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Introduction
Policy and environmental interventions account for much of the success of the first public health revolution.(1) Sanitarians contributed to the nation's health through improved environmental conditions fostered by rules (policies) that required cleaner food preparation facilities in slaughterhouses, factories, and restaurants; better technologies (environmental changes), such as refrigeration; better sanitation, including garbage collection, sewage treatment, and water purification; and significant changes in norms, attitudes, and behaviors (e.g., washing hands and not spitting in public).(1-3)
Strategies to Address Chronic Diseases
A contemporary public health revolution must respond to chronic diseases such as cardiovascular disease and cancer that have complex and multiple causes. It is now generally accepted in the more developed world that people's behaviors and the environments that elicit and maintain them, rather than inadvertent exposure to infectious disease agents, are the primary causes of today's major health problems.(4) Risk factors for cardiovascular disease, the leading cause of death, are primarily behavioral and include tobacco use, inadequate physical activity, and poor diet.(5-7)
Policy and Environmental Change
Societal-level changes necessary to address endemic chronic diseases successfully will include changes in policy and the environment to foster and maintain individual-level behavior change.(4,8) The need for such an approach is recognized in the Victoria Declaration on Heart Health, a consensus statement drafted by leading scientists and experts in public health. The Victoria declaration calls for those in public health "to join forces in eliminating this modern epidemic [cardiovascular disease] by adopting new policies, making regulatory changes, and implementing health promotion and disease prevention programs directed at entire populations."(8) The declaration strongly advocates combining health education efforts with environmental and policy measures, because neither can be as effective alone.
It is unreasonable to expect large proportions of the population to make individual behavior changes that are discouraged by the environment and existing social norms. It is equally unrealistic to expect communities or organizations to enact policy changes for which there is no broad-based understanding and support.(3,9) To be effective, a public health approach to cardiovascular disease prevention must incorporate environmental and policy measures as well as education and skills development for each of the sectors of individuals and organizations involved.
Policy Strategies
Policies can be defined as "those laws, regulations, formal, and informal rules and understandings that are...