams.

The Arizona Chronic Disease (AzCD) Plan is a
blueprint for developing a coordinated and
integrated approach to chronic disease
management in Arizona.

The Arizona Chronic Disease Plan

Health Disparities
Despite the advances in medical technology

Healthy Lifestyles
This AzCD Plan supports the promotion of healthy

impacting the early detection, diagnosis, and treatment

lifestyles as primary prevention strategies in combating

of chronic disease, minority groups and other

the key risk factors for chronic disease, i.e., poor

vulnerable populations still experience health care

nutrition, physical inactivity, and use of commercial

barriers and significantly higher rates of disease and

tobacco products. The role of tobacco prevention and

mortality. Eliminating these disparities has become a

cessation programs is critical in the management of

priority for the health care system nationally and in

chronic disease. The burden of overweight and obesity

Arizona.

contributes to premature death and disability, increased

How This Plan is Different
This plan is different than many other planning
documents. The scope of the plan is very broad,
encompassing several distinct disease categories: heart
disease, cancer, lung disease (COPD and asthma),

health care costs, lost productivity, and social issues.
While not all chronic diseases are addressed in this
plan, promoting a healthy lifestyle that includes good
nutrition, physical activity and no use of commercial
tobacco products will positively impact many chronic
diseases not specifically included in the plan.

stroke, and diabetes and the risk factor categories of
poor nutrition, physical inactivity, and use of
6

commercial tobacco products (see definition of

Summary
This plan represents the Arizona Department of

“tobacco” in glossary). Each of the disease-specific

Health Services’ ongoing commitment to reducing the

entities and risk factor categories has developed a

mortality and morbidity of chronic disease through

comprehensive and integrated planning document that

collaboration among all stakeholders. It is hoped that

outlines evidenced-based objectives and strategies. The

the plan will encourage the development of

goal of the AzCD Plan is to effectively merge the many

partnerships among state agencies, policy and decision

elements of the categorical plans into a coordinated,

makers, communities, organizations, health care

cohesive, and integrated model of the proposed system

providers, and consumers to promote a comprehensive

of care for the prevention and management of chronic

and integrated approach to improving the health of all

disease in Arizona.

Arizonans.

II
Executive Summary
7

III
Introduction

Introduction
Chronic disease accounts for seven out of the 10 leading causes of
death in the state of Arizona.1 Over the past several years, there
has been an expansion of chronic disease programs within the
This plan is intended to provide state level agencies,
Public Health Services Division
communities, health care providers, funding agencies,
of the Arizona Department
organizations, policy and decision makers, and
of Health Services (ADHS).
consumers direction and support in creating a system
Until recently, those chronic disease programs
functioned independently without coordination among
the various chronic disease initiatives, due in part to
categorical funding requirements. With the expansion
of chronic disease prevention, management, and control
efforts, a need was identified to develop a more

of care that proactively addresses the prevention, early
9

detection and treatment of chronic disease in Arizona.
It is hoped the framework presented will encourage the
development of partnerships to promote a
comprehensive and integrated approach to reducing
mortality and morbidity due to chronic disease.

comprehensive and integrated approach.
There is neither funding to implement every strategy
in the categorical plans, nor funding to support all of
the initiatives addressed in this comprehensive plan.
The reality is there are rarely sufficient financial
resources to fully fund any plan. Many of the items in

Vision for The Arizona
Chronic Disease Plan:
An Integrated Model for
Promoting Healthy Communities
1)

This Arizona Chronic Disease (AzCD) Plan is a

this comprehensive plan do not require funding, but a

blueprint for developing a coordinated and

more effective coordination of state and community

integrated approach to chronic disease

level efforts that are already in progress. ADHS is

management in Arizona.

committed to dedicating human resources, time, and
leadership to support implementation of the plan.

The Arizona Chronic Disease Plan

2)

The AzCD Plan will be used as a vehicle for
establishing partnerships with local communities

services that are based on best practices and

and organizations to develop programs to address

supported by evidence-based strategies.

the burden of chronic disease.
3)

Service delivery. ADHS believes in delivering

The AzCD Plan will be used to establish funding
priorities for a portion of the Arizona Tobacco
Tax and Health Care Fund – Health Education
Account. The funding priorities will address
prevention and early detection of the four leading
disease-related causes of death: heart disease,
cancer, lung disease (chronic obstructive
pulmonary disease or COPD), and stroke.

Cultural responsiveness. ADHS believes all
services and technical assistance should be provided
in a manner that is responsive to cultural differences
and values the importance of culture in the delivery of
services to all segments of the population.

Reduction in health disparities. ADHS
believes in order to reduce existing health disparities,
a culturally responsive system of care should be
developed and implemented among all levels of
Arizona health care providers, which includes but is

4)

The AzCD Plan provides a framework for

not limited to:

leveraging resources and exploring other funding
• Organizational self-assessment of cultural
streams.

ADHS Approach
10

Prevention and health promotion. ADHS
believes in prevention and health promotion as the
path to optimal health and wellness for all Arizonans.
The 2005–2009 ADHS Strategic Plan includes
specific strategies and objectives focusing on the

competence
• Integration of cultural and linguistic competence
measures into existing quality improvement
activities (See Appendix F for Culturally and
Linguistically Appropriate Services Standards)
• Development/review of comprehensive written
policies on cultural responsiveness
• Customer satisfaction surveys

prevention of chronic disease in Arizona through an
• Solicitation of customer input relative to
integrated and comprehensive approach:
The Department is working with health care
providers, employees, and organizations to place
greater emphasis on the importance of prevention
and health promotion activities. By providing
leadership and state-of-the-art health information
to professionals and consumers alike, the
Department can promote healthier lifestyles and
reduce the incidence of chronic and degenerative
diseases.2

individual needs, beliefs, and behaviors
• Trainings and forums for providers and staff.

III
In addition to services, technical assistance is a

impacting the early detection, diagnosis, and treatment

critical need to improve health conditions on the

of chronic disease, minority groups and other

reservations. Resources are significantly limited and

vulnerable populations still experience health care

capacity building or “nation building” is a critical

barriers and significantly higher rates of disease and

need. Tribes prefer technical assistance be made

mortality. Eliminating these disparities has become a

available to them in a manner that allows them to

priority for the health care system nationally and in

customize the assistance based on the needs of the

Arizona.

tribe.

Current health data on Arizona residents shows

Improved working relationships between the tribes

marked differences in rates of disease and

and state agencies need to be established so tribes can

mortality among specific population groups. The

be involved in future planning activities. Geographic

Department is committed to addressing disparities
in Arizona by increasing dialogue with

barriers and efficient and expedient methods of

communities, improving access to public health

communication present challenges in obtaining tribal

information, and working collaboratively on

input on planning activities at the state level.

community action specifically targeted to improve

Soliciting input from Indian Health Service (IHS) or

health outcomes through prevention. The
Department will also work to ensure that all

Introduction

Despite the advances in medical technology

the Bureau of Indian Affairs (BIA) is one way used to

Arizonans receive timely diagnosis and treatment

obtain the Native American perspective in planning

of health conditions through expanded access to

efforts; however, these agencies provide a federal

primary care.3

perspective, which is not necessarily the local tribal

Native American population in Arizona. In

perspective. While going directly to the tribes on the

addressing issues related to cultural competency and

reservations is the only true source of obtaining tribal

disparity, it is important to recognize that Arizona has

input, the Inter Tribal Council of Arizona (ITCA)

one of the largest Native American populations in the

presents an accessible and viable option for obtaining

country comprising approximately 5% of the state’s

a tribal perspective.

population.4

Background

There are 21 separate sovereign nations located on
In July of 2002, the ADHS Office of Nutrition
24 Native American reservations throughout Arizona.
Services merged with some of the chronic disease
This presents some distinct challenges in terms of
prevention programs in ADHS to form a new office
geographic barriers, history, tradition, communication,
titled the Office of Chronic Disease Prevention and
and governmental structure. The element of
sovereignty is a unique aspect of the Native American
population, not shared by other minority groups,
requiring additional accommodation to work
successfully.

The Arizona Chronic Disease Plan

11

Nutrition Services (OCDPNS). The chronic disease

determined by the Centers for Disease Control and

programs that merged included:

Prevention (CDC) or its successor agency.

• Diabetes Prevention and Control
• Arthritis Control

Initially, the Chronic Disease Fund, which resides
within ADHS, will address the following chronic
diseases: heart disease, cancer, lung disease (COPD)

• Well Woman Healthcheck Program (Breast and
Cervical Cancer Early Detection and Diagnosis)

and stroke. By statute, an external advisory
commission (Tobacco Revenue Use Spending and

During the next year, funding was secured for
planning grants in the areas of:

Tracking Commission or TRUST) was established
to oversee the Health Education Account. The

• Cardiovascular Risk Reduction

15-member, ADHS Director-appointed TRUST

• Nutrition and Physical Activity

Commission serves in an advisory capacity to ADHS

• Comprehensive Cancer Control

in providing oversight to the Tobacco Tax revenues,
including the Proposition 303 Tobacco Tax-based

With the growing number of chronic disease programs
chronic disease funds. Through internal and external
in OCDPNS, its chronic disease prevention efforts
stakeholder input, the decision was made to allocate
expanded and work began on establishing
these funds for screening and early detection
comprehensive chronic disease programming and
programs, promoting healthy lifestyle programs, and
planning.
12

development of a comprehensive chronic disease
An additional motivating factor for the
strategic plan.
development of the comprehensive chronic disease
As the public health agency that administers and
plan was the need to establish direction and funding
manages the chronic disease funds, the need for a
priorities for a portion of the Arizona Tobacco Tax
systems-level strategic plan that is both
and Health Care Fund – Health Education Account.
comprehensive and integrated is paramount. Having
Voter approval of Proposition 303 in 2002 increased
such a plan will ensure that chronic disease-related
the state tax on tobacco products and reenacted the
“baselines” are developed, actual needs are addressed,
Proposition 204 statute that established the Tobacco
and funds are allocated in support of policy change
Tax and Health Care Fund – Health Education
and programmatic services.
Account. As a voter approved initiative, a portion of
the tobacco tax revenue (2%) was directed to the
prevention and early detection of the four leading
disease-related causes of death as periodically

III
Introduction
13

14

III
Network, Social Marketing, Steps to a Healthier

a grant proposal to the Partnership for Prevention who

Arizona, Bureau of Public Health Statistics, Office of

had been designated by CDC to provide tailored

Health Systems Development, the Native American

technical assistance to selected states and

Liaison, and the coordinator from the Health

metropolitan areas in developing comprehensive and

Disparities Conference Committee, were added to the

integrated chronic disease prevention efforts. In

team as the planning process required their expertise.

January of 2004, ADHS was notified that Arizona was

The technical assistance consultants facilitated the

one of four sites out of 34 applicants to participate in

monthly CD Team meetings held from August 2004 to

the CDC project. During the planning process, the

May 2005. The CD Team served as a steering

consultants facilitated on-site meetings of the Chronic

committee providing direction and content

Disease Team and provided direction and follow-up to

information for the AzCD Plan. Decisions regarding

the OCDPNS Office Chief and the AzCD Plan

common messaging, cross-cutting strategies,

Manager during each of the on-site visits. In addition

conflicting objectives, establishing priorities, and

to the on-site meetings, the consultants were available

identifying gaps in the categorical objectives and

for individual phone consultation, conference calls as

strategies were all addressed through the CD Team.

needed, and review of written materials via email.

The CD Team also served as a review workgroup for

Chronic Disease Team
A Chronic Disease (CD) Team was established
within ADHS to assist in the development and provide

all written materials pertaining to the AzCD Plan.
15

Definition of Chronic Disease
For the purposes of this document, chronic disease

input on the AzCD Plan. Initially, the CD Team

is defined as in the February 2003 revision of the

included the representatives from each of the

Association of State and Territorial Chronic Disease

categorical plans and appropriate administrative staff

Program Directors Bylaws:5

within OCDPNS and the Office of Tobacco Education

Chronic disease is defined as an impairment or

and Prevention Program (TEPP). As the planning

deviation from normal health having any of the

process progressed, other members were gradually

following characteristics:

added to the CD Team to broaden the scope of

• related to avoidable behavioral/environmental

representation and/or provide needed input on relevant
topic areas. Representatives from ADHS Nutrition

Introduction

In the fall of 2003, the ADHS OCDPNS submitted

risk factors
• is permanent
• leaves residual disability
• is caused by irreversible pathological alterations

The Arizona Chronic Disease Plan

• requires special training of the patient for

Case for an Integrated Approach

rehabilitation
The intent of integration is to strengthen program
• may require a long period of supervision,

effectiveness and improve program impact thereby

observation, or care.
maximizing available resources. Achieving

Comprehensive Approach

integration is a process whereby participants learn by
sharing common strategies and goals, they can

Miriam Webster Online defines the term
increase the overall impact and efficiency of their
comprehensive as “covering completely or broadly.” 6
programs.
For the purpose of this plan, a comprehensive
An integrated approach to chronic disease
approach to chronic disease prevention and
prevention provides opportunities for programs to
management is defined as addressing:
work together to provide services more efficiently and
• The leading causes of death: heart disease,
cancer, lung disease (COPD), and stroke

effectively, promotes group problem solving and
teamwork by collaboratively addressing common

• Two of the most common and costly conditions:
diabetes and asthma

problems and issues, and supports a more synergistic
style of intervention so the combined impact of all

• The major risk factors for chronic disease:
physical inactivity, poor dietary habits, and use
of commercial tobacco products
16

• The issues related to chronic disease
management from a statewide perspective
including: the general population, high-risk
groups, and disparate populations
• The issues using a broad spectrum of

programs is enhanced.
Other benefits of addressing chronic disease with
an integrated and collaborative approach are:
• Improved effectiveness in reaching shared target
populations and organizations
• Ability to address common risk factors that are
the same for many of the prominent chronic

intergenerational strategies implemented through

diseases: poor nutrition, physical inactivity, and

a variety of intervention domains such as:

use of commercial tobacco products

schools, work sites, family and community, and
the health care system.

• Enhanced impact of common, consistent social
marketing messages and strategies
• Opportunity for mutual problem solving and
shared learning
• Coordination of similar intervention strategies
that allows for improved coordination and
effectiveness in developing interventions for
common intervention sites such as schools, work
sites, and communities

III
efficiency and effectiveness of programs and

Timeframe for The Arizona
Chronic Disease Plan

allows for improved allocation of limited funding
The initial cycle of the AzCD Plan will cover from
• Enhanced data sharing
• Improved capacity for identifying and resolving
gaps in service delivery when those issues are
viewed from a multifaceted perspective
• Sharing of standards and best practices to
eliminate duplication of effort and insuring
consistency in standards of care
• Enhanced coordination with external partners
that results in better communication across
programs
• Coordination of provider education efforts
• Development of training tools for providers that
facilitate the process for all concerned and
avoids duplication of efforts
• Expanded impact of policy and environmental
changes
• Clearly defined roles and responsibilities
• Overall greater impact and effectiveness of
programs.

2005 through 2008. The projected timeframes for the
categorical plans range from three years to five years
as follows:

Introduction

• Pooling of resources that maximize the

• Cardiovascular Disease Prevention Plan,
2005 – 2010
• Arizona Comprehensive Cancer Control Plan,
2005 – 2010
• Chronic Lung Disease Plan for the State of
Arizona, 2005 – 2008
• Diabetes Prevention and Control Program Plan,
2005 – 2008
• Arizona Nutrition and Physical Activity Plan,
2005 – 2010
• Tobacco Education and Prevention Program
Plan, 2005 – 2008
Given that strategies and priorities for the AzCD
Plan were derived from the categorical plans, the CD
Team decided that the overall timeframe for the AzCD
Plan should be within the parameters of the
categorical plans. The three-year timeframe for the
AzCD Plan does not mean all objectives will be met
within that period, rather the plan will be monitored,
reassessed, and revised after the three years as needed.

The Arizona Chronic Disease Plan

17

IV
The Plan

The Plan
The Burden of Chronic Disease in Arizona
The 20th century saw major improvements in the quality of life
for citizens in this country. The infant mortality rate dropped
significantly and life expectancy increased by 30 years. The
deaths were due to heart disease (24.9%) and 2,356
focus of public health also
were due to stroke (5.5%).
shifted dramatically from the
• Cancer is the second leading cause of death in
communicable diseases that
Arizona, second only to heart disease. There were
1

plagued the early part of this century to chronic disease
as the primary causes of death and disability to our
7

9,451 deaths attributed to cancer in 2003 (22.1%).1
• Chronic Lower Respiratory Disease or Chronic

citizens. Today, diseases such as heart disease, cancer,

Obstructive Pulmonary Disease (COPD) was the

lung disease, and stroke are among the most common,

third leading cause of death in Arizona for 2003,

costly and preventable causes of mortality and
morbidity.8 The aging of the baby-boomer generation,
and the popularity of Arizona as a retirement state,

accounting for 5.9% of deaths.1
• It was estimated that about 262,686 Arizonans had
diabetes in 2002. The rate of diabetes-related
hospital discharges increased from 133 per 100,000

place additional responsibilities on public health and

population in 2000, to 147 per 100,000 population

the health care system to aggressively address chronic

in 2002.9

disease from a prevention perspective and utilize

• Asthma is one of the nation’s most common and

screening and early detection to reduce the burden of

costly diseases, affecting 17 million Americans,

chronic disease.

including almost five million children. The

Chronic disease accounts for seven out of the 10
leading causes of death in the state of Arizona.1 They
are the most prevalent, costly, and preventable of all
health problems.
• In Arizona, heart disease and stroke were the first

prevalence for asthma among Arizona adults
(persons 18 years of age or older) was approximately
13.9% in 2002.10
• “In 2002, more than half of the deaths in Arizona
(54.8%) were from diseases for which overweight
and obesity are known to increase risk, including

and fourth leading cause of death in 2003; 10,649
The Arizona Chronic Disease Plan

19

diseases of the heart (25.9%), malignant neoplasms
(22.4%), and cerebrovascular disease (6.5%).”

11

• “An estimated 65% of adults in the United States are
overweight or obese.”

12

obese.11

urban and rural communities, Asian, African American,

bisexual/transsexual populations.18 Also, between
November 2004 and March 2005, over 40 focus groups

• “The obesity rate among Arizona adults increased by
11

representing Arizonans 65 years of age and over were held
by the Governor’s Council on Aging to provide input for

• “More than 60% of American adults do not get
enough physical activity to provide health benefits
and 26% are not active at all.” 13

the Aging 2020 Plan.
Many common themes surfaced during the focus
groups. The commonalities often identified the broader

• In 2003, prevalence data indicated that 21.2% of
Arizonans did not engage in any physical activity.14
• “An estimated 45.8 million adults in the United
States smoke cigarettes even though this single
behavior will result in death or disability for half of

elements of the system of care and how responsive or
unresponsive that system was to the needs of the
individual groups. Common issues such as the need for a
greater focus on prevention and early detection of chronic
disease, culturally responsive health care and health

all regular smokers.” 15
• Each year, approximately 440,000 people die due to

education, strategies to address uninsured/underinsured,
and access to care (primary and specialty) surfaced across

tobacco-related diseases, which calculates to
20

populations throughout the state. Participants represented

Hispanic, Native American, White, and gay/lesbian/

• In Arizona, 57.1% of adults are overweight or

80% from 1990 to 2002.”

discuss the issues related to chronic disease and minority

approximately 20% of all deaths in the United

the groups. The results of the touch point comparison of

States.16

the disease entities as well as the results of the focus

• “If current smoking patterns continue, 6.4 million
people currently younger than 18 will die
prematurely from a tobacco-related disease.”

groups indicate a clear need for addressing these common
elements through a coordinated, comprehensive, and

16

integrated plan.

• The 2002 prevalence rate for Arizona adults who
smoke was 20%.17

Health Disparities
There are distinct differences in the rates of mortality

The Need for an Arizona
Chronic Disease Plan
Reviewing the objectives and strategies among the

and morbidity for certain populations and racial and ethnic
groups. While there are a number of common themes
within the health-related issues for these groups, the

disease-specific entities, it becomes evident that there are

solutions for these common issues may be different due to

many commonalities that overlap the disease categories

the varied needs, cultural diversity, and geographic

such as common risk factors, service delivery

locations relevant to the specific group(s). There may also

methodologies, intervention sites, target populations, and

be targeted issues that pertain only to certain populations.

need for common messages.
Between September 2004 and April 2005, seven focus
groups were held in conjunction with the Chronic Disease
Disparities in Arizona Conference (April 13–15, 2005) to

In addition to the common issues, the chart to the
right depicts examples of specific issues as identified by
each group.

IV

• Critical health issues: hypertension, diabetes, high cholesterol, prostate
and breast cancer

The Plan

African American Community (Phoenix, AZ)

• Sickness viewed as a sign of weakness
• Credibility is increased when information comes from person of same race and gender
• Males tend to not seek medical attention
• Wellness programs are well-received when connected to churches

H i s p a n i c C o m m u n i t i e s ( Yu m a a n d S o u t h Tu c s o n , A Z )
• Critical health issues: heart disease, diabetes, stroke, and hypertension
• Language barriers; lack of translation services in hospitals
• Immigrant status – legal v.s. non-legal
• In border communities, prefer to cross border to Mexico for health care
• Males tend to not seek health care
• Need for more lay health workers/promotoras

21

R u r a l C o m m u n i t i e s ( C o t t o n w o o d a re a )
• Critical health issues: cardiovascular disease and cancer
• Geographic isolation; lack of transportation to providers
• Socio-economic disparities – includes very wealthy and very low income
• Underserved and high rate of uninsured
• Limited health resources
Native American Population (Native American Community Health
Center (NACHC), Indian Health Service)
• Critical health issues: diabetes and obesity
• Native American provider for Native American clients is very important
• Cultural differences, language barriers
• Distance and transportation are challenges in access to services
• Cultural belief that discussing disease puts them at risk for transmission

The Arizona Chronic Disease Plan

A s i a n C o m m u n i t y ( M e t ro P h o e n i x , A Z )
• Critical health issues: hepatitis B/liver cancer, cardiovascular disease (hypertension,
stroke, diabetes), cervical cancer, and tobacco
• Lack of general preventive health information
• Unaware that risk for breast cancer significantly increases for Asian women who have
been in U.S. for 10 years or more
• Language barriers
• Medical interpreters needed
• Demographically dispersed
• Potential contradictions between Western medicine and Eastern medicine (homeopathic,
acupuncture, etc.)

A g e 6 5 Ye a r s a n d O v e r, A g i n g 2 0 2 0 F o r u m

22

• Critical health issues: heart disease, cancer, cerebrovascular disease,
chronic respiratory disease, and Alzheimer’s disease
• Need for a single point of access to information and services
• Identify and disseminate models to learn about healthy aging
• A focus on prevention will require public education campaigns for lifelong education
and healthy lifestyle education, active lifestyle programs, health information
• Increase use of computer and Internet based information (make programs
less intimidating to older adults)
• Prioritize and educate about chronic diseases as they relate to high-risk populations

G a y / L e s b i a n / B i s e x u a l / Tr a n s s e x u a l ( G L B T ) ( W i n g s p a n – Tu c s o n , A Z )

• Critical health issues: no cancer screening; health programs tied to HIV/STD screening
• Health movement does not exist unless focused on HIV
• Data is not collected specific to GLBT
• Lack of provider education about lesbian health
• Healthcare is the number one problem for transsexual community

IV
of the Native American and the general U.S.
population. “Health gains among Indians have
slowed or ceased altogether in recent years as
disease patterns have changed. Injuries, chronic
disease, and behavior-related diseases have emerged

• Share information, resources, and technical
assistance among all stakeholders
• Provide information and training to tribes
regarding the available telemedicine options

The Plan

Significant disparities exist between the health

• Encourage the design and implementation of
programs that address access to care issues
such as transportation, insurance applications

as new challenges. The new disease patterns are

procedures, and alternative medicine resources

associated with consequences from poverty and
• Explore available options for expanding
cultural dislocation. Inadequate education, high
rates of unemployment, and discrimination all
contribute to unhealthy lifestyles and disparities in
access to care.”

19

traditional medicine programs
• Find innovative ways to address the health care
provider workforce challenges.

Native Americans born today have

a life expectancy of 72.9 years as compared with the
life expectancy of 76.5 for all races in the U.S., an
almost four year difference.

20

In Arizona, the

The Cost of Not Taking Action
Americans are living longer due to advances in
science and medical technology and improvements

disparity in life expectancy between Native

in living conditions. Life expectancy has increased

Americans and all Arizonans is even more striking.

from 59 years of age in 1950, to 77 years of age

In 2003, the average age at death from all causes in

today. The percentage of the population over age 65

Arizona was 71.2 for all Arizonans compared with

years has significantly increased and will continue

54.7 for Native Americans, more than a 16 year

to rise. Since 1900, the number of people in

difference.

21

America age 65 years or older has increased from

In April 2003, ADHS published a Report of the
Arizona Native American Primary Care Resources

three million to nearly 35 million and this number is
expected to double to 70 million in the next 30

22

Workshop/Forum Series, which was a summary of

years. Because health care needs of older adults are

work conducted during the summer of 2002

usually greater than younger adults, medical costs

regarding the primary care resource needs of the

can be expected to increase with the growing

Native American population in Arizona. Some of

numbers of adults over age 65 years.23

the key recommendations from that report are:
• Support and expand data sharing agreements
and encourage collaboration among data

The growing number of adults over the age of 65
years, the cost of improvements in medical
technology, and inflation have all contributed to the

holders to prevent fragmentation and improve
data validity
• Encourage and support inter-tribal partnerships
and collaboration

The Arizona Chronic Disease Plan

23

rising costs of health care. If current trends
continue, by 2011, we can expect to be spending
over 2.8 trillion dollars nationally on health care.

• “In 2000, the total cost of obesity in the United
States was estimated to be $117 billion, of
which $61 billion was for direct medical costs
and $56 billion was for indirect costs.”

26

With a public health focus that emphasizes
prevention as a priority, we can become a healthier

• “Each year, over $33 billion in medical costs
and $9 billion in lost productivity due to heart

society and enjoy five to seven additional years of

disease, cancer, stroke, and diabetes are

healthy life if we improve access to quality health

attributed to diet.”

26

care, emphasize healthy lifestyles, and focus on
reaching the greatest number of people at the lowest
cost through effective policies and strategies.24
Chronic disease is not an inevitable result of the

Estimated cost of physical inactivity.
• Blue Cross Blue Shield of Minnesota did a
study calculating the dollars required to treat

aging process. In many cases, chronic disease is the

the results of inactivity for its members.

result of preventable, behavioral practices that, over

“Using a ‘cost of illness’ approach to medical

time, significantly increase an individual’s risk for

expenses for particular diseases, the study found
that heart disease was the most expensive result

any one of a number of chronic diseases. Evidence

24

of a sedentary lifestyle, costing $35.3 million in

indicates that individuals will take control of their

2000. In that year, nearly 12% of depression

behavior and their health when presented with

and anxiety and 31% of colon cancer, heart
disease, osteoporosis and stroke cases were due

education and support.25

to physical inactivity. This translates to $83.6
While it is difficult to predict the cost of

million, or $56 per member.” 27

Arizona’s not taking action, there is ample national
• “In 2000, health care costs associated with
and state-specific evidence regarding the cost and

physical inactivity were more than $76 billion.” 26

impact of the primary risk factors for chronic
disease (i.e., poor dietary habits, physical inactivity,
and use of commercial tobacco products).

Estimated cost of poor dietary habits.

Estimated cost of commercial
tobacco use.
• “Direct medical expenditures attributed to
smoking total more than $75 billion per year.

• “Among children and adolescents, annual
hospital costs related to obesity were
$127 million during 1997–1999 ...up from
$35 million during 1979–1981.”

26

In addition, smoking costs an estimated $80
billion per year in lost productivity.”

28

• “About 14% of all Medicaid expenditures are
for smoking-related illnesses.” 7
• “Even if current tobacco use stopped, the
residual burden of use among past users would
cause disease for decades to come.”

29

IV
Each categorical plan presents a statewide

reduce their risk for chronic disease. CDC estimates

guideline for reducing the impact of chronic disease

that with as little as a 10% weight loss, an overweight

in Arizona from a disease-specific and/or risk factor

person can reduce their lifetime medical costs by as

perspective and will continue to function in that

much as $2,200 –$5,300, and if 10% of adults would

capacity. The goal of the AzCD Plan is to enhance

begin a walking program, $5.6 billion dollars in heart

the impact of these categorical plans by identifying

disease costs could be saved. 26 Additionally, smokers

common, cross-cutting objectives and strategies.

who stop smoking reduce the potential medical

The intent in identifying these overlapping areas is

costs associated with cardiovascular disease by

to maximize the effectiveness of implementing

approximately $47 the first year and $853 during the

cross-cutting strategies to achieve a synergistic

following seven years.16

effect. In other words, by working together, the

How This Plan is Different
This plan is different from many other planning
documents. The scope of the plan is very broad,
encompassing several distinct disease categories:
heart disease, cancer, lung disease (COPD), stroke,
and diabetes, and the risk factor categories of poor
nutrition, physical inactivity, and use of commercial
tobacco products. Each of the disease-specific
entities has developed a comprehensive and
integrated planning document that outlines
evidenced-based objectives and strategies particular
to the disease category. The risk factor categories of
poor nutrition, physical inactivity, and commercial
tobacco use have likewise developed planning
documents that identify the key strategies for
improving healthy lifestyle behaviors and reducing
risk for chronic disease. The categorical plans were
developed by bringing together appropriate agency

The Plan

By making healthier choices, individuals can

effectiveness of each plan is enhanced and the
overall results are potentially greater than what each
plan is able to accomplish individually. The
elements of systems coordination, collaboration, and
integration are critical to the success of this new
approach to chronic disease management and
prevention.
The overall planning process for the AzCD Plan
was unique in that it did not follow the typical
strategic planning format of needs assessment,
internal/external review, SWOT analysis,
establishment of goals and objectives. These aspects
of a typical planning process were accomplished in
the development of the individual categorical plans.
The goal of the AzCD Plan was to effectively merge
the many elements of the categorical plans into a
coordinated, cohesive, and integrated model of the
proposed system of care for the prevention and
management of chronic disease in Arizona.

and community partners, utilizing best practice
standards and guidelines, and conducting assessment
of state and community needs.

The Arizona Chronic Disease Plan

25

In the development of the AzCD Plan, a number
of matrices were used to visually represent those

the needs of the population. This plan represents

commonalities across the categorical plans.

ADHS’ efforts to approach chronic disease from a

Common areas were identified in service delivery

more comprehensive and integrated perspective. It

methodologies, risk factors, target populations,

is an innovative approach that is reflected in national

common messages, and intervention sites. (See

public health programs. The plan is an initial phase

Appendix A.) These matrices were also useful in

in the Department’s long-term commitment to

identifying contradicting areas and/or gaps in

reducing the impact of chronic disease in Arizona.

strategies. An important aspect of this analysis was

It is meant to be a guide for encouraging

to ensure that the common messages were consistent

collaboration among state agencies and community

and that overlapping strategies were not in conflict.

stakeholders in working together to combat the most

We recognize that the AzCD Plan does not
include all chronic diseases. However, it does
address the current four leading causes of mortality:
heart disease, cancer, lung disease, and stroke, and
diabetes and asthma, which are among the most
common and costly chronic diseases. Diabetes, in
26

advances in science and technology, and changes in

addition to being a disease category, is also a
significant risk factor for cardiovascular disease. In
addition to the disease-specific categories mentioned
above, the plan also includes the primary risk factors
of commercial tobacco use, poor nutrition, and
physical inactivity that impact the above disease
categories and many other chronic diseases.
Promoting a healthy lifestyle that includes good
nutrition, physical activity and no commercial
tobacco use will also positively impact many chronic
diseases not specifically addressed in the plan.
It is anticipated that additional disease categories
will be added to the AzCD Plan over time and that
priorities will be revised to reflect current trends,

common disease-related causes of mortality and
morbidity in Arizona.

Purpose of the Plan
Create a paradigm shift. The AzCD Plan shifts
the focus of chronic disease management and
control from the more traditional disease-specific
emphasis to a more comprehensive and integrated
risk factor approach. It reflects a paradigm shift in
how we think about chronic disease and what
methodologies are used in reducing the overall
impact of these diseases in our society.

Provide direction. The plan provides a clear
direction for addressing the issues of chronic disease
prevention and early detection in Arizona. Key
cross-cutting strategies will be identified in the
primary risk factor areas and in the disease-specific
priority areas.

IV
The Plan
27

28

IV
initial funding priorities, specifically for the
Proposition 303 Tobacco Tax chronic disease fund.

small projects or segments of larger projects to
implement.

Description of Categorical Plans

The plan provides direction for the allocation of
these funds over the next three-year period. Per
Arizona Revised Statutes, these funds are to be used
“for the prevention and early detection of the four

The Plan

Set funding priorities. The plan identifies

There are six programs plans involved in the
development of the AzCD Plan:
1. Arizona Cardiovascular Disease Prevention
Plan

leading disease-related causes of death in this state,
as periodically determined by the Centers for Disease

2. The Arizona Comprehensive Cancer
Control Plan

Control and Prevention, or its successor agency.
Initially, these are cancer, heart disease, stroke and
pulmonary disease.” (Statutory reference –
Appendix B.)

Ensure ongoing assessment and evaluation.
The plan provides a consistent vehicle for ongoing
assessment of chronic disease programs and a
system for evaluating the effectiveness of strategies

3. Lung Disease Plan for the State of Arizona
4. Diabetes Prevention and Control
Program Plan
5. Arizona Nutrition and Physical Activity Plan
6. Tobacco Education and Prevention Program
Plan
Each program has developed a plan using widely

designed to reduce the burden of chronic disease. It

accepted national standards and evidenced-based

includes a plan for periodic review that consists of

strategies. The categorical plans were developed

evaluation and revision of established priorities,

using a variety of methodologies and formats due

timeframes, and strategies.

to many factors such as availability of resources

How to Use This Document

and timeframes, and requirements of specific
grants and funding streams. A conscious decision

The objectives and strategies in the AzCD Plan
was made not to require any specific structure or
are not meant to be mandates, but rather a guide to
format in the development of the individual plans,
assist communities and organizations in
implementing strategies locally. Examples of
current projects and community initiatives are
described. Suggestions and opportunities are
provided for communities and organizations to
become involved in systems change at the local level
to the extent that is feasible based on their current

but rather allow the workgroups and subcommittees
to develop the individual plans based on identified
needs.

Arizona Cardiovascular Disease Prevention
Plan. The goal of the Arizona Cardiovascular
Disease (CVD) Prevention Plan is to create an

resources. Communities are encouraged to select

The Arizona Chronic Disease Plan

29

integrated and comprehensive state action plan to

coordinated approach to reduce the incidence,

increase the cardiovascular health of all Arizonans

morbidity, and mortality of cancer through

and decrease the burden of heart disease and

prevention, early detection, treatment,

cerebrovascular disease. The CVD Prevention Plan

rehabilitation, and palliation.”

will establish a community partnership in order to

achieved through a partnership of public and

share existing data and ideas. Through this

private stakeholders who hold the common mission

partnership it will be possible to assess the status

of reducing the overall burden of cancer. ADHS,

of CVD in Arizona in relation to health education,

in conjunction with partners, has developed a

health status and policy. The plan focuses on

statewide comprehensive cancer control plan.

secondary prevention for those individuals who

Partners include: American Cancer Society, the

have been diagnosed with some form of CVD. The

University of Arizona’s Arizona Cancer Center and

prevention and education strategies are aimed at

College of Public Health, Arizona Health Care Cost

decreasing the risk of a second CVD event such as

Containment System, American College of

a stroke or a heart attack. It also focuses on

Surgeons, Arizona Oncology Nursing Society,

reducing the disability associated with CVD.

Phoenix Indian Medical Center, Translational

The emphasis of the CVD Prevention Plan is
secondary prevention. Categories for the
30

29

CCC is a process

Genomics Research Institute (TGen), and many
more organizations.

secondary prevention objectives and strategies are

Chronic Lung Disease Plan for the State

primarily intervention targets and/or sites such as:

of Arizona. The Chronic Lung Disease Plan for

individual interventions, community, education,

the State of Arizona has two components: a plan

health care system (hospitals, providers, first

addressing chronic obstructive pulmonary disease

responders), work site, policy and environmental

(COPD) and a plan addressing asthma. The overall

changes, health marketing, disparities, and

goals of the COPD Plan are to reduce the

surveillance.

proportion of adults in Arizona whose activity is

Arizona Comprehensive Cancer Control
Plan. The goal of the Arizona Comprehensive
Cancer Control (CCC) Plan is to reduce the overall

limited due to chronic lung disease and reduce
deaths from COPD among Arizona adults.
The primary goals for the Asthma Plan are to

burden of cancer through the prevention, early

reduce asthma deaths in Arizona, asthma-related

detection, and effective treatment of cancer, and

hospitalizations and emergency department visits,

improving the quality of life of those living with
cancer through a statewide system of care.
According to the CDC, CCC is “an integrated and

IV
prevention, the most recent standards of care and

and workdays.

best practices, health systems improvements

ADHS initiated the development of these plans

through on-site chart audits, staff training and

with the intent of setting priorities by formulating

evaluation, and training of community health

objectives and suggesting strategies to address

workers in diabetes self-management skills. The

chronic obstructive pulmonary disease and asthma

population they serve is culturally diverse and

as serious public health issues in Arizona.

usually lacks access to care. The plan targets

The Chronic Lung Disease Plan for the State of
Arizona (both COPD and Asthma) used a
combination of disease specific and system

at-risk populations, persons living with diabetes,
and their families.
The Diabetes Prevention and Control Program

intervention strategies. The COPD categories for

Plan components include: identifying and reducing

the objectives and strategies included:

health disparities in the Hispanic and Native

epidemiology and research, treatment and

American populations, establishing linkages to

management, consumer education and quality of

promote wellness and physical activity, as well as

life, prevention, disparity, collaborative efforts,

measurement procedures to track program success,

advocacy, and public awareness. Asthma

reducing the number of new cases and end-stage

incorporated most of the above categories as well,

renal disease related to diabetes, and decreasing the

except that prevention was changed to secondary

number of persons with diabetes that receive lower

prevention and school childcare issues was added

extremity amputations.

to the list of objectives.

Diabetes Prevention and Control Program

The Diabetes Prevention and Control Program
Plan used the Ten Essential Public Health Services

Plan. The goal of the Diabetes Prevention and

as the framework for developing strategies. There

Control Program Plan is to reduce the burden of

were three subcommittees who worked on

diabetes in the state of Arizona. Much of this

developing the strategies: Surveillance, Education,

burden can be prevented with early detection,

and Advocacy. Each of the strategies were then

improved delivery of care, and better education on

linked to the appropriate Essential Public Health

diabetes self-management. The program is

Service.

committed to providing communities statewide

The Plan

and the number of asthma-related missed school

Arizona Nutrition and Physical Activity

with technical assistance and support resources to

Plan. The goals of the Arizona Nutrition and

address the quality of life for people living with

Physical Activity (NUPA) Plan are to reduce the

diabetes. The Diabetes Program provides

burden of chronic disease and obesity in Arizona

continuing education to health care professionals
and lay health workers on primary and secondary

The Arizona Chronic Disease Plan

31

through nutrition and physical activity efforts. The

promoting quitting among young people and adults,

purpose of the plan is to provide guidelines for

specifically those identified who have high

schools, health care providers, communities, and

prevalence of commercial tobacco use; eliminating

work sites to address overweight and obesity in

nonsmokers’ exposure to environmental tobacco

Arizona. It also represents an opportunity to

smoke; identifying and eliminating the disparities

develop policies and modify our environments in

related to commercial tobacco use and its effects

ways that will ultimately help Arizona residents

among different population groups.29 The core

lead healthier lives. The plan provides Arizona with

elements of the plan, as found in most

a wide range of public health opportunities with

comprehensive tobacco control programs, include

objectives and strategies for action. The

preventing the initiation of tobacco use among

development of this plan demonstrates that working

youth and young adults, promoting smoking

together to address the burden of chronic disease

cessation, and reducing exposure to secondhand

and obesity are the first steps towards combating

smoke.

this problem in Arizona.
The Arizona Nutrition and Physical Activity

32

The TEPP Plan was developed primarily as an
internal operational plan. Objectives and strategies

Plan, developed by the NUPA Program, used

focused on intervention sites and/or types of

intervention sites as the focus for their workgroups.

intervention necessary to reduce the burden of

Originally there were seven workgroups consisting

commercial tobacco use, i.e., community programs,

of Family and Community, Schools, Physical

chronic disease programs, health care, school,

Environment, Health Care, Special Needs and

enforcement, statewide programs, counter-

Work Site. In the final version of the plan, health

marketing, cessation programs, surveillance and

care was incorporated into the family and

evaluation, and administration and management.

community section and the special needs objectives,

Although the plan was developed primarily by

strategies, and action steps were incorporated into

internal staff, an external advisory committee

all of the above sections of the plan.

provided input and feedback in the development of

Tobacco Education and Prevention
Program Plan. The goal of the Tobacco
Education and Prevention Program (TEPP) Plan is
to reduce disease, disability, and death related to
tobacco use by: preventing the initiation of
commercial tobacco use among young people;

the objectives and strategies.

IV
The Plan
33

V
Integration

Integration
Healthy Lifestyles
“Tobacco use is the single most preventable cause of death and
disease in our society.” 30 The role of tobacco prevention and
cessation programs is critical in the management of chronic disease.
BMI can also be calculated by multiplying weight
The burden of overweight and
(in pounds) by 705, then dividing by height (in
obesity manifests itself in
inches) twice.”
“premature death and disability,
Healthy weight for adults is defined as:
33

in health care costs, in lost productivity, and in social

BMI >18.5 < 24.9.

stigmatization.” 31 If allowed to continue, overweight

• BMI standard for “overweight” is defined as

and obesity may cause as much disease and death as
tobacco use.32
This AzCD Plan supports the promotion of healthy

BMI > 25.0 – 29.9.
• BMI standard for “obese” is defined as a
BMI ≥ 30.0. 14

lifestyles as primary prevention strategies in combating

Healthy weight for children is defined as a BMI

the key risk factors for chronic disease, i.e., poor

for age from the 5th percentile to the 85th percentile.

nutrition, physical inactivity, and use of commercial

• “Underweight” is defined as BMI-for-age

tobacco products. A healthy lifestyle includes:
maintaining healthy weight, following healthy eating
guidelines, engaging in regular physical activity, and no
use of commercial tobacco products.

Healthy weight. Body Mass Index (BMI) is used
to determine whether or not a person is overweight.
It is calculated by “dividing a person's weight (in
kilograms) by his or her height (in meters, squared).

< 5th percentile.
• “At risk/overweight” is BMI for age between the
85th – 95th percentile.
• “Obese” is defined as BMI-for-age > 95th
percentile. 34

Healthy eating. Healthy eating is defined as
(complete definition in Appendix C.):
• Making smart choices from every food group

The Arizona Chronic Disease Plan

35

• Finding your balance between food and physical
activity
• Getting the most nutrition out of your calories.

• Cross-cutting strategies, integrated approach
• Reach/impact; return on investment

A healthy eating plan is one that:

• Evidenced-based, standards, guidelines

• Emphasizes fruits, vegetables, whole grains, and
fat-free or low-fat milk and milk products

• Resources: financial, human resources,

• Includes lean meats, poultry, fish, beans, eggs,
and nuts

The matrix in Appendix D lists all of the priorities

• Is low in saturated fats, transfats, cholesterol, salt
(sodium), and added sugars
• Promotes indigenous foods grown as close to the
consumer as possible.

Physical activity. Physical activity is defined as: 35
• 30 to 60 minutes of moderate activity most days
of the week for the average adult

36

• Catalyst for change

community assets, stakeholder engagement.

submitted by the categorical plans. These priorities
were later re-configured within the context of the
framework established by the CD Team as described on
the following page.

Priorities
Once the priorities were identified from the
categorical plans, they were placed under the

• 60 minutes of moderate to vigorous activity most
days of the week for children.

appropriate intervention level of the framework

Tobacco-free.

Systems support) and divided into integrated and

• Do not use commercial tobacco products of
any kind.

disease-specific priorities. Some of the disease-

• If you use commercial tobacco products, stop as
soon as possible.

level as appropriate. The designation of integrated and

Priorities for Chronic Disease
Prevention
Selection of priorities. In the selection of
priorities for the AzCD Plan, the categorical plans were
asked to identify 5–10 priorities. Criteria for
establishing plan priorities included:

(Individual choice, Health care provider responsibility,

specific priorities appear in more than one intervention

disease-specific perspectives acknowledges both the
common areas of overlap as well as the unique aspects
of each disease category.

I. Individual Priorities
(Consumer Education)
A. Promote healthy lifestyles as primary
prevention for chronic disease.

• Ability to make a difference

Integrated:

• Needs, gaps, health disparities

• Saturate communities with consistent, culturally

• Feasibility

 Community action



State action

• Systems change, provides sustainability
• Measurable, outcome driven

sensitive and intergenerational messages
regarding healthy lifestyles

V

The CD Team reviewed the selected priorities from the categorical plans. The integrated priorities
for the plan were identified as the common overlapping areas from the categorical plans in three
functional areas:

Integration

Framework

1. Individual choice (consumer education)
2. Health care provider responsibility (provider education and training)
3. System support

System Support
• Capacity building
• Technical assistance
• Data / Surveillance
• Policy / Environmental change
• Resources / Workforce
• Access to care

37

Individual
Choices
• Make healthy choices
• Be aware – benefits
of screening & early
detection
• Take responsibility for
requesting screening
services

Education
Training

Provider
Responsibility
• Knowledge re: screening
protocols & guidelines
• Order tests according to
accepted guidelines
• Make referrals and/or
follow accepted
treatment standards

The Arizona Chronic Disease Plan

The AzCD Plan Envisions...
AN INDIVIDUAL WHO...
• Eats a healthy diet
• Maintains a healthy weight
• Engages in regular physical activity
• Abstains from or quits using commercial tobacco products of any kind
• Participates in chronic disease early detection and screening
• Actively requests referral for appropriate screening procedures from health care provider
• Complies with recommended treatment and follow-up to screening procedures
• Takes responsibility for partnering with the health care provider in making decisions about
personal health screening, diagnosis, treatment, and follow-up.

A HEALTH CARE PROVIDER WHO...
• Counsels patients regarding healthy lifestyle behaviors
• Orders appropriate screening tests based on standards of care for chronic disease
38

• Utilizes current advances in screening technology and screening protocols
• Provides information on all appropriate options for treatment and/or follow-up
for patient consideration
• Makes appropriate arrangements for treatment and/or follow-up
• Monitors patient compliance with recommended treatment and/or follow-up.

A SUPPORTIVE SYSTEM THAT...
• Creates a process for collecting accurate and timely data for surveillance
and evaluation purposes
• Promotes policy and environmental changes to support individual healthy lifestyle choices
and provider involvement in the prevention and early detection of chronic disease
• Provides technical assistance to facilitate “capacity building” and sustainability
in local communities
• Provides access to affordable, quality health care for all residents
• Promotes collaboration of advocacy groups for resolution of common
cross-cutting issues
• Strives to eliminate disparities in mortality and morbidity due to chronic disease.

V
Cardiovascular

Cardiovascular

• Increase the number of people who are aware

• Increase the number of those diagnosed with
heart and cerebrovascular disease who
participate in cardiac rehabilitation and other
formal, multidisciplinary approaches to
secondary prevention of the heart and
cerebrovascular disease
Cancer
• Reduce the risks for developing cancer among

and can recognize the signs and symptoms of a
heart attack or myocardial infarction
Cardiovascular
• Increase the number of women who are aware

Integration

Disease-Specific:

of the symptoms of a heart attack, which are
very different from the signs of a heart attack
for men
Cancer

all Arizonans by promoting and engaging in
healthy behaviors

• Promote, increase, and optimize the appropriate
utilization of high-quality cancer screening and

Lung
• Promote healthy living practices that provide
the most effective method of preventing COPD
(tobacco abstinence, periodic health checks, and
avoidance of unhealthy work environments)

follow-up services
Cancer
• Increase the proportion of women aged 40 and
over who have received a mammogram and
clinical breast exam within the past year to 70%

Lung
• Improve self-management knowledge and
behavior in people with COPD, their families
and other caregivers

by 2010
Cancer
• For adults aged 50 and over, increase the
proportion of the population who has been

B. Inform, educate, and empower consumers
regarding benefits of early detection and
the availability of screening resources.

screened for colorectal cancer using
colonoscopy, sigmoidoscopy, or fecal occult
blood test to 50% by 2010

Integrated:

Lung

• Implement health marketing campaigns

• Improve early detection and diagnosis of COPD

regarding the benefits of and options for early
detection of chronic disease
• Develop and implement a health marketing
campaign to encourage consumers to become
actively involved as partners with their health

C. Link people to needed personal health
services by developing and disseminating a
comprehensive list of resources regarding
screening, early detection and treatment
services.

care provider in initiating referrals for screening
services

Disease-Specific:
Cardiovascular

Integrated:
• Develop database of screening/early detection
resources

• Increase the number of people who are aware
and can recognize the signs and symptoms
of a stroke and know the next step that needs
to be taken

The Arizona Chronic Disease Plan

39

• Provide multi-media access for screening/early
detection resource database

Disease-Specific:
Cancer
• By 2008, increase access to quality information

Cancer
• For adults aged 50 and over, increase the
proportion of the population who have been
screened for colorectal cancer using
colonoscopy, sigmoidoscopy, or fecal occult
blood test to 50% by 2010

and patient navigation sites across the state and
identify barriers to access
Cancer
• Educate the public regarding the importance and
relevance of participating in clinical trials
Lung

Lungs
• Improve early detection and diagnosis of COPD

B. Assure competent public and personal
health care by educating providers
regarding benefits of screening and
screening benchmarks.

• Improve self-management knowledge and
behavior in people with COPD, their families

Integrated:

and other caregivers

• Train physicians on appropriate screening and
referral protocols for chronic disease

II. Health Care Provider Priorities
(Provider Training)
A. Promote screening for chronic disease
according to established guidelines.
40

Integrated:

• Encourage public health systems to develop
effective health communication and education
strategies for providers
• Increase number of health care systems that
incorporate basic skills intervention trainings as
professional development for staff and service

• Develop and disseminate adult early, periodic,

providers

screening, diagnosis, and treatment guidelines
for chronic disease

• Increase provider education and training offered
to medical students regarding disparities

Disease-Specific:
Cancer
• Promote, increase, and optimize the appropriate
utilization of high-quality cancer screening and
follow-up services

Disease-Specific:
Cancer
• Promote, increase, and optimize the appropriate
utilization of high-quality cancer screening and
follow-up services

Cancer
• Increase the proportion of women aged 40 and
over who have received a mammogram and

Cancer
• Increase the proportion of women aged 40 and

clinical breast exam within the past year to 70%

over who have received a mammogram and

by 2010

clinical breast exam within the past year to 70%
by 2010

V
Integration
41

42

V
Cancer

• For adults aged 50 and over, increase the

• Promote, increase, and optimize the appropriate

proportion of the population who has been

utilization of high-quality cancer screening and

screened for colorectal cancer using

follow-up services

colonoscopy, sigmoidoscopy, or fecal occult
blood test to 50% by 2010

Lung
• Educate health care providers to manage

Lung

patients with COPD to increase longevity and

• Improve early detection and diagnosis of COPD

quality of life and reduce exacerbation of

Lung
• Increase awareness of the medical community,

Integration

Cancer

the disease
Lung

public health officials and the general public

• Promote better care for patients with COPD in

that COPD is a serious public health problem

Arizona according to established guidelines

in Arizona

C. Educate providers regarding appropriate
referrals based on screening outcomes.

III. System Support Priorities
A. Improve data and surveillance systems.

Integrated:

Integrated:

• Train physicians on appropriate referral

• Expand existing data collection to include more

protocols for chronic disease

Disease-Specific:
Cardiovascular
• Increase the number of people that are being

specific ethnicity, socioeconomic, geographic,
and linguistic information
• Ensure adequate resources to develop and
maintain surveillance data systems

referred to the appropriate professionals to

Disease-Specific:

receive medical nutrition therapy and a formal

Cardiovascular

exercise prescription to treat high cholesterol
and high blood pressure
Cardiovascular
• Increase the number of those diagnosed with
heart and cerebrovascular disease who
participate in cardiac rehabilitation and other
formal, multidisciplinary approaches to

• Increase the number of hospitals participating in
the American Heart Association’s program "Get
With The Guidelines"
Cancer
• Create database inventory or clearinghouse for
cancer researchers in the state

secondary prevention of the heart and

Lung

cerebrovascular disease

• Establish a surveillance system to accurately

Cancer
• Educate the public regarding the importance and
relevance of participating in clinical trials

track the mortality and morbidity of COPD in
Arizona and also measure the impact on the
economy of the state

The Arizona Chronic Disease Plan

43

B. Develop policies and environmental changes
to support community and individual health
efforts.

C. Support plans and actions that support the
development of community infrastructure.
Integrated:

Integrated:
• Work with policymakers to encourage screening
and diagnostic services as benefits in existing
health plans
• Partner with governmental regulatory agencies
to manage environmental and occupational risk
factors

Disease-Specific:

• Encourage planners, developers, and
policymakers to design healthy communities
• Work with architect and engineer educators
regarding the inclusion of healthy environmental
design in curriculum
• Provide technical assistance to communities in
terms of capacity building
• Create multiple mechanisms for community

Cardiovascular

health care agencies to exchange information to

• Implement protocols whereby a paramedic/EMT

solidify a universal message/program

unit may bypass a hospital in order to transport
a stroke victim to a primary stroke center,
thereby increasing their chance for survival

D. Promote access to quality personal and
population-based health services.

Cancer

Integrated:

• Increase access to appropriate and effective

• Promote access to and provide economic

cancer diagnosis and treatment services
44

support for convenient health care, prevention,
and early detection services

Cancer
• Increase support for health care providers and




four leading causes of death: heart disease,

payers in directing those affected by cancer to

cancer, lung disease (COPD), and stroke

quality of life services
Lung

Improve access to screening services for the




Provide financial support for screening
services (four leading causes of death)

• Advocate and support policies to reduce the
prevalence of commercial tobacco use and
secondhand smoke exposure among Arizonans




Increase access to telemedicine sites around
Arizona

Lung

• Improve provider accessibility and availability

• Support research into COPD etiology and

• Set measurable clinical standards based on

clinical management, as well as health care
policies and outcomes particularly as the
activities relate to state issues

scientifically valid guidelines

Disease-Specific:
Cardiovascular
• Increase the number of hospitals participating
in the American Heart Associations program
"Get With The Guidelines"

V
Cancer

• Increase the number of primary stroke centers

• By 2007, utilize telemedicine to increase access

in AZ from six to 15
Cardiovascular

to state of the art diagnosis and treatment
techniques and expertise as well as second
opinions and resources

• Increase the number of automated external
defibrillators in the public, beginning where

Cancer

people congregate in large numbers and where

• Increase support for health care providers and

EMS availability may be delayed
Cardiovascular
• Increase the number of people that are being
referred to the appropriate professionals to

payers in directing those affected by cancer to
quality of life services
Cancer
• Promote participation in cancer clinical trials in

receive medical nutrition therapy and a formal

Arizona, specifically among underserved

exercise prescription to treat high cholesterol

populations

and high blood pressure
Cancer
• Increase access to appropriate and effective
cancer diagnosis and treatment services
Cancer
• Increase the proportion of women aged 40 and
over who have received a mammogram and

Lung
• Increase awareness of the medical community,
public health officials and the general public
that COPD is a serious public health problem in
Arizona
Lung
• Improve access to pulmonary rehab programs

clinical breast exam within the past year to

for Arizonans with COPD to prevent premature

70% by 2010

morbidity and mortality

Cancer
• For adults aged 50 and over, increase the

E. Mobilize community partnerships and
promote collaboration of advocacy groups.

proportion of the population who has been
screened for colorectal cancer using

Integrated:

colonoscopy, sigmoidoscopy, or fecal occult

• Encourage advocates for chronic disease entities

blood test to 50% by 2010
Cancer
• Educate the public regarding the importance
and relevance of participating in clinical trials

to work together
• Create multiple mechanisms for community
health care agencies to exchange information to
solidify a universal message/program

Cancer

Disease-Specific:

• Increase access to the comprehensive

Cardiovascular

management of acute, chronic, and delayed
effects of cancer and its treatments

Integration

Cardiovascular

• Support a capacity building conference,
promoting collaboration among existing
agencies in order to disseminate information
about current and developing screening methods
and tools by 2010

The Arizona Chronic Disease Plan

45

F.

Monitor health status to identify and strive
to reduce disparities.

These funds give Arizona a unique opportunity to

Integrated:

prevention and early detection of the four leading

• Ensure that all Arizonans receive quality

causes of death, but does it in an innovative manner

screening, diagnostic, and treatment services

design a funding stream which not only supports the

which simultaneously promotes the integration of

Disease-Specific:

resources where commonalities exist and disease

Cancer

specific initiatives where they are most needed.

• Reduce cancer disparities among Arizonans

The unique aspects of this funding allows the

Cancer

TRUST to design a system to reduce the impact of

• By Fall 2005, create a health disparities work

chronic disease and, as such, is a major strength of this

group that will research and identify current

funding source. Example A, below, shows a more

barriers to care as well as draft strategies to
reduce inequalities in cancer care

traditional model where funding streams have tended to
be very targeted, which has limited the ability to

Funding Priorities

integrate program efforts. Example B, also below,

One of the motivating reasons for developing the

demonstrates an integrated model for customizing a

AzCD Plan was to provide direction and set funding

system of care to address multiple priorities through

priorities for the Proposition 303 Tobacco Tax funds.

combined funding streams.

46

EXAMPLE

A

Tobacco
Tax $$

Community’s
Own
Resources

Community Resources
Traditional Model
Targeted Resources

Procured
Resources
Foundations/
Grants

State &
Federal $$$

EXAMPLE

B

Community Resources
Integrated Model
Transcends Targeted Resources

bac
o
T

c o Ta x
$$

Community’s
Own
Grant’s
Foundation

State
Federal
$$

V
Integration
47

Implementing an Integrated
Approach
For the purposes of this plan, an integrated approach
to the management of chronic disease requires, at a
minimum, addressing one integration priority in each

intervention modalities to more than one disease/risk
factor specific categorical area. It combines the
integrated perspective with the targeted approach to
achieve a more comprehensive and coordinated model.
As pictured on the next page, to implement an

of the three areas (Individual, Health Care Provider,

integrated model, programs would select one

and System) across at least two or more disease/risk

integration priority from each outer circle and link

factor related categories. This can be accomplished

those to two or more of the inner circle disease and/or

by initiating two or more new categorical areas

risk factor specific categories.

simultaneously or by adding a new categorical area to

State Level Action

existing services or resources.

ADHS has many health care initiatives currently in

In other words...

operation including: programs involving border health,

1) Program chooses one or more integration

children with special health care needs, minority health

priorities in each of the three areas:

and disparities, medically underserved areas, tobacco

• Individual

education and prevention, chronic disease, older adults,

• Health Care Provider

linkages with local health departments, and primary

• System

care. For a list of related ADHS programs and

2) For each of the integration priorities, the program

services, see Appendix E.

48

must cut across two or more categorical areas,
i.e., disease/risk factor related.

Community Level Action
There are also a number of communities who have
developed model integrated systems for promoting the

Add a new categorical interest
area to existing services / resources
OR

“healthy community” concept. The following are
examples of some of those programs:

Steps to a Healthier Arizona
The Steps to a Healthier US five-year cooperative

Promote two or more new
categorical areas simultaneously

agreement program funds states, cities, and tribal
entities to implement chronic disease prevention efforts
focused on reducing the burden of diabetes,
overweight, obesity, and asthma and addressing three

This approach is based on addressing chronic
related risk factors: physical inactivity, poor nutrition,
disease issues from multiple levels of integration
and commercial tobacco use.
interventions including the individual, the provider, and
finally the system of care, and linking those

V

Line up selected disease, risk factor and strategy for each level of intervention
(individual, provider, system) with the arrow. Use the resulting framework to develop

Integration

Integration Wheel
an operational plan with specific action steps, timelines and responsible individuals.

49

The Arizona Chronic Disease Plan

50

V
of input. An evaluation survey form will be included

Cochise County, Santa Cruz County, Yuma County, and

in the document. Users of the plan will be asked to

the Tohono O’odham Nation – participating in this

complete the form and submit their comments and

model of reducing chronic disease disparities. Special

feedback regarding the priorities, strategies, and

action groups in each community, consisting of

integrated model proposed in the plan.

providers, families, community organizations, and
schools, form partnerships to address chronic disease
issues in their communities. For more information on
the Steps program, see http://www.healthierus.gov

Healthy Avondale
Healthy Avondale is based on the statewide Healthy
Arizona 2010 initiative. The Healthy Avondale
program has been in existence since October 2003 and
is a partnership with ADHS, local businesses, schools,

Quarterly meetings of the CD Team. The CD
Team will meet at a minimum on a quarterly basis to:
• Present updates on the status of the
implementation of the categorical plans
• Document new integrated community initiatives
• Track data from categorical plans
• Provide ongoing CD Team assessment and
feedback of the AzCD Plan

Contract performance measures and

health care providers, community and faith-based

deliverables. Contracts issued under the Proposition

organizations, and others. The program promotes

303 funding will be monitored to track outcomes,

participation in four primary areas: healthy lifestyle

performance measures and deliverables.

choices, healthy eating, physical activity, and early

51

State level integration initiatives. New

detection and screening. The intent of the program is

integrated chronic disease organizational initiatives

to involve the entire community and build a place

within ADHS will be documented.

where all residents can live a healthier life. For more
information on the Healthy Avondale program, see
http://www.avondale.org

Evaluation

Summary
This plan represents ADHS’ ongoing commitment to
reducing the mortality and morbidity of chronic disease
through collaboration among all stakeholders. It is

Ongoing assessment and revision of

hoped that the AzCD Plan will encourage the

the AzCD Plan

development of partnerships among state agencies,

Over the next three years, the AzCD Plan will be

Integration

There are several border communities in Arizona –

policy and decision makers, communities,

monitored on an ongoing basis through various

organizations, health care providers, and consumers to

methods with revisions made as needed. Outlined

promote a comprehensive and integrated approach to

below are some of the assessment strategies that will be

improving the health of all Arizonans.

implemented.

Annual review. There will be a review of the
AzCD Plan on an annual basis based on several sources

The Arizona Chronic Disease Plan

VI
Appendix A

Appendix A:
Sample Matrices

SERVICE DELIVERY

PROGRAM CATEGORY
NUTRITION/
PHYSICAL
ACTIVITY

HEART

STROKE

CANCER

LUNG

SCREENING & DETECTION

X

X

X

X

SECONDARY PREVENTION

X

X

DIAGNOSIS & TREATMENT

X

X

X

X

MASS MEDIA / HEALTH
MARKETING

X

X

X

X

X

X

X

POLICY / ENVIRONMENTAL
CHANGE

X

X

X

X

X

X

X

ADVOCACY

X

X

X

HEALTH EDUCATION
(CONSUMER)

X

X

X

X

X

PROVIDER EDUCATION

X

X

X

X

INFRASTRUCTURE / DATA
SURVEILLANCE

X

X

X

ACCESS TO CARE

X

X

X

DIABETES

TOBACCO

X
X
X

X

X
X

X

X
X

X

X

X

X

X

X

X

RESEARCH

X

X

X

FINANCIAL / INSURANCE
ISSUES

X

X

X

X
X

QUALITY OF CARE

X

X

X

X

X

X

X

COLLABORATION

X

X

X

X

X

X

X

FUNDING / GRANTS

X

X

X

TOBACCO CONTROL

X

X

X

X
X

CULTURAL COMPETENCY /
SENSITIVITY

X
X

X

INTERVENTION SITES

PROGRAM CATEGORY
HEART

STROKE

SCHOOLS

NUTRITION/
PHYSICAL
ACTIVITY

TOBACCO

X

X

X

X

X

X
X

X

CANCER

LUNG

X

DIABETES

WORK SITES

X

X

X

X

COMMUNITY & FAMILY

X

X

X

X

X

HEALTH CARE SYSTEM

X

X

X

X

X

X

The Arizona Chronic Disease Plan

53

PROGRAM CATEGORY
HEART

PREVENTION
& EARLY
DETECTION

54

MESSAGES

NUTRITION

PHYSICAL
ACTIVITY

• Cholesterol screening
• BP screening
• Work site health
screenings

STROKE

• Cholesterol screening

• Sun protection

• BP screening

• Colon cancer screening

• Work site health
screenings–Stroke
Check

• Breast cancer screening

• 5 A Day

• 5 A Day

• AZ Nutrition Network

• AZ Nutrition Network

• BMI

• BMI

• P.L.A.Y.

• P.L.A.Y.

• W.E.L.L.

• W.E.L.L.

• Work site programs

• Work site programs

• Physical education in
schools

• Physical education in
schools

• Cervical cancer screening
• Prostate cancer screening

• 5 A Day
• Fiber
• Kilocalories
• Low-fat

• Moderate activity:
30 – 60 minute/day
5 days per week

• Abstain or
moderate intake

ALCOHOL

TOBACCO

CANCER

• Smoking cessation

• Smoking cessation

• Smoke-free
environments

• Smoke-free
environments

• Smoking prevention,
cessation, & secondhand smoke
• “Quit line” for AZ

VI

LUNG

DIABETES

• ABCs of Diabetes
• Periodic health checks
• Avoid unhealthy work
environments

• Decrease: Hb-A-1C
level BP Cholesterol
• Foot exams
• Eye exams

NUTRITION /
PHYSICAL ACTIVITY

TOBACCO

• Culturally sensitive &
intergenerational
media messages
re: preventive
screening, healthy
weight & physical activity

Appendix A

PROGRAM CATEGORY

• Healthy eating; healthy
lifestyles
• Achieve & maintain
healthy weight

• Encourage work site
breast-feeding policy

• BMI

• BMI
• 5 A Day
• Portion Control

• P.L.A.Y.

55

• Physical activity;
healthy lifestyles

• Abstain

• “Go Cold Turkey”
• Cessation for Diabetics
• “Inhale Life”;
“Be Tobacco Free”
• Tobacco abstinence

• Reduce / abstain

• Native American
“Breathe Tradition,
Respect Tobacco”
• Spanish language–
“Respire Vive”
• African & Asian – “Ashes to
Ashes – be tobacco free”

The Arizona Chronic Disease Plan

ANALYSIS OF CATEGORICAL PLAN OBJECTIVES (sample)
CARDIOVASCULAR

• Increase numbers of
Arizonans who know their
cholesterol numbers

CANCER

• Routine oral cancer
screening
• Skin self exams

• Increase numbers of
Arizonans who know their
BP numbers

PREVENTION & EARLY DETECTION

56

ANALYSIS OF OBJECTIVES (sample)

• Increase numbers of
physicians who follow
guidelines for cholesterol
screening & treatment
• Increase numbers of
physicians who follow
guidelines for BP
screening & treatment
• Increase numbers of
physicians & EMTs who
follow triage guidelines
for stroke
• Follow “Barbershop
Hypertension Screening
Program” re: identifying
hypertension in
African Americans

• Increase numbers of
Arizonans who use
effective sun protection
• Promote use of American
Cancer Society guidelines
• Develop consistent
screening guidelines for
colon cancer
• Consistent standards for
all populations
• Screening tool for lung
cancer
• Increase to 70% women
40 yrs+ who had breast
exam & mammogram
within past year
• Prostate cancer
screening for high-risk
groups
• Adults 50+, increase
colorectal screening to
50%
• Women 18yrs+, increase
pap test to 95%
• Total body screening
for skin cancer

LUNG (COPD)

• Reduce exposure to
environmental and
occupational risk factors
• Improve early detection &
diagnosis of COPD
• Promote healthy living
practices
• Reduce exposure to
environmental &
occupational risk factors
• Develop practical &
feasible list of indicators
for spirometry
• Encourage PCPs to
perform office spirometry
for all patients who report
smoking or have
symptoms of COPD
• Develop consensus for
severity assessment
criteria

VI

DIABETES

• The Diabetes Prevention
and Control Program is
mandated to lead
diabetes-related secondary
and tertiary prevention

NUTRITION /
PHYSICAL ACTIVITY

• Saturate communities
with culturally sensitive
& intergenerational
messages re: preventive
screening, healthy weight &
physical activity
• Streamline and focus
obesity prevention efforts
in AZ

TOBACCO

• Fund early detection
screenings of COPD,

Appendix A

ANALYSIS OF CATEGORICAL PLAN OBJECTIVES (sample)

• Increase number of health
care professionals who
provide intervention
messages and encourage
cessation to clients
• Promote Public Health
Cessation Standards
through health care
provider trainings

57

The Arizona Chronic Disease Plan

58

Courtesy of Heard Museum

VI

Arizona Revised Statutes
Title 36 Public Health and Safety
Chapter 6 Public Health Control
A r t i c l e 8 To b a c c o Ta x F u n d s
36-770. Tobacco products tax fund
(Caution: 1998 Prop. 105 applies)
A. The tobacco products tax fund is established
consisting of revenues deposited in the fund pursuant to
section 42-3251.01 and interest earned on those
monies. The Arizona health care cost containment
system administration shall administer the fund.

Appendix B

Appendix B:

3. Are exempt from the provisions of section 35-190
relating to lapsing of appropriations.

36-771. Tobacco tax and health
care fund
A. The tobacco tax and health care fund is established.
The fund consists of all revenues deposited in the fund
pursuant to sections 42-3252 and 42-3302 and interest

B. Forty-two cents of each dollar in the fund shall be

earned on those monies. On notice from the

deposited in the proposition 204 protection account

department, the state treasurer shall invest and divest

established by section 36-778.

monies in the fund and in all accounts in the fund as

C. Five cents of each dollar in the fund shall be

provided by section 35-313, and monies earned from

deposited in the health research fund established by

investment shall be credited to the fund.

section 36-275.

B. The fund shall be deposited in four separate

D. Twenty-seven cents of each dollar in the fund shall

accounts and shall be administered pursuant to the

be deposited in the medically needy account

provisions of and for the purposes prescribed by this

established by section 36-774.

article.

E. Twenty cents of each dollar in the fund shall be

C. Except as provided by subsection F of this section,

deposited in the emergency health services account

the fund and its accounts are not subject to

established by section 36-776.

appropriation. Expenditures from each account are not
subject to additional approval, notwithstanding any

F. Four cents of each dollar in the fund shall be

statutory provision to the contrary.

deposited in the health care adjustment account
established by section 36-777.

D. Monies in the fund and its accounts:

G. Two cents of each dollar in the fund shall be

1. Do not revert to the state general fund under any

deposited in the health education account established

circumstances.

by section 36-772.

2. Are exempt from the provisions of section 35-190

H. Except as provided in section 36-776, monies in the

relating to lapsing of appropriations.

fund:

E. Monies in the fund:

1. Are continuously appropriated.

1. Shall be spent only for purposes that are

2. Do not revert to the state general fund.

authorized by this article.

The Arizona Chronic Disease Plan

59

2. Shall not be used for expenditures on capital

(a) Contracts with county health departments,

construction projects, lobbying activities involving

qualifying community health centers as defined in

elected officials or political campaigns for

section 36-2907.06, Indian tribes, accredited

individuals or any ballot proposal.

schools, nonprofit organizations, community

F. Notwithstanding any other provision of this section,
the legislature may appropriate monies from the fund to

colleges and universities for education programs
related to preventing and reducing tobacco use.

the department of revenue for the reasonable

(b) Administrative expenditures related to

administration and enforcement costs of the department

implementing and operating a program developed

in administering the levy of taxes that are dedicated to

pursuant to subdivision (a) to award and oversee

the fund pursuant to section 42-3252. The

contracts for education programs including

appropriation shall be applied before monies are

obtaining expert services to assist in evaluating

deposited in the fund accounts. Any unused monies at

requests for proposals and responses to those

the end of the fiscal year revert to the fund.

requests.
(c) Department of health services expenditures for

36-772. Health education account;
audit; reports

developing and delivering education programs that

(Caution: 1998 Prop. 105 applies)

including radio, television or print media costs.

A. In addition to the monies deposited pursuant to
section 36-770, twenty-three cents of each dollar in the
tobacco tax and health care fund shall be deposited in
60

the health education account for programs for the
prevention and reduction of tobacco use, through public
health education programs, including community based
education, cessation, evaluation and other programs to
discourage tobacco use among the general population
as well as minors and culturally diverse populations.

are designed to prevent or reduce tobacco use
When contracting for the development and
production of original advertising materials, the
department shall require advertising, production and
editorial firms to use their best efforts to employ or
contract with residents of this state to manage,
produce and edit the original advertising. The
department shall report annually by December 1 to
the governor, the president of the senate and the
speaker of the house of representatives regarding
instances when the department did not employ or

B. The department of health services shall administer

contract with residents of this state, including the

the account.

reasons for failing to do so.

C. Except as provided in subsection D of this section,

(d) The evaluations required by subsection F of this

monies that are deposited in the health education

section.

account:

D. The department of health services shall use monies

1. Shall be used to supplement monies that are

deposited in the account pursuant to section 36-770 for

appropriated by the legislature for health education

the prevention and early detection of the four leading

purposes and shall not be used to supplant those

disease related causes of death in this state, as

appropriated monies.

periodically determined by the centers for disease

2. Shall be spent for the following purposes:

control and prevention, or its successor agency.
Initially, these are cancer, heart disease, stroke and
pulmonary disease. The monies shall only be used to
supplement monies that are appropriated by the

VI
needy account to provide health care services to

appropriated monies.

persons who are determined to be eligible for services

E. Monies from the health education account shall not
be spent for lobbying activities involving elected
officials or political campaigns for individuals or any
ballot measure.

pursuant to section 36-2901.01 or 36-2901.04 as
provided by the Arizona health care cost containment
system pursuant to chapter 29, article 1 of this title or
any expansion of that program or any substantially
equivalent or expanded successor program established

F. The department of health services shall evaluate the

by the legislature providing health care services to

programs established pursuant to subsection C,

persons who cannot afford those services and for whom

paragraph 2 of this section and shall biennially submit

there would otherwise be no coverage. These services

a written report of its findings to the governor, the

shall include preventive care and the treatment of

president of the senate and the speaker of the house of

catastrophic illness or injury, as provided by the

representatives. The department of health services shall

Arizona health care cost containment system.

provide a copy of each report to the secretary of state
and the director of the Arizona state library, archives
and public records. The department of health services
shall submit its first report on or before November 15,

Appendix B

legislature and shall not be used to supplant those

B. The Arizona health care cost containment system
administration or any successor shall administer the
account.

2004. The first report shall include data beginning in

C. Monies that are deposited in the medically needy

fiscal year 2001-2002

account:
1. Shall only be used to supplement monies that are

36-773. Health research account

appropriated by the legislature for the purpose of

A. Five cents of each dollar in the tobacco tax and

providing levels of service that are established

health care fund shall be deposited in the health

pursuant to chapter 29, article 1 of this title to

research account for research on preventing and

eligible persons as defined in section 36-2901 or

treating tobacco-related disease and addiction.

any expansion of those levels of service, or for any

B. The Arizona disease control research commission
shall administer the account.

successor program established by the legislature
providing levels of service that are substantially
equivalent to, or expanding, those provided pursuant

C. Monies that are deposited in the health research

to chapter 29, article 1 of this title to eligible

account shall only be used to supplement monies that

persons.

are appropriated by the legislature for health research
purposes and shall not be used to supplant those
appropriated monies.

2. Shall not be used to supplant monies that are
appropriated by the legislature for the purpose of
providing levels of service established pursuant to
chapter 29, article 1 of this title.

36-774. Medically needy account;
definition
A. Seventy cents of each dollar in the tobacco tax and
health care fund shall be deposited in the medically

D. For purposes of this section, "levels of service"
means the provider payment methodology, eligibility
criteria and covered services established pursuant to
chapter 29, article 1 of this title in effect on July 1,
1993.

The Arizona Chronic Disease Plan

61

36-775. Adjustment account
A. Two cents of each dollar in the tobacco tax and

account.

health care fund shall be deposited in the adjustment

B. The department of revenue shall transfer appropriate

account for transfer of appropriate amounts to the

amounts of account monies to the health education

corrections fund established by section 41-1641 to

account established by section 36-772, the health

compensate for decreases in the corrections fund

research account established by section 36-773 and the

resulting from lower tobacco tax revenues available

medically needy account established by section 36-774

under section 42-3104 as a result of the levy of luxury

to compensate for decreases in these accounts due to

taxes that are dedicated to the tobacco tax and health

lower tobacco tax revenues available under section 36-

care fund pursuant to section 42-3252. Any monies in

771 as a result of the levy of luxury taxes that are

the adjustment account in excess of the amount needed

dedicated to the tobacco products tax fund pursuant to

for the adjustment revert to the tobacco tax and health

section 42-3251.01.

care fund for distribution in equal proportions to the
accounts described under sections 36-772, 36-773 and
36-774.

62

770. The department of revenue shall administer the

C. Any monies in the account in excess of the amount
needed for the adjustments prescribed in this section
revert to the tobacco products tax fund for distribution

B. The department of revenue shall administer the

in equal amounts to the accounts described in section

adjustment account.

36-770, subsections B, C, D and E.

36-776. Emergency health
services account

36-778. Proposition 204
protection account

(Caution: 1998 Prop. 105 applies)

(Caution: 1998 Prop. 105 applies)

A. The emergency health services account is

A. The proposition 204 protection account is

established consisting of monies deposited pursuant to

established consisting of monies deposited pursuant to

section 36-770. The Arizona health care cost

section 36-770. The Arizona health care cost

containment system administration shall administer the

containment system administration shall administer the

account. The administration shall use account monies

account.

solely for the reimbursement of uncompensated care,
primary care services and trauma center readiness costs.

B. The administration shall use account monies to
implement and fund programs and services required as

B. Monies in the account are subject to legislative

a result of the expanded definition of an eligible person

appropriation. Any monies remaining unexpended and

prescribed in section 36-2901.01.

unencumbered on June 30 of each year in the account
revert to the proposition 204 protection account
established by section 36-778.

C. The administration shall spend the balance of
monies in the account before it spends monies from the
Arizona tobacco litigation settlement fund established
by section 36-2901.02.

36-777. Health care adjustment
account
(Caution: 1998 Prop. 105 applies)
A. The health care adjustment account is established
consisting of monies deposited pursuant to section 36-

VI
Appendix B
63

64

VI

Arizona Department of Health Services
Healthy Eating Guidelines
The purpose of these guidelines is to ensure uniform

• Be developed utilizing social marketing approaches,

healthy eating messages are utilized in programs,

including with formative research of the target

services, and materials provided by the Arizona

audience. When formative research for a specific

Department of Health Services.

audience cannot be conducted, messages should be

Healthy eating messages and materials should:

Appendix C

Appendix C:

selected from nationally developed campaigns
including: Healthy Lifestyles from the U.S.

• Be based on the U.S. Dietary Guidelines, 6th edition,
and U.S. Food Guide.
• Be tailored to meet the specific nutrient needs of

Department of Health and Human Services; 5 A Day
from the National Cancer Institute; Eat Smart, Play
Hard from the U.S. Department of Agriculture; Verb

target populations such as children and adolescents,

from the Centers for Disease Control and Prevention;

pregnant women, breastfeeding women, and older

Milk Matters from the U.S. Department of

adults. Please refer to the Arizona Department of

Agriculture; and Small Steps, Big Rewards from the

Health Services, Office of Chronic Disease

National Diabetes Education Program.

Prevention and Nutrition Services, Nutrition

Programs, services, and materials for the general public

Standards for guidance.

should reflect the following key recommendations.

• Recommend exclusive breastfeeding for all infants
unless a specific contraindication exists.
• Reflect a 2,000 calorie per day reference intake for
sample menus, examples, and recipes unless the
materials are specifically for a target population with
differing needs (such as teen age or the older adult).
• Utilize terminology consistent with the Food Facts
Label and the U.S. Dietary Guidelines.

Adequate Nutrients Within
Calorie Needs
Key Recommendations:
• Consume a variety of nutrient-dense foods and
beverages within and among the basic food groups
while choosing foods that limit the intake of
saturated and trans fats, cholesterol, added sugars,
salt, and alcohol.

• Include foods, recipes, and cooking methods that
reflect the culture of the target audience.

• Meet recommended intakes within energy needs by
adopting a balanced eating pattern, such as the

• Promote indigenous foods grown as close to

USDA Food Guide or the DASH Eating Plan.

consumers as possible.

The Arizona Chronic Disease Plan

65

Weight Management

Fats

Key Recommendations:

Key Recommendations:

• To maintain body weight in a healthy range, balance

• Consume less than 10% of calories from saturated

calories from foods and beverages with calories

fatty acids and less than 300 mg/day of cholesterol,

expended.

and keep trans fatty acid consumption as low as

• To prevent gradual weight gain over time, make
small decreases in food and beverage calories and
increase physical activity.

possible.
• Keep total fat intake between 20 to 35% of calories,
with most fats coming from sources of
polyunsaturated and monounsaturated fatty acids,

Food Groups to Encourage
Key Recommendations:
• Consume a sufficient amount of fruits and vegetables
while staying within energy needs. Two cups of fruit
and 2 1/2 cups of vegetables per day are

such as fish, nuts, and vegetable oils.
• When selecting and preparing meat, poultry, dry
beans, and milk or milk products, make choices that
are lean, low-fat, or fat-free.
• Limit intake of fats and oils high in saturated and/or

recommended for a reference 2,000 calorie intake,

trans fatty acids, and choose products low in such

with higher or lower amounts depending on the

fats and oils.

calorie level.
66

• Choose a variety of fruits and vegetables each day. In

Carbohydrates

particular, select from all five vegetable subgroups

Key Recommendations:

(dark green, orange, legumes, starchy vegetables, and
other vegetables) several times a week.
• Consume 3 or more ounce-equivalents of wholegrain products per day, with the rest of the
recommended grains coming from enriched or
whole-grain products. In general, at least half the

• Choose fiber-rich fruits, vegetables, and whole grains
often.
• Choose and prepare foods and beverages with little
added sugars or caloric sweeteners, such as amounts
suggested by the USDA Food Guide and the DASH
Eating Plan.

grains should come from whole grains.
• Reduce the incidence of dental caries by practicing
• Consume 3 cups per day of fat-free or low-fat milk
or equivalent milk products.
• All women capable of becoming pregnant should
consume 400 micrograms of synthetic folic acid
daily, from fortified foods or supplements, or a
combination of the two, in addition to folate in foods
from a varied diet.

good oral hygiene and consuming sugar- and starchcontaining foods and beverages less frequently.

VI



defrost foods properly.

Key Recommendations:
• Consume less than 2,300 mg (approximately 1 tsp of
salt) of sodium per day.

Chill (refrigerate) perishable food promptly and




Avoid raw (unpasteurized) milk or any products
made from unpasteurized milk, raw or partially
cooked eggs or foods containing raw eggs, raw or

• Choose and prepare foods with little salt. At the same
time, consume potassium-rich foods, such as fruits

Appendix C

Sodium and Potassium

undercooked meat and poultry, unpasteurized
juices, and raw sprouts.

and vegetables.

Alcoholic Beverages
Key Recommendations:

Messages and materials for consumers
should include these key points:
• Make smart choices from every food group.

• Those who choose to drink alcoholic beverages
should do so sensibly and in moderation—defined as
the consumption of up to one drink per day for
women and up to two drinks per day for men.
• Alcoholic beverages should not be consumed by
some individuals, including those who cannot restrict
their alcohol intake, women of childbearing age who

• Find your balance between food and physical
activity.
• Get the most nutrition out of your calories.
A healthy eating plan is one that:
• Emphasizes fruits, vegetables, whole grains, and fatfree or low-fat milk and milk products.

may become pregnant, pregnant and lactating
women, children and adolescents, individuals taking
medications that can interact with alcohol, and those
with specific medical conditions.
• Alcoholic beverages should be avoided by individuals
engaging in activities that require attention, skill, or

• Includes lean meats, poultry, fish, beans, eggs, and
nuts.
• Is low in saturated fats, trans fats, cholesterol, salt
(sodium), and added sugars.
Some general recommendations include:

coordination, such as driving or operating machinery.

Focus on fruits. Eat a variety of fruits. Choose fresh,

Food Safety

frozen, canned, or dried fruit. Go easy on fruit juice.

Key Recommendations:

Vary your vegetables. Eat more dark green
vegetables like broccoli, spinach, and other dark leafy

• To avoid microbial food borne illness:






greens. Eat more orange vegetables like carrots, sweet

Clean hands, food contact surfaces, and fruits and

potatoes, and winter squash. Eat more dry beans and

vegetables.

peas, such as pinto beans, kidney beans, and lentils.

Separate raw, cooked, and ready-to-eat foods
while shopping, preparing, or storing foods.




Cook foods to a safe temperature to kill
microorganisms.

The Arizona Chronic Disease Plan

67

Make half your grains whole. Eat at least 3 ounces

first few ingredients. Some names for added sugars

of whole-grain cereals, breads, crackers, rice, or pasta

(caloric sweeteners) include sucrose, glucose, high

every day. One ounce is about 1 slice of bread, 1 cup of

fructose corn syrup, corn syrup, maple syrup, and

breakfast cereal, or 1/2 cup of cooked rice or pasta.

fructose.

Look to see that grains such as wheat, rice, oats, or
corn are referred to as “whole” in the list of
ingredients.

trans fats, and cholesterol to help reduce the risk of
heart disease (5% DV or less is low, 20% DV or more

Go lean with protein. Choose lean meats and

is high). Most of the fats you eat should be

poultry. Bake it, broil it, or grill it. Vary your protein

polyunsaturated and monounsaturated fats. Keep total

choices with more fish, beans, peas, nuts, and seeds.

fat intake between 20% to 35% of calories.

Get your calcium-rich foods. Get 3 cups of low-fat

Reduce sodium (salt), increase potassium.

or fat-free milk—or an equivalent amount of low-fat

Research shows that eating less than 2,300 mg of

yogurt and/or low-fat cheese (1 1/2 ounces of cheese

sodium (about 1 tsp of salt) per day may reduce the

equals 1 cup of milk)—every day. If you don’t or can’t

risk of high blood pressure. Most of the sodium people

consume milk, choose lactose-free milk products

eat comes from processed foods, not from the salt

and/or calcium-fortified foods and beverages.

shaker. Also look for foods high in potassium, which

Check servings and calories. Look at the serving
68

Know your fats. Look for foods low in saturated fats,

counteracts some of sodium’s effects on blood pressure.

size and how many servings you are actually

Play it safe with food. Know how to prepare, handle,

consuming. If you double the servings you eat, you

and store food safely to keep you and your family safe:

double the calories and nutrients, including the % Daily
Values (DV).

Make your calories count. Look at the calories on
the label and compare them with what nutrients you are

• Clean hands, food-contact surfaces, fruits, and
vegetables.
• Separate raw, cooked, and ready-to-eat foods while
shopping, preparing, or storing.

also getting to decide whether the food is worth eating.
When one serving of a single food item has over 400
calories per serving, it is high in calories.

Don’t sugarcoat it. Since sugars contribute calories
with few, if any, nutrients, look for foods and beverages

• Cook meat, poultry, and fish to safe internal
temperatures to kill microorganisms.
• Chill perishable foods promptly and thaw foods
properly.

low in added sugars. Water would be a good substitute

About alcohol. If you choose to drink alcohol, do so

for sugar-containing beverages. Read the ingredient

in moderation. Moderate drinking means up to 1 drink

list and make sure that added sugars are not one of the

a day for women and up to 2 drinks for men.
Remember that alcoholic beverages have calories but
are low in nutritional value.

VI
A reference page to the DASH Eating Plan at 1,600-,

Two major studies have shown that blood pressure can
be lowered by following a particular eating plan, the
Dietary Approaches to Stop Hypertension (DASH) Diet
Eating Plan, and reducing the sodium in one’s diet.

2,000-, 2,600-, and 3,100- Calorie Levels is also part of
the 6th edition of the Dietary Guidelines available at
www.health.gov/dietaryguidelines/dga2005/document/h
tml/appendixA.htm.

The eating plan alone lowers blood pressure, but the

1. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM,

combination of the eating plan and reduced sodium

Svetkey LP, Sacks FM, et al. A clinical trial of the

intake gives the biggest benefits and may help prevent

effects of dietary patterns on blood pressure. DASH

the development of high blood pressure.

1, 2

The DASH Diet Eating Plan emphasizes fruits,

Collaborative Research Group. N Engl J Med. 1997;
336:1117-1124.

vegetables and low-fat dairy products. It is moderate in

2. Vollmer WM, Sacks FM, Ard J, Appel LJ, Bray GA

total fat and low in saturated fat and cholesterol. It

Simons-Morton, DG, Conlin PR, Svetkey LP, Erlinger

includes whole grains, poultry, beans, fish and nuts.

TP, Moore TJ and Karanja N. Effects of Diet and

The following publication includes a week’s worth of
sample menus, recipes for heart healthy dishes and a
summary of the findings from the “Dietary Approaches
to Stop Hypertension” clinical study. It has a form to

Appendix C

Description of DASH Diet

Sodium Intake on Blood Pressure: Subgroup Analysis
of the DASH-Sodium Trial. DASH Collaborative
Research Group. Ann Intern Med. 2001; 135:10191028.

track food habits before starting the plan and a chart to
69

help with meal planning and grocery shopping.
Facts About the DASH Eating Plan, 24 pages, NIH
Publication No. 03-4082 is available online and single
orders are free.
See www.nhlbi.nih.gov/health/public/heart/hbp/dash or
NHLBI Health Information Center
P.O. Box 30105
Bethesda, MD 20824-0105
Phone: 301-629-3255

The Arizona Chronic Disease Plan

Appendix D:
To p P r i o r i t i e s F r o m C a t e g o r i c a l P l a n s
TOP PRIORITIES FROM CATEGORICAL PLANS
CARDIOVASCULAR

CANCER

PREVENTION

• Increase the number of hospitals
participating in the American Heart
Association program “Get With
The Guidelines.”

• To reduce the risks for developing
cancer among all Arizonans by
promoting and engaging in healthy
behaviors.

EARLY DETECTION

• Increase the number of people who
are aware and can recognize the
signs and symptoms of a stroke
and know the next step that needs
to be taken.

• To promote, increase, and optimize
the appropriate utilization of
high-quality cancer screening & followup services

70

• Increase the number of people who
are aware and can recognize the
signs and symptoms of a heart
attack or myocardial infarction.
• Increase the number of women
who are aware of the symptoms
of a heart attack, which are very
different from the signs of a heart
attack for men.

• Increase the proportion of women
aged 40 and over who have received
a mammogram and
clinical breast exam within the past
year to 70% by 2010
• For adults aged 50 and over, increase
the proportion of the population who
has been screened for colorectal
cancer using colonoscopy,
sigmoidoscopy, or fecal occult blood
test to 50% by 2010

VI

LUNG (COPD)
• Increase awareness of the
medical community, public
health officials and the
general public that COPD is
a serious public health
problem in Arizona.
• Promote healthy living
practices, which provide the
most effective method of
preventing COPD (tobacco
abstinence, periodic health
checks, avoidance of
unhealthy work
environments).

NUTRITION /
PHYSICAL ACTIVITY

Appendix D

TOP PRIORITIES FROM CATEGORICAL PLANS
TOBACCO

• Promote and encourage all Arizona
residents to make healthy lifestyle
choices.
• Establish a comprehensive healthy
school environment with support of
staff, students, parents and
community members in all Arizona
school districts.

• To prevent and reduce tobacco
use among all Arizonans.
• To reduce all Arizonans’ exposure
to secondhand smoke.

• Encourage, recommend and support
work cultures that promote and are
conducive to physical activity and
healthy eating.
• Deliver a health marketing campaign
about measures that can be taken
to prevent obesity that provides
culturally sensitive & intergenerational
media messages promoting
preventive screening, healthy weight
and physical activity options.
• Educate residents about and
promote healthy design of Arizona
communities.
• Integrate a culture of physical activity
throughout Arizona communities.

• Improve early detection and
diagnosis of COPD.

The Arizona Chronic Disease Plan

71

TOP PRIORITIES FROM CATEGORICAL PLANS

TREATMENT

CARDIOVASCULAR

CANCER

• Increase the number of primary stroke
centers in Arizona from six to 15.

• Increase access to appropriate
and effective cancer diagnosis and
treatment services.

• Increase the number of those
diagnosed with heart and cerebrovascular disease that participate in
cardiac rehabilitation and other
formal, multidisciplinary approaches
to secondary prevention of the heart
and cerebrovascular disease.

• Educate the public regarding the
importance and relevance of
participating in cancer clinical
trials.

• Increase the number of people that
are being referred to the appropriate
professionals to receive medical
nutrition therapy and a formal
exercise prescription to treat high
cholesterol and high blood pressure.
• Increase the availability of automated
external defibrillators in the public,
beginning where people congregate
in large numbers and where EMS
availability may be delayed.

72

QUALITY &
ACCESS TO CARE

• By 2007, utilize telemedicine to
increase access to state-of-the-art
diagnosis and treatment techniques
and expertise as well as second
opinions and resources.
• By 2008, increase access to quality
information and patient navigation
sites across the state and identify
barriers to access.
• Increase access to the
comprehensive management of
acute, chronic, and delayed effects
of cancer and its treatments.
• Create the opportunity for optimal
utilization of local, state, and national
resources.
• Increase support for health care
providers and payers in directing
those affected by cancer to quality
of life services.
• By Fall 2005, create a health
disparities work group that will
research and identify current barriers
to care as well as draft strategies to
reduce inequalities in cancer care.

VI

LUNG (COPD)

• Educate health care providers to
manage patients with COPD to
increase longevity & quality of life,
& reduce exacerbation of the
disease.
• Promote better care for patients
with COPD in AZ according to
established guidelines.
• Improve access to pulmonary
rehabilitation programs for
Arizonans with COPD to prevent
and forestall premature morbidity
& mortality.

NUTRITION /
PHYSICAL ACTIVITY

TOBACCO

• To provide and support
accessible, affordable and
effective cessation services and
systems.
• To provide and support effective
cessation services, including
pharmacotherapy.
• To work with health care systems
to provide intervention protocols
for health care professionals.
• To identify, reduce and eliminate
tobacco-related health disparities
and tobacco use.

• Improve self-management
knowledge and behavior in
people with COPD, their families
and other caregivers.

The Arizona Chronic Disease Plan

Appendix D

TOP PRIORITIES FROM CATEGORICAL PLANS

73

TOP PRIORITIES FROM CATEGORICAL PLANS
CARDIOVASCULAR

CANCER

DATA

POLICY &
ENVIRONMENTAL
CHANGE

RESEARCH

• Implement protocols whereby a
paramedic/EMT unit may bypass a
hospital in order to transport a
stroke victim to a primary stroke
center, thereby increasing their
chance of survival with less severe
disabilities.

• Promote participation in cancer
clinical trials in Arizona, specifically
among underserved populations.
• Establish a clearinghouse /database
for cancer researchers to access
and use in Arizona.

74

OTHER

• Support a capacity building
conference, promoting collaboration
among existing agencies in order to
disseminate information about
current and developing screening
methods and tools by 2010.

VI

LUNG (COPD)
• Establish a surveillance system to
accurately track the mortality and
morbidity of COPD in Arizona and
measure its impact on the
economy of the state.

NUTRITION /
PHYSICAL ACTIVITY

TOBACCO

• Create multiple mechanisms for
community health care agencies
to exchange information to
solidify a universal
message/program.

Appendix D

TOP PRIORITIES FROM CATEGORICAL PLANS

• Advocate and support policies to
reduce the prevalence of tobacco
use and secondhand smoke
exposure among Arizonans.

• Support research into COPD
etiology and clinical management,
as well as health care policies
and outcomes particularly as the
activities relate to state issues.

75

The Arizona Chronic Disease Plan

76

VI

Arizona Department of Health Services
Office of the Director

Division of Public Health Services

Office of Public Information

Local Health Liaison

The Public Information Office is committed to

The Local Health Liaison strengthens coordination and

providing the public and the media with health

collaboration between the Arizona Department of

information in a timely, accurate, and helpful manner.

Health Services and local health departments through

This Office provides news releases, health alerts,

communication, advocacy, and consultation. The Local

publications, the 2004 Annual Report, and other health

Health Liaison coordinates the direct and per capita

agency resources.

reimbursement grants to county health departments.

(602) 542-1001

(602) 364-2401

www.azdhs.gov/diro/pio/index.htm

www.azdhs.gov/phs/local_health/index.htm

Employee Wellness Council

Physical Activity Program

The mission of the ADHS Employee Wellness Council

The Physical Activity Program goal is to reduce the

is to enhance the overall health and well-being of

prevalence of chronic disease such as cardiovascular

ADHS employees by providing quality programs and

disease, diabetes, osteoporosis, and some types of

creating an environment that promotes and supports

cancer by increasing the number of Arizonans who get

healthy lifestyles.

30–60 minutes of moderate to vigorous intensity

(602) 364-2401

physical activity on most days of the week. Programs
include state and county level work groups and

Native American Liaison

coalitions, statewide intervention programs, as well as

The propose of the Native American Liaison position is

the Walk Everyday & Live Longer Program.

to serve as an advocate, resource, and communication

(602) 364-2402

link between the Arizona Department of Health
Services and Arizona’s Native American health care
community comprised of 21 tribal health offices, three

www.azdhs.gov/phs/physicalactivity/

Bureau of Epidemiology & Disease

Urban Indian Health Programs, three Indian Health

The goal of the Bureau is to monitor, prevent, and

Service Area Offices, Inter Tribal Council of Arizona,

control diseases in Arizona through program activities.

Inc., and other agencies and entities providing direct or

(602) 364-3860

indirect public health services to Arizona’s Native

www.azdhs.gov/phs/edc/index.htm

American communities.
(602) 364-1041
www.azdhs.gov/phs/tribal/index.htm

The Arizona Chronic Disease Plan

Appendix E

Appendix E:

77

Office of Chronic Disease Prevention
and Nutrition Services
The Office of Chronic Disease Prevention and
Nutrition Services and its partners empower Arizonans
to achieve optimal health through nutrition and disease
prevention and control services.

servings each day by children and their families. The
program includes three classroom sessions that
promote the “5 A Day” message and one produce tour
at a local grocery store.

Comprehensive Cancer Control Program

(602) 542-1886

The mission of this program is to reduce the overall

www.azdhs.gov/phs/oncdps

burden of cancer through prevention and early
detection of cancer, effective treatment for cancer, and

Asthma Control Program
The primary functions of the Asthma Control Program
include the development of a surveillance system and
collaboration with Arizona’s asthma coalitions to
improve the lives of persons with asthma. The
program’s goal through the Office of Chronic Disease
Prevention and Nutrition Services is to eliminate
complications and deaths from asthma in Arizona.
www.azdhs.gov/phs/oncdps/asthma/index.htm

Cardiovascular Risk Reduction Program
78

The goal of this program is to increase the
cardiovascular health of all Arizonans and decrease the
burden of heart disease and cerebrovascular disease.
Prevention and education information is provided to
those individuals who have been diagnosed with some
form of cardiovascular disease in order to decrease the
risk of stroke and/or heart attack. Surveillance and
assessment of the status of cardiovascular disease,
particularly in relation to health education and policy,
is conducted through various community partnerships.

Community Nutrition Program
The Community Nutrition Program provides nutrition
services for 12 rural counties, including a standardized
series of four “5 A Day” classes for low-income third
grade students. These interactive classes are designed
to address the increasing rates of obesity and
overweight among children and focus on increasing
consumption of fruits and vegetables to five or more

improvement of the quality of life for those living with
cancer. This is achieved through a partnership of public
and private stakeholders, including American Cancer
Society, the University of Arizona’s Arizona Cancer
Center and College of Public Health, Arizona Health
Care Cost Containment System, Phoenix Indian
Medical Center, and many more organizations.
www.azcancercontrol.gov

Diabetes Prevention and Control Program
The Diabetes Prevention and Control Program assists
with the prevention of diabetes; develops the state’s
capacity to reduce the incidence and severity of
primary and secondary complications related to
diabetes; coordinates educational and training
opportunities that involve state leadership, health
professionals, and communities; and promotes
coordinated approaches to the provision of diabetes
care and services through the state.
www.azdhs.gov/phs/oncdps/diabetes/index.htm

Nutrition and Physical Activity Program
The mission of this program is to improve the health
and quality of life of Arizona residents by reducing the
incidence and severity of chronic disease and obesity
through physical activity and nutrition interventions.
“Eat smart. Get active. Be healthy.”
www.azdhs.gov/phs/oncdps/opp/

VI
Arizona Farmers’ Market Nutrition Program

The Well Woman Healthcheck Program is a statewide

The Arizona Farmers' Market Nutrition Program goal is

program that provides free cancer screenings to women

to increase the fruit and vegetable consumption among

who qualify. Women on the program may receive a

low income women, children, and seniors while

clinical breast exam, mammogram, pelvic exam, and

supporting local farmers' markets.

pap test.

www.azdhs.gov/phs/oncdps/azfmnp/index.htm

Appendix E

Well Woman Healthcheck Program

www.azdhs.gov/phs/oncdps/wellwoman/index.htm

Arthritis Program
Special Supplemental Nutrition Program for
Woman, Infants, and Children Program

Arthritis is the most prevalent chronic disease and the

Arizona Women, Infants, and Children (WIC) is a

Arthritis Program works with members of the Arizona

federally-funded program that provides Arizona

Arthritis Partnership to improve the quality of life for

residents with nourishing supplemental foods, nutrition

people with arthritis.

education, and referrals. The participants of WIC are

(602) 542-1886

either pregnant, breastfeeding, or postpartum women,

www.azdhs.gov/phs/oncdps/arthritis/index.htm

leading cause of disability in the U.S. and Arizona. The

and infants and children who have nutritional needs
and meet income guidelines.
www.azdhs.gov/phs/oncdps/wic/index.htm

Arizona Nutrition Network

Early Childhood Nutrition Program
Provides consultation and training for licensed child
care centers. Nutrition consultation, technical
assistance, and workshops are provided for licensed

The Arizona Nutrition Network (AzNN) is comprised

child care programs to better the quality of the nutrition

of an ever-expanding group of public and private

component of their programs.

organizations committed to working together to shape

(602) 542-1886

food consumption in a positive way, promote health,

www.azdhs.gov/phs/oncdps/earlychildhood/index.htm

and reduce disease among lower income Arizonans
through nutrition education and a social marketing
campaign.
www.eatwellbewell.org

Arizona Commodity Supplemental Food
Program
The Arizona Commodity Supplemental Food Program,

Folic Acid Education & Distribution Program
Participants in the Folic Acid Education and
Distribution Program receive a year supply of
multivitamins (with 400 micrograms of folic acid) in
addition to education.
(602) 542-1886
www.azdhs.gov/phs/oncdps/folicacid/index.htm

also known as Food Plus, is a federal food distribution
program. The participants include pregnant, breast
feeding, and postpartum women, children, and elderly
persons who meet income and residence guidelines.
www.azdhs.gov/phs/oncdps/csfp/index.htm

The Arizona Chronic Disease Plan

79

Children with Special Health Care Needs
The Office of Chronic Disease Prevention and Nutrition
Services provides nutrition consultation and technical
assistance for CRS dietitians, professional staff, and
caregivers of children with special health care needs.

Arizona Health Office (Mexico), Action Border Health
Conference, Arizona Mexico Commission, and Border
Health Studies.
(520) 770-3110
www.azdhs.gov/phs/borderhealth/index.htm

(602) 542-1886

80

www.azdhs.gov/phs/oncdps/children/index.htm

Office of Tobacco Education and
Prevention Program

Steps to a Healthier Arizona Initiative

Broad-based, statewide distribution of tobacco

The goal of the Steps to a Healthier Arizona Initiative

information is an Office of Tobacco Education and

is to reduce the burden of asthma, diabetes and obesity

Prevention Program goal. Key components include

and address the related risk factors of inadequate

print media, toll-free telephone services, onsite training

dietary intake, physical inactivity and tobacco use in

and technical assistance, face-to-face community

Cochise, Santa Cruz and Yuma Counties and the

outreach, and the Internet to reach the citizens of

Tohono O’odham Nation. Program partners include

Arizona. Services offered cover a wide range of issues

the Arizona Department of Health Services, the

such as tobacco use prevention and education, public

Arizona Department of Education, Cochise County

access to information, help in quitting tobacco,

Health Department, Mariposa Community Health

analysis and research into smoking policies for work

Center (Santa Cruz County), University of Arizona

sites, school, and restaurants, and training and

Cooperative Extension (Yuma County), Department of

technical assistance for those who want to learn more

Human Services (Tohono O’odham Nation), and the

about tobacco.

University of Arizona Mel & Enid Zuckerman Arizona

(602) 364-0824

College of Public Health. Numerous community

www.azdhs.gov/phs/tepp/index.htm

subcontractors also partner with these agencies.

Office of Health Systems Development
Office of Border Health

Health Systems Development supports a variety of

The Office of Border Health promotes and protects the

programs and services meant to improve access to high

health of all border area residents through sound,

quality primary health care, particularly for the

competent public health practices along the Arizona-

uninsured and other vulnerable populations.

Sonora border. The Office of Border Health

(602) 542-1219

coordinates and integrates public health program

www.azdhs.gov/hsd/index.htm

efforts to identify, monitor, control and prevent adverse
health events in border communities, as well as

Arizona Loan Repayment Program

strengthen cross-border public health collaboration

The purpose of the AZ Loan Repayment Program is to

with Sonora, Mexico. Programs include Binational

provide an incentive for primary care providers and

Terrorism and Public Health Emergency Response,

dentists to provide services in the underserved areas of

U.S.-Mexico Border Health Commission Arizona

the State. Program funds are used to repay qualifying

Delegation, Diabetes Education and Outreach ArizonaSonora, Border Binational Health Week, Sonora

VI
provisions in federally designated Health Professional
Shortage Areas.
www.azdhs.gov/hsd/az_loan_repayment.htm

Arizona Medically Underserved Areas
The Arizona Medically Underserved Areas designation
may be used for planning for delivery of primary
care services.
www.azdhs.gov/hsd/azmuadesignation.htm

Arizona Primary Care Area Statistical Profiles

Healthy Aging 2010 Initiative
Working in partnership with the Healthy Arizona 2010
Initiative, this project promotes health and good quality
of life for older adults in Arizona.
www.azdhs.gov/phs/healthyaging2010/index.htm

Appendix E

educational loans in return for primary care service

Healthy Communities
Healthy Communities was established with the mission
to identify, link, and support Arizona communities that
are using collaborative approaches to health planning,
disease prevention, and the promotion of healthy
lifestyles.

Community Health Profiles are available for 87

www.azdhs.gov/phs/hcc

incorporated towns and cities in Arizona with
aggregate data from various agencies to improve the
accessibility of health-rated data. These profiles can
assist interested parties in addressing a number of
health issues and facilitate health program planning,
implementation, and improvement in communities.
www.azdhs.gov/hsd/profiles2005

Health Professional Shortage Areas

J-1 Visa Waiver Program
The Arizona Department of Health Services J-1 Visa
Waiver Program supports waivers for primary care
physicians (family or general practice, pediatrics,
obstetrics/gynecology, and general internal medicine)
in federally designated Health Professional Shortage
Areas, Medically Underserved Areas, or Medically
Underserved Populations, and for psychiatrists in

The federal Health Professional Shortage Area (HPSA)

mental health Health Professional Shortage Areas. The

designation identifies an area or population as having a

J-1 Visa Waiver Program supports waivers for J-1

shortage of dental, mental, and primary health care

physicians in specialties when exceptional need for the

providers. HPSA designation is used to qualify for

specialty is substantiated.

state and federal programs aimed at increasing primary

www.azdhs.gov/hsd/visa_waiver.htm

care services to underserved areas and populations.
www.azdhs.gov/hsd/hpsa.htm

Healthy Arizona 2010 Program

Medically Underserved Areas/Populations
The federal Medically Underserved Area/Population
(MUA/MUP) designation identifies areas or

This is a comprehensive statewide prevention agenda

populations as having a need for medical services on

designed to improve the health of all Arizonans over

the bases of demographic data. These designations are

the next decade. Whether through participation as part

important when seeking a Community and Migrant

of an organization, or through a personal commitment

Health Center or Federally Qualified Health Center

to change, this plan is designed to help you determine

status.

what you can do to improve your health and the health

www.azdhs.gov./hsd/mua_mup.htm

of your community.
www.azdhs.gov/phs/healthyaz2010/index.htm

The Arizona Chronic Disease Plan

81

National Health Service Corps
The National Health Service Corps (NHSC) recruits

Food Safety and Environmental Services
Program

and places health professionals at eligible sites within

The Food Safety and Environmental Services Program

federally designated HPSAs. NHSC recruits primary

is responsible for managing a statewide Food Safety

care physicians, nurse practitioners, physician

Program and a voluntary Food Biosecurity Program.

assistants, certified nurse-midwives, dentists, dental

(602) 364-3118

hygenists, and mental health professionals. These

www.azdhs.gov/phs/oeh/fses

providers serve in community-based systems of care in
return for scholarship or loan repayment assistance.
www.azdhs.gov/hsd/nhsc.htm

Primary Care Programs

Children’s Environmental Health Section
In accordance with the Governor’s Children’s
Environmental Health Project Initiative, the Office of
Environmental Health assessed the environmental

Two Primary Care Programs have been established to

factors that most affect Arizona’s children. The

provide access to primary care health services for

Arizona’s Children and the Environment report details

uninsured, low-income Arizona residents of all ages.

information to assist organizations and individuals

www.azdhs.gov/hsd/primary_care.htm

interested in developing specific objectives for helping
reduce exposures.

Office of Environmental Health

(602) 364-3118
www.azdhs.gov/phs/oeh/invsurv

82

Environmental Health Consultation Services
Program

SunWise School Program

The Environmental Health Consultation Services

This program encourages elementary schools to adopt

Program conducts public health assessments and

sun-safe policies and promote sun-safe educational

consultations for the United States Environmental

programs to educate children about sun safety and to

Protection Agency (USEPA) superfund sites in Arizona.

encourage life-long sun-safe behaviors.

Most of the health reports completed by the program

(602) 364-3118

discuss the health effects at USEPA superfund sites.

www.azdhs.gov/phs/sunwise

Consultations for other environmental exposures upon
request.

Office of Health Registries

(602) 364-3118
www.azdhs.gov/phs/oeh/atsdr.htm

Arizona Cancer Registry
The Arizona Cancer Registry is a population-based
surveillance system that collects, manages, and
analyzes information on the incidence, survival, and
mortality of persons having been diagnosed with
cancer.
(602) 542-7320
www.azdhs.gov/phs/phstats/acr/index.htm

VI
Appendix E
83

84

VI

National Standards for Culturally and
Linguistically Appropriate Services (CLAS)
in Health Care
Standard 1. Health care organizations should ensure

Standard 6. Health care organizations must assure

that patients/consumers receive from all staff

the competence of language assistance provided to

members effective, understandable, and respectful

limited English proficient patients/consumers by

care that is provided in a manner compatible with

interpreters and bilingual staff. Family and friends

their cultural health beliefs and practices and

should not be used to provide interpretation services

preferred language.

(except on request by the patient/consumer).

Standard 2. Health care organizations should

Standard 7. Health care organizations must make

implement strategies to recruit, retain, and promote at

available easily understood patient-related materials

all levels of the organization a diverse staff and

and post signage in the languages of the commonly

leadership that are representative of the demographic

encountered groups and/or groups represented in the

characteristics of the service area.

service area.

Appendix F

Appendix F:

85

Standard 3. Health care organizations should ensure

Standard 8. Health care organizations should

that staff at all levels and across all disciplines receive

develop, implement, and promote a written strategic

ongoing education and training in culturally and

plan that outlines clear goals, policies, operational

linguistically appropriate service delivery.

plans, and management accountability/oversight
mechanisms to provide culturally and linguistically

Standard 4. Health care organizations must offer

appropriate services.

and provide language assistance services, including
bilingual staff and interpreter services, at no cost to

Standard 9. Health care organizations should conduct

each patient/consumer with limited English

initial and ongoing organizational self-assessments of

proficiency at all points of contact, in a timely

CLAS-related activities and are encouraged to

manner during all hours of operation.

integrate cultural and linguistic competence-related
measures into their internal audits, performance

Standard 5. Health care organizations must provide

improvement programs, patient satisfaction

to patients/consumers in their preferred language both

assessments, and outcomes-based evaluations.

verbal offers and written notices informing them of
their right to receive language assistance services.

The Arizona Chronic Disease Plan

Standard 10. Health care organizations should

Standard 14. Health care organizations are

ensure that data on the individual patient’s/consumer’s

encouraged to regularly make available to the public

race, ethnicity, and spoken and written language are

information about their progress and successful

collected in health records, integrated into the

innovations in implementing the CLAS standards and

organization’s management information systems, and

to provide public notice in their communities about

periodically updated.

the availability of this information.

Standard 11. Health care organizations should
maintain a current demographic, cultural, and
epidemiological profile of the community as well as a
needs assessment to accurately plan for and
implement services that respond to the cultural and
linguistic characteristics of the service area.

Standard 12. Health care organizations should
develop participatory, collaborative partnerships with
communities and utilize a variety of formal and
informal mechanisms to facilitate community and
86

patient/consumer involvement in designing and
implementing CLAS-related activities.

Standard 13. Health care organizations should
ensure that conflict and grievance resolution processes
are culturally and linguistically sensitive and capable
of identifying, preventing, and resolving cross-cultural
conflicts or complaints by patients/consumers.

More detailed information can be obtained on
each of the Standards above through:
U.S. Department of Health and Human Services.
Office of Minority Health. National Standards for
Culturally and Linguistically Appropriate Services in
Health Care. March 2001. Retrieved July 15, 2005
from http://www.omhrc.gov/omh/programs/
2pgprograms/finalreport.pdf

VI

References
1. Arizona Department of Health Services. Public

8. U.S. Department of Health and Human Services.

Health Services. Arizona Health Status and Vital

Centers for Disease Control and Prevention.

Statistics. (2003) Retrieved June 1, 2005, from

National Center for Chronic Disease Prevention

http://www.azdhs.gov/plan

and Health Promotion. (2004) Chronic Disease

/report/ahs/ahs2003/pdf/103_117text2b.pdf.

Overview. Retrieved May 23, 2005, from

Appendix G

Appendix G:

http://www.cdc.gov /nccdphp /overview.htm.
2. Arizona Department of Health Services. Office of
the Director. Planning and Quality Improvement,
Strategic Plan 2005-2009. October, 2004. Pg 4

9. Arizona Department of Health Services. Public
Health Services. Arizona Chronic Disease
Surveillance Indicators Report. September, 2004,

3. Arizona Department of Health Services. Office of

Pg 11.

the Director. Planning and Quality Improvement,
Strategic Plan 2005-2009. October 2004. Pg 6

10. Arizona Department of Health Services. Public
Health Services. Arizona Chronic Disease

4. Encarta. Retrieved May 23, 2005 from
http://Encarta.msn.com/encyclopedia

Surveillance Indicators Report. September, 2004.
87

Pg 6-7.

_761570033_5/ Arizona.html.
11. Arizona Department of Health Services. Public
5. Association of State and Territorial Chronic
Disease Program Directors Bylaws (revised

Health Services. Arizona Nutrition and Physical
Activity State Plan. January 1, 2005. Pg 29.

February 2003). Retrieved July 20, 2005 from
http://www.chronicdisease.org/ bylaws.html

12. Arizona Department of Health Services. Public
Health Services. Arizona Nutrition and Physical

6. Miriam Webster Online. Retrieved March 1, 2005

Activity State Plan. January 1, 2005. Pg 27.

from http://www.m-w.com/cgi-bin/dictionary ?book
=Dictionary&va=comprehensive&x=8&y=16.

13. Arizona Department of Health Services. Public
Health Services. Arizona Nutrition and Physical

7. U.S. Department of Health and Human Services,

Activity State Plan. January 1, 2005. Pg 28.

Public Health Service. The Surgeon General’s
Call to Action to Prevent and Decrease

14. Arizona Department of Health Services. Public

Overweight and Obesity, Pg XI. (2001).

Health Services. Arizona Nutrition and Physical

Retrieved February 25, 2005 from

Activity State Plan. January 1, 2005. Pg 30.

http://www.surgeongeneral.gov/topics/obesity/callto
action/CalltoAction.pdf.

The Arizona Chronic Disease Plan

15. U.S. Department of Health and Human Services.

20. U.S. Department of Health and Human Services.

Centers for Disease Control and Prevention.

Indian Health Service. Facts on Indian Health

National Center for Chronic Disease Prevention

Disparities. (January 2005). Retrieved March 15,

and Health Promotion. (2005) Targeting Tobacco

2005 from http://info.ihs.gov/Health/11_

Use: The Nation’s Leading Cause of Death.

DisparitiesFacts-Jan2005.doc

Retrieved March 22, 2005 from http://www.cdc.
gov/nccdphp/aag/aag_osh.htm

21. Arizona Department of Health Services. Public
Health Services. Health Status Profile of American

16. U.S. Department of Health and Human Services.

Indians in Arizona – 2003 Data Book, Pg 27.

Centers for Disease Control and Prevention.

(November 2004) Retrieved March 11, 2005 from

National Center for Chronic Disease Prevention

http://www.azdhs.gov/plan/report/hspam

and Health Promotion. Reducing Tobacco Use.

/indian03.pdf

Retrieved March 22, 2005 from
http://www.cdc.gov/nccdphp/bb_ tobacco/

22. Arizona Department of Health Services. Public
Health Services. Report of the Arizona Native

17. Arizona Department of Health Services. Public
Health Services. Office of Tobacco Education and

American Primary Care Resources Workshop
Forum Series. Pgs. IV-4 – IV-8. (April 2003).

Prevention, 2004 Biennial Evaluation Report.
Retrieved August 19, 2005 from
88

http://www.azdhs.gov/ phs/tepp/reports.htm

23. U.S. Department of Health and Human Services.
Centers for Disease Control and Prevention.
National Center for Chronic Disease Prevention

18. Arizona Department of Health Services. Public

and Health Promotion. The Power of Prevention.

Health Services. Health Disparities Conference

Reducing the Health and Economic Burden of

Focus Groups. Retrieved June 1, 2005 from

Chronic Disease. Pg 4 (2003) Retrieved February

http://www.azdhs.gov/hsd conf/ health _disparities

28, 2005 from http://www.cdc.gov/nccdphp

_focus_group_complete_2004_2005.pdf

/power_prevention/pdf/power_of_prevention.pdf.

19. U.S. Department of Health and Human Services.

24. U.S. Department of Health and Human Services.

Indian Health Service. Heritage and Health, Pg 5.

Centers for Disease Control and Prevention.

(January 2005) Retrieved July 21, 2005 from

National Center for Chronic Disease Prevention

http://info.ihs.gov/HERITAGE_&_HEALTH

and Health Promotion. The Power of Prevention.

_2005.pdf

Reducing the Health and Economic Burden of
Chronic Disease. Pg 7 (2003) Retrieved February
28, 2005 from http://www.cdc.gov/nccdph
p/powerprevention/pdf/power_of_prevention.pdf.

VI
Appendix G
89

90

VI
30. U.S. Department of Health and Human Services.

Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention.

National Center for Chronic Disease Prevention

National Center for Chronic Disease Prevention

and Health Promotion. The Power of Prevention.

and Health Promotion. Guidance for

Reducing the Health and Economic Burden of

Comprehensive Cancer Control Planning, Vol. 1:

Chronic Disease. Pg 8 (2003) Retrieved February

Guidelines. Retrieved June 1, 2005 from

28, 2005 from http://www.cdc.gov/nccdphp/power

http://www.cdc.gov/cancer/ncccp/guidelines/

prevention/pdf/power_of_prevention.pdf

part1/section1.htm.

26. U.S. Department of Health and Human Services.

Appendix G

25. U.S. Department of Health and Human Services.

31. U.S. Department of Health and Human Services,

Centers for Disease Control and Prevention.

The Surgeon General’s Call to Action to Prevent

National Center for Chronic Disease Prevention

and Decrease Overweight and Obesity, Pg 1.

and Health Promotion. Preventing Obesity and

(2001). Retrieved February 25, 2005 from

Chronic Disease Through and Nutrition and

http://www.surgeongeneral.gov/topics/obesity

Physical Activity. (2003) Retrieved March 21, 2005

/calltoaction/CalltoAction.pdf.

from http://www.cdc.gov/nccdphp/pe_factsheets/
pe_pa.htm.

32. U.S. Department of Health and Human Services,
The Surgeon General’s Call to Action to Prevent

27. IDEA Fitness Journal. February 2005 edition. Pg 21.

and Decrease Overweight and Obesity, Pg XIII.
(2001). Retrieved February 25, 2005 from

28. U.S. Department of Health and Human Services.
Centers for Disease Control and Prevention.

http://www.surgeongeneral.gov/topics/obesit
y/calltoaction/CalltoAction.pdf.

National Center for Chronic Disease Prevention
and Health Promotion. Preventing Tobacco Use.

33. WebMD. Weight Loss: Body Mass Index (BMI).

(August 2004). Retrieved March 22, 2005 from

Retrieved June 1, 2005 from http://my.webmd.com/

http://www.cdc.gov/nccdphp/pe_factsheets/pe

content/article/46/2731_1657.htm

_tobacco.htm.
34. U.S. Department of Health and Human Services.
29. U.S. Department of Health and Human Services.

Centers for Disease Control and Prevention. BMI –

Centers for Disease Control and Prevention.

Body Mass Index: BMI for Children and Teens.

National Center for Chronic Disease Prevention

Retrieved July 6, 2005 from http://www.cdc.gov

and Health Promotion. Best Practices for

/nccdphp/dnpa/bmi/bmi-for-age.htm

Comprehensive Tobacco Control Programs, Pg 3.
(August 1999). Retrieved March 1, 2005 from
http://www.cdc.gov /tobacco/research
_data/stat_nat_data/bestprac.pdf

35. Arizona Department of Health Services. Public
Health Services. Arizona Nutrition and Physical
Activity State Plan. Pg 34 (January 2005).

The Arizona Chronic Disease Plan

91

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VI

Glossary
Advocacy: The act of pleading or arguing in favor

Diagnosis: Identifying a disease by its signs or

of something, such as a cause, idea, or policy; active

symptoms, and by using imaging procedures and

support of any of the above.

laboratory findings.

Collaboration: Working in partnership with other

Disparities: Health disparities are differences in the

individuals, groups, or organizations toward a

incidence, prevalence, mortality, and burden of

common goal.

chronic disease that exist among specific population

Community: A social unit that can encompass
where people live and interact socially (a city,
county, neighborhood, subdivision or housing
complex). It can be a social organization wherein

groups in the United States. These population
groups may be characterized by gender, age,
ethnicity, education, income, social class, disability,
geographic location, or sexual orientation.

people share common concerns or interests. Often, a

Early Detection: Procedures, examinations,

community is a union of subgroups defined by a

screening tests performed according to

variety of factors including age, ethnicity, gender,

recommended guidelines for the purpose of

occupation, and socioeconomic status.

detecting the presence of disease as early as possible

Cultural Competence or Cultural Responsiveness:

Appendix H

Appendix H:

in individuals who are otherwise asymptomatic.

A set of congruent behaviors, attitudes, and policies

Healthy Eating: An eating pattern that is consistent

that come together in a system, agency, or among

with the USDA Dietary Guidelines for Americans.

professionals to work effectively in cross-cultural

Individual and cultural preferences can be

situations. Operationally, cultural competence is the

accommodated within an eating pattern that is

integration and transformation of knowledge about

considered healthy (see complete definition in

individuals and groups of people into specific

Appendix C).

standards, policies, practices, and attitudes used in
appropriate cultural settings to increase the quality

Infrastructure: An underlying base or foundation

of services; thereby producing better outcomes.

especially for an organization or system, or the basic
facilities, services, and installations needed for the
functioning of a community or society.

The Arizona Chronic Disease Plan

93

Policy: A plan or course of action, as of a

Surveillance: A continuous, integrated and

government, political party, or business, intended to

systematic collection of health-related data.

influence and determine decisions, actions, and other
matters.

Tobacco: References in the AzCD Plan regarding the
prevention and/or cessation of tobacco use, tobacco-

Primary Prevention: Preventing or reducing risks of

free healthy lifestyle, and/or tobacco as a risk factor

developing a disease done through promotion of

for chronic disease relate to the commercial or

modifying individual lifestyle changes or at the

recreational use of manufactured tobacco products.

system level through policy and environmental

Those references do not include the traditional

changes.

practices and/or ceremonial use of tobacco that is an
integral part of Native American religious beliefs

Screening: Early detection of disease in persons

and culture.

without signs or symptoms suggestive of the disease.
Treatment: Administration or application of
Secondary Prevention: Identifying and treating
people with established disease and those at very
high risk of developing disease, or treating and
rehabilitating patients who have a disease to prevent
a reoccurrence (e.g., cardiac rehabilitation to prevent
94

another heart attack).
Social Marketing/Health Marketing: The
application of traditional commercial advertising and
marketing concepts to the analysis, planning,
implementation and evaluation of programs and
advertising campaigns intended to influence the
voluntary behavior change of a target audience in
order to improve personal welfare and that of
society. Like traditional marketing, social marketing
uses research to precisely tailor messages for a
particular target audience.

remedies to a patient for a disease or injury;
medicinal or surgical management; therapy.

VI
Appendix H
95

The Arizona
Chronic Disease Plan
Arizona Department of Health Services
Division of Public Health
Office of Chronic Disease Prevention and Nutrition Services
www.azdhs.gov/phs/oncdps/