The shift from infectious diseases to chronic illnesses as the leading causes of death required a new strategic direction for the field of public health (1). Identifying a single agent or threat was no longer sufficient to address the complex factors underlying the rise in chronic disease burden and deaths (1). This reality, coupled with a greater understanding of the link between behaviors and chronic disease and an expanded appreciation for the contributions of the social sciences, led to the growth of health promotion in public health science and practice (2). Health promotion has its roots in an ecological framework; that is, it emphasizes the interaction between the individual and the physical and social environment and addresses these determinants of health through social networks, agencies and institutions, neighborhoods, and communities. Recognizing the interaction of these environmental factors offers the possibility of new approaches to influencing and supporting individuals, as members of communities, to adopt and maintain healthy lifestyles (3).

Community health promotion emphasizes the social, cultural, and environmental contexts that shape health status and works through collaborative partnerships to improve the health of a population within a defined geographic area (3). Community-based participatory strategies, such as community organization and mobilization, bring to bear shared values and experiences of community members, who are viewed as having the best knowledge of and perspective on improving the health of their community (4). The community is regarded as an influential determinant of health, and community members are involved in all aspects of public health research, interventions, and evaluations (4).

Health promotion's foundation rests in several landmark documents, including the Lalonde report from Canada, the Ottawa Charter, the Canadian Epp Framework, and Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (5-8). Each called for new public health strategies that focus not only on personal behavior change but also on the social, psychological, and economic determinants of health (9). As a response to this movement, in 1981, the Centers for Disease Control and Prevention (CDC) established a center for health promotion and education that focused on health issues such as sexual and contraceptive behavior, nutrition, smoking, alcohol use, physical fitness, stress, violence, injury, and other risk factors of public health significance. This center provided the only source of federal funds to state agencies to support health education and health promotion through the Health Education and Risk Reduction grant program.

In subsequent years, the center expanded its scope to support community-wide planning (with the creation of the Planned Approach to Community Health [PATCH] model) and state-based public health surveillance (with the creation of the Behavioral Risk Factor Surveillance System and other key surveillance programs) (10). By 1988, the center, by then known as the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), became increasingly disease- and risk factor-specific, with its existing health education and community health promotion expertise spread across its categorical programs. Although this expertise has become integral to prevention research and categorical health programs throughout the center, a point of access for public health scientists and practitioners seeking to improve the efficacy and effectiveness of community health promotion that was once clearly concentrated is now diffuse and dispersed.

As prevalence rates and costs of chronic diseases continue to rise, societal institutions — such as businesses, health care settings, and schools — increasingly demand that public health programs show health impact and cost savings in the short term. The challenge for NCCDPHP and other leaders in public health is to emphasize the important role of long-term community health promotion in addressing the social and environmental determinants of health in an atmosphere that demands evidence of health impact and return on investment. The Institute of Medicine's report The Future of the Public's Health in the 21st Century and several recent articles challenge the public health community to establish a new vision for public health science and practice that measures and addresses these social and environmental determinants and supports the role of the community in improving health and wellness (10-13). NCCDPHP and its Division of Adult and Community Health (DACH) responded to this challenge by inviting a panel of experts to act as an external review board and to provide guidance to advance community health promotion (14). The expert panel was charged with the following: 1) identifying and summarizing gaps in the field of community health promotion, as well as relevant and cutting-edge initiatives for community health promotion, and 2) developing and prioritizing recommendations for center-wide activities to promote community health within the next 3 to 5 years.

In March 2006, 25 people representing various health care sectors and broad areas of public health and community expertise participated in the National Expert Panel on Community Health Promotion. Those invited to the 2-day meeting included experts on community-based participatory research, local community-based practice, aging, and mental health; leaders from community-based and nonprofit organizations; and state and local health department representatives. The participants were selected on the basis of their current affiliation, a specific area of expertise, or prior collaborations with CDC. An ad hoc committee of CDC staff from several branches and programs within NCCDPHP observed the meeting to provide clarification on CDC programs and to comment on the recommendations.

The meeting was facilitated by representatives of the Institute for Alternative Futures (IAF), a nonprofit futurist organization that conducts futures research, visioning, and strategy development for nonprofits, associations, and governments. IAF was responsible for designing the interactive and creative meeting to lead the panel in developing a set of actionable recommendations.

Before the meeting, the panel reviewed supplemental materials, including a brief history of community health promotion activities at CDC, several examples of socioecological models for health promotion, and a summary of CDC-sponsored cutting-edge initiatives. During the first day of the meeting, participants discussed socioecological models and CDC's various roles in community health promotion (e.g., leader/advocate, standards developer, knowledge disseminator/translator). On the second day, the panel separated into subgroups to discuss innovative initiatives and to propose and refine recommendations for furthering community health promotion efforts. The larger group then reconvened to review and categorize the recommendations. Later, IAF summarized the notes of the meeting and consolidated all of the panel's proposals into eight specific recommendations. The CDC ad hoc committee met to review and prioritize the recommendations according to their appropriateness and feasibility.

In June 2006, the panel held a conference call to review a draft report of the discussions and the final recommendations proposed at the March meeting. Members considered the following issues: 1) Were the recommendations a strategic advance in community health promotion for CDC? 2) Do they align CDC with other leaders in community health promotion? 3) Was the report faithful to the intent of the recommendations proposed by the panel?

The final report was revised and disseminated as a white paper to the panel, the CDC ad hoc committee, CDC division directors, and other audiences.

Discussions of socioecological models and CDC roles served as a creative platform to stimulate discussion and guide the formation of the recommendations. The panel acknowledged that ecological models have been useful in furthering community health promotion efforts, particularly as they relate to environmental influences on health status and behavior. In addition, the panel acknowledged CDC's valuable role in validating effective practices of community health promotion and supporting community-based participatory research and public health surveillance. The panel also affirmed CDC's role in disseminating public health knowledge across communities and serving as the voice among federal agencies for community health promotion.

However, the panel noted critical gaps in current ecological approaches and in CDC's current approach to health promotion. For example, even the best operational measures of the socioecological approach missed critical opportunities for change, including mental health and wellness, spirituality, and complementary and alternative medicine; access to care; political and economic contexts of decisions; race, racism, and discrimination; cultural beliefs and values as risk factors and protective factors; and elements of community efficacy, such as social capital and community competencies. The panel reported the need for an ecological approach to be sufficiently flexible to allow community choices based on available resources and local realities. Additionally, future approaches should facilitate discussions on power relationships, the political process, chronic social stressors (e.g., poverty), acute situations (e.g., hurricanes), and the engagement of nontraditional partners. Furthermore, the panel suggested that NCCDPHP extend its leadership role by looking beyond the traditional view of health to investigate what truly constitutes wellness in our society in partnership with universities, state and local health agencies, private organizations, nonprofit community institutions, and communities across the country.

The expert panel offered eight recommendations for NCCDPHP over the next 3 to 5 years related to community-based research and surveillance, training and capacity building, new program directions, and federal investments.

The leading causes of death and disability in the United States — heart disease, cancer, and stroke — are among the chronic diseases that have well-known behavioral, social, and environmental risk factors (16). Through NCCDPHP, CDC has pioneered and sustained a rich legacy of community-based health promotion and chronic disease prevention programs that have contributed to reversing trends in chronic disease mortality and morbidity. Working in concert with a range of governmental and private partners, CDC has developed a strong portfolio of accomplishments in the area of individual behavior change and a growing slate of health policy and environmental change interventions that are driving efforts across the nation to support healthy people and healthy communities.

Convening the National Expert Panel on Community Health Promotion provided the opportunity to conduct a critical external review of existing community health programs supported by NCCDPHP and to solicit the input of our nation's leading health promotion scholars, researchers, and practitioners in defining advances in community health promotion that can be championed by CDC. The recommendations put forth by the expert panel map a comprehensive socioecological approach to community health promotion that ranges from building surveillance systems that monitor social determinants of health to developing public health programs that promote mental health and wellness throughout the life stages. CDC, in collaboration with its partners and sister federal agencies, is uniquely positioned to provide significant scientific and programmatic leadership for evidence-based interventions that build healthy communities and eliminate health disparities. We view the work of the expert panel as a national call to action to multiple sectors of the public health system and a strategic advance for CDC.