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OCR for page 15
3. Implementing the Objectives at State and
Local Levels
The realization of national objectives depends, in
large measure, on the extent to which national,
regional, state, and local organizations-both public
and private-use and adapt them to better understand
and act on the health concerns of the groups and
communities they serve. The testifiers made clear
that translating national objectives into an action plan
for the United States must involve the building blocks
of the U.S. public health system-each and every state
and local health department. It also must involve the
efforts of the private sector, including businesses,
educational institutions, community groups, and
professional or voluntary organizations. Individuals
from all sectors must be encouraged to take
'ownership' of the objectives," according to the
Association of State and Territorial Health Officials.
(#750)
Almost 200 witnesses addressed implementation
issues. Their comments summed up experience with
the objectives at state and local levels, and focused
especially on the relationship between the national
objectives and the Model Standards for Community
Preventive Health Seances, an effort of a coalition of
public health professional organizations.t Testifiers
also addressed other issues that can be summed up as
the need for cooperation with the general public, with
communities, and with the private sector, on a state
and regional basis, as well as with the federal govern-
ment. Strong pleas were made for more federal
funding in support of state and local health depart-
ment programs aimed at achieving the objectives.
STATE AND LOCAL PUBLIC HEALTH INITIATIVES
Since the publication of the 1990 Objectives, many
states, counties, and cities have developed their own
objectives based on the national model, and state and
local health officers testified at length about the
successes and failures. Successes tend to be related to
cooperation across governmental levels, with the
private sector and the community, and to use of the
objectives to set priorities and manage resources.
State and Local Health Department Experience
Hawaii was one of the first states to hold a meeting
addressing the 1990 Objectives," according to Julian
Lipsher of the Hawaii State Department of Health.
"The Governor's Conference on Health Promotion
and Disease Prevention was designed, not to just
establish the objectives as part of a state agenda, but
as a community-based process involving organizations,
agencies, and sectors of our community who would
own the objectives and be, in part, responsible for
their attainment. (~340)
According to Thomas Halpin and Karen Evans of
the Ohio State Department of Health:
The 1990 Objectives have given Ohio strong
direction in planning strategies for health
promotion and disease prevention throughout
the state. They have served as the primary
guide in the development of the Health Promo-
tion and Disease Prevention Component of the
Ohio State Health Plan and in the preparation
of the annual Preventive Health and Health
Services Block Grant Plan. The objectives have
strongly influenced the implementation of
community-based health promotion projects and
have directed attention to issues of statewide
significance, such as hypertension. (#129J
The Indiana State Board of Health found the 1990
Objectives helpful in providing a framework for
several activities, including developing strategic initia-
fives, assessing health needs, and formulating a state
health plan. (#405) The Mississippi State Depart-
ment of Health used the 1990 Objectives in develop-
ing an operational plan for the agency as well as a
state health plan. (#125J
The Texas Department of Health also is an avid
supporter of the 1990 Objectives process. It has used
the process in setting and influencing state health
policy and in organizing traditional and nontraditional
community organizations that have the ability to influ
lmplementing the Objectives at State and focal Levels 15
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r Furthermore, the
objectives are influencing management practice by
being integrated with Model Standards language into
performance contracts established with local health
departments. (~020J
According to Dick Welch of the Minnesota Depart-
ment of Health, "The 1990 Objectives had an impor-
tant influence in Minnesota at both the state and
local level. The 1990 goals have helped turn what
were broad generalities into pragmatic goals. This
pragmatism has made our job easier in developing our
own statewide initiatives such as the recent Nutrition
Initiative and the earlier Non-Smoking Initiative."
(#225)
Robert Harmon, Director of the Missouri Depart-
ment of Health, says that his agency "has a strong
commitment to goal-directed public health manage-
ment. The 1990 Objectives and the Model Standards
have been acknowledged as important documents to
which Missouri public health must respond. The
Department of Health chose first to pursue long-
range strategic planning for the year 2000, and now is
in the process of addressing the 1990 Objectives in
the form of a mid-range plan." (~085)
The West Virginia Department of Health also used
the national objectives to develop health goals for the
year 2000. The state health department will develop
a list of the major health problems in each county
that account for the most potential years of life lost.
Each local health department will prioritize its major
public health risk hazards and develop health promo-
t~on and disease prevention plans. (~098J
The national objectives have also been used at the
local level. Bud Nicola, Director of the Seattle-King
County Department of Public Health, states that his
department
ence Public health within the state.
has made good use of both the Model Standards
and the 1990 Objectives in its long-range plan-
ning process and in annual program review and
budget preparation. Historically, local govern-
ment services are not prioritized or based on
major causes of morbidity and mortalit~not
even on measures such as years of life lost. The
use of national objectives helps us at a local
level to use morbidity and mortality data to
allow policy makers and the public to focus on
health status outcome measures, interrelated and
developed in a broad context as a basis for
policy, rather than individual perceptions.
(~320J
16 Healthy People 2000: Citizens Chart the Course
"The Allentown Pennsylvania Health Bureau has
used the 1990 Objectives as its primary programmatic
planning guide" says Gary Gurian, the bureau's
director. The Health Bureau has shifted its emphasis
from what was generally an acute problem agency to
a professional public health organization providing the
community it serves with prevention-oriented leader-
ship and services. Most of the Health Bureau's
award-winning initiatives have their roots in the 1990
Objectives. These initiatives include home and motor
vehicle injury prevention services, targeted smoking
cessation and awareness activities, and cancer preven-
tion and early detection services. Unfortunately,"
Gurian adds, "this nation's 1990 Objectives remain
one of the best kept secrets. They have been a
seldom-used tool by this nation's network of private
and public sector health organizations and decision
makers." (~076)
According to Thomas Milne, representing the
Washington State Association of Local Public Health
Officials, local health departments need more informa-
tion and encouragement to join in the objectives.
Most have not had the resources, time, or inclination
to assimilate the objectives into their work plans. To
increase the participation of local health departments,
Milne suggests (1) seeking more active involvement of
national organizations representing state and local
health officers, (2) distributing the revised objectives
to all local health departments and encouraging their
participation, (3) promoting and providing expanded
technical assistance for implementation of the Model
Standards, and (4) establishing a national focus in
each of the priority areas at different times during the
l990s and distributing materials to local health
departments to promote their involvement. (~328)
Robert Spengler of the Vermont Department of
Health is concerned that the 1990 Objectives lacked
practical implementation suggestions, such as how to
use multiple approaches, coalitions, and limited
resources to achieve results at the state level.
Resources, motivation, commitment, and account-
ability at the state level have been missing from the
1990 experience, along with valid studies about which
approaches work and which do not. He has three
suggestions:
1. Establish priorities. "List the top 10 achievable
objectives that should be considered first as national
priorities in health promotion or disease prevention.
An alternative might be to identify the top priority
for each of the major content areas."
2. Establish motivational efforts. "Detailed plans
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are needed to translate objectives into action at the
state and local levels. Motivational efforts are needed
and can be fostered by more technical support and
guidance from federal agencies, educational institu-
tions and the private sector." Financial support for
demonstration projects is also needed.
3. Establish evaluation efforts. "A greater em-
phasis must be placed on agencies/organizations with
principal responsibilities being held accountable for
monitoring and evaluation." These agencies should
determine "efficacy, effectiveness, efficiency, cost-
benefits, and transferability of program activities" and
should share data and compare intervention strategies
and evaluations across states. (#458J
Robert Bernstein, Texas Commissioner of Health,
suggests that As we move forward with the develop-
ment of Year 2000 Health Objectives, it is essential
that the roles of states are fully established in the
objective-setting process." He recommends that time
be provided for states to react and start a companion
process to establish their own objectives while the
Year 2000 Health Objectives are being drafted. Once
national and state objectives are established, state and
local implementation plans must be written to incor-
porate the appropriate strategies and actions into
operational plans of appropriate organizations.
(#020)
The Model Standards
The 1990 Objectives are not the only federal approach
to improving health promotion and disease preven-
tion. In particular, many state and local health
officers and others make reference in their testimony
to the Model Standards for Community Preventive
Health Services, a collaborative effort of the Centers
for Disease Control, the American Public Health
Association (APHA), and a number of public health
professional associations to establish local standards
through planning. According to the testimony, some
communities, when presented with the Model
Standards and the 1990 Objectives, have had difficulty
in understanding how the two are related.
This confusion results from differences between the
documents. First, the 1990 Objectives are national in
scope, whereas the Model Standards are oriented to
local action. Although the goals of the Model
Standards and the 1990 Objectives are complementary,
they often are seen as two sets of policy directives for
already limited resources. The Model Standards,
however, can assist states and localities as an
implementation tool to make the 1990 Objectives
meaningful and applicable at the local level, and as a
means of gaining strong partnership and commitment
to these objectives.
For instance, William Schmidt of the Wisconsin
Department of Health and Social Services says, "I
perceive the objectives for the nation as a statement
of intent, and Model Standards as the linking mecha-
nism between those intentions and an achievable
public mission. The objectives set the direction, but
Model Standards describe the organizational capaci-
ties, administrative and program processes, and by
inference, the financial resources to get there.
Objectives without standards are unfocused public
will; standards without objectives are unfocused public
resources." (~4 76) Richard Biery, Director of the
Kansas City Health Department, adds that Setting
national objectives is only an empty and futile gesture
without, at the same time, promoting a practical,
usable implementation plan for achieving the objec-
tives, one that involves every unit of our public health
system. (#365)
According to Susan Addiss, Director of the
Quinnipiack Valley Health District in Connecticut,
"The Model Standards provide the quintessential
process for successful implementation of the Year
2000 Health Objectives at the state and local levels.
Because the outcome objectives are set by the com-
munity itself, it is possible to establish incremental
steps that are attainable and that give the community
a sense of accomplishment on the way to attainment
of a national objective that may by itself appear
unattainable." (~460)
Nelson Frissell, Director of the CiW-County Health
Department in Casper, Wyoming, says:
The Model Standards process is a primary and
inherent ingredient in the development of any
objective. It becomes a way of thinking, a way
of looking at the ability to come from a com-
mon ground to diverse but specific outcomes
within the overall umbrella of a national effort
rather than trying to get from the diversity of
local effort back into some common denomina-
tor of maximum effect. By using the Model
Standards process, it is easier to see how we
integrate one with another even though the
ultimate objective may seem different. It's a
universal tool, a common skill basis, that can
highlight and emphasize the connectedness, that
notices and points out the similarities, and
focuses where we fit together instead of where
we don't. I view the Model Standards process
Implementing the Objectives at State and Local Levels 17
OCR for page 18
as the building block, as the basis for com-
plementing efforts, the process from which the
objectives for the nation can flotsam allowance
and assistance of local implementation and
focus, while augmenting interconnected actions
in the local effort to define roles and relation-
ships by utilizing a common process to focus on
a larger national impact. (#364)
The fact that the Year 2000 Health Objectives are
objectives for the nation is both their principal
strength and their principal weakness, according to
Schmidt.
The strength is in the recognition that all
sections of the U.S. health care system, public
and private and at all levels, need to marshal
behind these objectives. The weakness is that
objectives for all, conceptually, can all too easily
become objectives for none in actuality. Model
Standards has recognized this by stressing the
concept of "A Governmental Presence At the
Local Level (AGPALL3." (#476)
Carole Samuelson, Director of the Jefferson County
Department of Health in Alabama, adds that
AGPALL represents
the idea that government, either at the local or
state level, is ultimately responsible for ensuring
that standards are met. Not that government can
or should do everything that has to be done to
meet all standards, but that government must
take the lead in this process (by providing
necessary services or at least making sure that
the necessary services are being provided). The
very best objectives are unlikely to be accom-
plished unless a specific person or agency
assumes leadership for promoting and achieving
them. Likewise, it is extremely important that
while one agency is responsible, objectives must
be community-oriented and must promote inter-
agency and intergovernmental cooperation.
(~260)
The 1990 Objectives document gives specific rates
and figures for objectives, whereas the Model Stan-
dards document uses an open-ended, fill-in-the-blank
framework for local objectives.
Many testifiers note that in instances where the
intent of the two documents is the same, incongruent
terminology between them sometimes masks their
18 Healthy People 2000: Citizens Chart the Course
agreement and complicates their relationship.
Samuelson says that One of our frustrations In using
the Model Standards has been the confusion that
occurs because there are two very similar documents:
the Model Standards document and the 1990 Objec-
tives document. There have been instances when the
wording in the two documents is similar but different
enough to cause confusion." (~260)
Schmidt says that the "process of using both
documents works, but it takes a great deal of effort
and requires patching the two together. Often,
though the overall intention of the two documents is
the same, the terminology differs and the relationships
are difficult to ascertain. It doesn't have to be that
way. It would be a tremendous service to the people
using the two documents to meld them together so
that they flow and complement each other." (~476)
Many other witnesses? such as Carol Spain of the
Health Officers Association of California, suggest that
the national objectives and the Model Standards be
better integrated.
The Year 2000 Health Objectives need to go
further by actually integrating the relevant
Model Standards in the appropriate sections of
the year 2000 document. This integration is
critically needed in order to provide the imple-
mentation framework for achievement of process
and outcome objectives that will assist each local
and state health department in meeting the Year
2000 Health Objectives within their own juris-
dictions. It is only through the achievement of
the Year 2000 Health Objectives at the local
level that the objectives will be achieved at the
highest level, the nation. (~204)
The witnesses suggest that the merged document
keep some of the philosophy (e.g., Bexibili~,
AGPALL, community involvement) of the Model
Standards for use by states and localities. The
merged document "should establish national objectives
but have a mechanism for local communities to
convert these national objectives into attainable local
objectives. The document also should stress the
government's responsibility to ensure that objectives
are met, but emphasize the importance of the entire
communing working toward a common goal." (~260)
The Model Standards committee and the U.S.
Public Health Services (PHS) Office of Disease
Prevention and Health Promotion are currently
planning to develop such a document. Represen-
tatives of the Model Standards committee are working
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with the groups drafting the Year 2000 Health
Objectives, and the Model Standards committee will
produce a companion document for use by state and
local health agencies that employs the Year 2000
Health Objectives as a base and focuses on the steps
required to implement them on a community level.
Federal Funding
Many witnesses called for a federal leadership role in
implementing as well as determining the objectives.
Their suggestions ranged from providing research
results and technical assistance in implementing the
objectives to the financing of state and local activities.
According to William Blockstein of the University
of Wisconsin-Madison, for instance, there should be
a separate federal interagency work group for each
health problem, and this structure should be dupli-
cated at the state level by using a consortium of state
and territorial health departments and private sector
professional and voluntary organizations. These ef-
forts should be coordinated by the PHS. The work
groups should develop (1) print, radio, and television
public service announcements in a variety of lan-
guages, in tune with the educational level and cultural
values of the subculture being addressed; (2) help
lines that will provide callers with nonthreatening,
helpful, and comprehensible information on preventive
measures; and (3) resource manuals that detail
successful prevention programs in many languages and
for various educational or cultural backgrounds.
(~518)
According to Alfred Berg of the University of
Washington:
The United States needs a process of ~den-
titring essential services and ensuring that they
are delivered. The scientific basis underlying
health promotion and disease prevention can be
expected to change constantly, so that a per-
manent body constituted to monitor the state of
the art and to advise the government should be
appointed. The U.S. Preventive Services Task
Force should become a permanent advisory
body, and its scope of responsibilities expanded
to include access and manpower issues. A
mechanism for incorporating recommendations
from the Task Force into national health policy
should be identified; the recommendations
should include a minimum core of essential im
munizations, screening tests, and health promo-
tion activities. All Americans should have ac-
cess to the recommended core of health pro-
motion and disease prevention services,
regardless of insurance status. (#315)
Stephen Goldston of the University of California,
Los Angeles suggests that federal health agencies be
required to budget specific funds to implement the
plans for achieving the Year 2000 Health Objectives,
emphasizing primary prevention, rather than secon-
da~y or tertiary prevention. (#280J Nor due con-
sideration of the major chronic diseases, the National
Institutes of Health should be involved," writes Lester
Breslow of the UCLA School of Public Health.
That involvement did not occur to any great
extent in setting the objectives for 1990, thereby
perhaps limiting the achievement. You will re-
call that in the 1990 Objectives no mention of
the major chronic diseases appeared. Now the
Public Health Service appears to be embarking,
with all of its relevant elements, on a full and
appropriate health agenda. That is a highly
promising development. It will tend to bring
the National Institutes of Health into what many
of us always thought should be included in their
missions, namely, efforts to prevent the chronic
diseases and promote health, especially among
the elderly. (#026)
Many witnesses testified that state and local health
departments lack the resources necessary to imple-
ment the national objectives. Their suggestions for
addressing this problem include direct federal funding
of health promotion/disease prevention activities,
demonstration projects at the state or local level, and
direct support through already existing funding pro-
grams. Many of these issues are discussed in more
depth in Chapter 8.
The American Public Health Association's Com-
munity Health Planning Section reports that since the
Midcourse Review came out in 1986,2 there have
been substantial decreases in federal funding for some
health programs. If new goals are to be attained, or
old ones maintained, the objectives are going to have
to deal more with supporting infrastructures. With-
out federal funding and strong community planning,
states lose focus and the ability to implement the
objectives. (#756)
Implementing the Objectives at State and Local Levels 19
OCR for page 20
The Association of State and Territorial Health
Officials comes to the following conclusion:
Establishing and achieving the national health
objectives is a process that will require the
commitment of resources from all levels of
government-not just the federal government as
well as from private sources. Lawmaking
bodies, from the Congress to individual city
councils, must accept the idea of national health
objectives and support the objectives by appro-
priating funds. For example, the federal gover-
nment should consider funding staff for the
objectives-setting process at the state level. In
turn, states must work to ensure provision of
technical assistance to local governments in
building community support for priority health
objectives.
Even when the burden is shared, resources
for achieving the national health objectives will
be limited. To be successful, the objectives must
be realistic in terms of the expected resources
available to achieve them. Existing and poten-
tial resources must be tied to the national
objectives, and, in turn, the objectives must be
realistic to accommodate limited resources.
(#750)
Rhode Island's Director of Health, Denman Scott,
agrees that state health departments are in a strategic
position to translate the Year 2000 Health Objectives
into action. To help them do this, he suggests that
the federal government specifically earmark a pool of
money for attainment of the Year 2000 Health Objec-
tives at state and local levels. As a prerequisite to
receiving such assistance, health departments would
be required to produce a health objectives plan. "In
order to give this proposed program the momentum
it deserves," says Scott, An initial funding base of $1
per person, or about $250 million per year should be
allocated to the state health departments based on the
size of their state populations and the quality of their
national health objectives plan." Scott suggests that
the Centers for Disease Control administer the
process Because of its excellent track record of work-
ing collaboratively and constructively with state health
departments." (#461J
A number of witnesses testified that some of the
20 Healthy People 2000: Citizens Chart the Course
funding problems could be solved by tying currently
existing federal funding programs to the national
objectives. The preventive health and health services
block grant program, funds for community health
centers, and Medicare and Medicaid were all dis-
cussed.
Mark Richards, Secretary of Health for the
Commonwealth of Pennsylvania, recommends "that all
recipients of block and categorical grant funds should
clearly demonstrate how they will help to meet the
appropriate Year 2000 Health Objectives." (#387)
Based on her experience with the 1990 Objectives in
South Dakota, Katherine Kinsman suggests that one
way for the federal government to consistently sup-
port the objectives is to use them as the focus and
criteria for federal grants. (#629J
Thomas Halpin and Karen Evans report that the
preventive health and health services block grants
have been crucial in shaping disease prevention and
health promotion plans in Ohio. "Well-prepared
plans and strategies that lack resources for implemen-
tation are lofty but unobtainable ideals," they write.
"The objectives must be supported with a con-
centrated, cooperative effort at the federal, state, and
local level to continue and to increase the preventive
health and health services block grant." (#129)
Karen Grieder, Director of Research with the
Texas Association of Community Health Centers,
writes that centers are federally funded and serge poor
or indigent populations. In South Texas, for instance,
the community health centers are primarily used by
minorities, migrants, uninsured females, and border
communities-people who have nowhere else to go for
health care. These centers operate on limited budgets
and do not have or collect very much data. They
must, however, write their health plans around the
1990 Objectives when applying for grant money. This
is especially difficult because the cases they are
seeing~iabetes, for example-are not specifically
targeted in the 1990 Objectives. Grieder asks for
better coordination between state and federal agen-
cies, improved funding, and a realistic expectation
from the government of what community health
centers are to monitor and implement. f#747J
Many testifiers also suggested that Medicare and
Medicaid should more consistently cover preventive
health. Richards says that The Medicaid and Medi-
care programs should be restructured to encourage
and allow for the reimbursement of preventive and
early disease detection services." (~387)
OCR for page 21
INTERSECTORAL COOPERATION: ROLE OF THE
PRIVATE SECTOR
Across the board, witnesses testified about the need
for various sorts of intersectoral cooperation in
implementing the national objectives at a local level.
States and local health departments were seen as
having the pivotal role in implementing national
objectives locally, but testifiers repeatedly stressed the
need for cooperation with other sectors. Some called
for involving the general public, for community
participation, and for developing partnerships with the
private sector. Others stressed the need for local,
state, and regional efforts, and the need for a federal
role in implementation. Harmon suggests that public
health institutions at each level of government take
the lead in identifying other public or private par-
ticipants and inviting them into the Year 2000 Health
Objectives process. The objectives, he says, are "natu-
ral bridges for cooperative interagency ventures to
promote public health." (#085J
Professional organizations also have an important
role to play in formulating and implementing the
national objectives. According to the American Asso-
ciation of Public Health Dentistry, success in meeting
the objectives "is only possible through coordinated
public and professional efforts, individually and
collectively. Each professional association must be
involved and must identifSr potential roles that its
members may play in accomplishing the objectives and
make efforts to challenge its members to do soy
(#156)
Many of these issues are discussed in depth in
Chapters 8 and 9 on health promotion and disease
prevention in medical and nonmedical settings.
Community Participation
As Jerrold Michael of the University of Hawaii at
Manoa says, The achievement of health is not in the
hands of the health professions alone. The resources
of health, education, economic development, and hu-
man services must become connected to and inter-
woven with health objectives." (#149) Many other
witnesses supported this point of New, and called for
public and community participation in implementing
the objectives. Some spoke about mobilizing indivi-
duals and ~consumers." Others called for efforts to
mobilize entire communities. Some testifiers ad-
dressed the potential role of community organizations
and professional societies.
The APHA calls for strong public participation in
the objectives process.
There is a need to involve the general public in
health promotion and disease prevention, in
order to enable individuals to determine for
themselves the means to achieve optimal health.
Methods should be developed to increase con-
sumer participation and expand the roles of
health consumers in achieving the objectives for
the nation. The objectives should go well
beyond health professionals and health agencies
and develop consumer roles and outreach pro-
grams that are more conducive to achieving the
objectives and reaching the population in great-
est need.
The APHA testimony contains three suggestions for
increasing public participation: (1) developing state
implementation plans that have public service materi-
als supporting an active role for health consumers and
health professionals, (2) developing curricula material
for public health professionals to promote public
educational programs, and (3) building coalitions of
health consumers and providers. (~198)
Woodrow Myers, Indiana State Health Commis-
sioner, says that "we must do more work within our
communities to revive their ability to identity and
address their own health needs, to look for local
solutions to local problems, and where appropriate, to
link these problems to statewide solutions that affect
other communities' problems and ultimately to
national solutions, whether private or public, to
address those needs." (#405J
Colorado's Governor Roy Romer agrees that
communities must get involved in preventive health
care. At a hearing on the Year 2000 Health Objec-
tives in Denver, he described a successful community-
based program in Colorado aimed at preventing
alcohol and drug abuse. "We are talking to high
school youngsters about what they can do, themselves,
within their own peer groups and within their own
community to begin to set the stage for mutual
reinforcement of coming to terms with their own
responsibility as citizens." (~786) Many other
community-oriented programs are described In
Chapter 9 of this report.
Herbert Rader of the Salvation Army uses his
organization's efforts as an example of the role that
community organizations can play in implementing
national objectives. The Salvation Army has activities
that address (1) health needs of the poor; (2) sub-
stance abuse (including intravenous drug use and
Implementing the Objectives at State and Local Levels 21
OCR for page 22
AIDS); (3) homelessness; (4) assisting young people
to avoid high-risk behaviors; and (5) sexual behavior,
unintentional pregnancy, and sexually transmitted
diseases. Rader says that psychosocial factors and
religious principles play a major role in determining
the content of these programs. (~432J
"Our nation does not lack the epidemiological or
biostatistical evidence for the benefits of disease
prevention and health promotion initiatives," writes
Bertram Yaffe, President of the Erna Yaffe Founda-
tion.
Nor do we lack the educational or primary
prevention techniques for the deployment of
these initiatives. What we do lack is a sustained
dialogue between health professionals and the
individuals who can create the political will to
transform the curative model of health services
into a preventive model of a health system. We
need a constituency for prevention-a broad-
based, advocacy process analogous to the civil
rights, feminist, and environmental movements.
It must be global in its concerns, but politically
very local and indigenous In implementation. It
is the leadership in the creation of the move-
ment, that is the future and the real challenge
of Public Health. Health status is a reflection,
not of lifestyle alone, but of social, economic,
political, and all other circumstances that impact
on individuals. We must recognize that it is not
sufficient for health status goals to be articu-
lated by health professionals alone; they must
also be delivered as messages of political com-
mitment. All of us must be agents for the
creation of a nonpartisan, but very political,
movement to promote the Ecology of Health.
(#454)
Yaffe calls for more regional consortia on health
promotion and disease prevention. The New England
Conference for Disease Prevention, Health Protection
and Health Promotion (NECON), which Yaffe chairs,
is a coalition of six New England public health
departments; four schools of public health; federal
health agencies in the region; various departments of
the schools of medicine and allied health professions;
educators; legislators; and representatives from in-
dustry, labor, and voluntary organizations. It was set
up to assess the progress of the New England states
toward the 1990 Objectives and to offer some strate-
gies for further improvements in the health status of
the region. It is funded by grants from the public
22 Healthy People 2000: Citizens Chart the Course
and private sectors.
Through a series of conferences and task force
activities, NECON has developed a regional network
of nearly 300 individuals That has evolved into an
effective, nonpartisan constituency to achieve healthy
public policies and develop specific programs." The
New England Governors' Conference has recognized
the importance of NECON's goals and activities, and
has established a New England Regional Health
Committee to receive and consider NECON's recom-
mendations. (#454)
The Colorado Trust is another group that believes
that grass roots health promotion can lead to lasting
improvements in health status. According to its
executive director, Bruce Rockwell, the trust is a
philanthropic, grant-making foundation devoted to
health, medical, and human services in Colorado.
One of its major programs is Colorado Action for
Healthy People, which is based directly on the 1990
Objectives, funded by the Colorado Trust and the
Kaiser Family Foundation, and carried out through
the auspices of the Colorado Health Department.
The program's strategies include (~) grants to com-
munities that already are well organized to seIve as
demonstration projects for other communities; (2)
technical assistance in community organization such as
needs assessment, selection of interventions, and
evaluation; and (3) state-level activities, including
media campaigns, data collection, dissemination, and
regulatory activities. (#709)
Corporate Partnerships
The business community, too, has a role to play In
implementing the Year 2000 Health Objectives. The
testimony shows that there is interest in the business
world.
For instance, a survey of 48 companies about
business involvement in health promotion and disease
prevention, more specifically the national objectives
process, conducted by the Washington Business Group
on Health found the following:
Many of the objectives are especially relevant
to businesses who pay for the health care costs
of not only their employees, but also their
dependents end retirees. Increasingly,companies
are concerned with maintaining and improving
health. In addition, it is hoped that businesses
will use the new objectives to help set their own
health goals. Therefore, it is not only impor
tant, but necessary that America's businesses
OCR for page 23
play a key role in the process of establishing
new national health objectives for the year 2000.
The survey showed that over half of the firms that
responded (27) had heard of the 1990 Objectives, and
almost a quarter (11) had used them in some way.
Some companies used them to gain support for health
promotion and disease prevention activities in general,
to justify adding new programs, and as a means of
comparing their company's performance to national
standards. Others used them to change or reinforce
existing programs, help target new programs, and set
goals and objectives for long-range strategic plans.
(#355)
Paul Entmacher of the Business Roundtable says
that "as corporate citizens and as major taxpayers, the
countries major companies have a shared interest in
the health of the nation. Ceding the primary leader-
ship role to the government, however, the Business
Roundtable endorses the concept of ongoing, nonpar-
tisan, appropriate, public-private collaboration in
setting and measuring the nation's health objectives."
(~465)
The New York Business Group on Health calls the
work!site ha uniquely advantageous arena for programs
of health education/promotion that will further help
to achieve the national objectives." The work setting
offers the opportunity to target individuals based on
age, sex, education, and ethnic backgrounds; in
addition, it offers economies of scale, ease of access,
and peer pressure to increase program effectiveness.
(~448)
Virtually all the objectives can be addressed
through a specific workplace program, according to
testimony by the American Occupational Medical
Association. Health education and promotion pro-
grams developed to address problems of reproduc-
tion, childrearing, immunization, mental health,
substance abuse, hazard exposure, risk taking, and
self-destructive habits, can be provided efficiently and
effectively at the workplace. (~071)
Carl Schramm writes that the Health Insurance
Association of America (HIAA) has encouraged
coalitions by business and industry to foster a com-
munity environment" for health promotion and
disease prevention. For example, the HIAA's Center
for Corporate Public Involvement "sought to influence
the AIDS public debate by increased public/private
sector collaboration and through the expansion of
industry resources to combat the epidemic." Schramm
says that 21 community organizations received funds
for AIDS information and education and for support
programs from HIAA and the American Council of
Life Insurance member companies through a chal-
lenge grant program. (#619)
SURVEILLANCE AND INFORMATION
RESOURCES
The need for better data, in general, for specific
health problems and special populations arose repeat-
edly in testimony on the Year 204)0 Health Objectives.
For instance, Harmon says that Data represents the
single most critical element to successful planning."
As part of the objectives process, the nation must
identify data base weaknesses and build information
systems to fill the gaps. (~085J Others discussed the
need for other kinds of information, such as technical
assistance in implementing the objectives and informa-
tion about the effectiveness of health promotion and
disease prevention interventions.
Like a number of testifiers, the American Public
Health Association sees a need for an improved
system of data collection and analysis in order to
monitor the achievement of objectives. "lithe data
collection and analysis system is crucially according to
the AP HA, in identifying the nature and scale of
problems to be faced in achieving the objectives and
also in evaluating implementation activities to make
sure that the most effective program is in place to
achieve the objectives. (#198) Other witnesses re-
cognized the importance of establishing baseline data
in order to measure progress and evaluate outcomes.
State and Local Data Systems
Many witnesses spoke about the need for state and
local data and surveillance systems to set objectives
and to monitor progress toward them. Three criteria
came up repeatedly: uniformity, timeliness, and quali-
ty.
The Association of State and Territorial Health
Officials suggests that "data should, when feasible, be
collected in standardized forms across the country,
allowing for comparison of how different cities, states,
and regions are faring. For data that are not col-
lected nationally, state and local data should be
utilized in lieu of establishing new data systems."
(#750)
Viewing matters from the state level, Harmon calls
for efforts at both national and state levels to arrive
at a uniform data base with data that are no more
than two years old. (~085) Mary Anne Freedman,
representing the Association for Vital Records and
Implementing the Objectives at State and Local Levels 23
OCR for page 24
Health Statistics, stresses data uniformity and quality.
Data derived from systems that have multiple collec-
tion points with non-uniform collection methodologies
or non-standard sampling techniques must be used
with caution." Furthermore, "since the Year 2000
Health Objectives will provide a focus for many
agencies working to improve the health of all citizens
and are expected to be translated to state and local
needs, many state and local agencies will also adopt
the objectives." Therefore, says Freedman, "data
systems should address the needs of state and local
agencies as well as those for the nation. (#527)
Tom Jones, speaking for the Northwest Portland
Area Indian Health Board, says that healthy com-
munities depend on contributions from the individual
and family, the health delivery system, and community
government. He recommends an objective that would
urge all communities to have an information system
and appropriate statistical tools that could diagnose
the community's health problems, assess risk factors,
monitor health status progress, evaluate the effective-
ness of health programs, and identify additional
requirements necessary to arrive at an acceptable level
of health. The Native American tribes of the North-
west, Jones reports, are currently developing such a
system. (#473)
At the local level, "one would ideally have a local
office to gather, tabulate, interpret, and disseminate
those data needed to track the community's progress,
or lack thereof, relative to the various objectives for
the nation," according to Joel Nitzkin, Director of the
Monroe County Health Department in New York.
"Placing this function within the health department
will facilitate access to birth and death certificate data
and data on reportable communicable disease. In
more realistic circumstances, one can still do pretty
well with some relatively simple indicators that may
indicate the presence or absence of an obvious
problem." In addition, Nitzkin says, an "effective
means for integrating the surveillance data and
epidemiological process into the priority setting and
budgeting processes is also necessary. (#523)
Nitzkin suggests that The surveillance activity not
limit itself to simple totals and averages for the entire
jurisdiction. The jurisdiction should be divided
geographically, socioeconomically, and racially/
ethnically into subpopulations representing different
levels of health risk and geographic areas that might
be considered for targeting of programming. By
sorting both the numerator and denominator data this
way, one can avoid missing small areas of high risk
because they had been hidden Within a larger popula
24 Healthy People 2000: Citizens Chart the Course
lion at much lower risky (#523)
Specific Diseases and Problems
Many witnesses call for better data and data systems
on particular health issues. For example, testifiers
call for the following
.
An expansion of the current nutritional data
system by using registered dietitians as data gatherers.
(~5 72)
· Better data on environmental issues and
occupational safety and health. (~104)
· A "comprehensive and integrated system for
periodic determination of the oral health status,
dental treatment needs, and utilization of dental
services of the U.S. population." (#106J
· A national registry to measure the incidence of
fetal alcohol syndrome and fetal alcohol effects.
(~542)
· Better data on the incidence and prevalence of
AIDS and HIV (human immunodeficiency virus)
infection, as well as incidence and prevalence of other
retroviral illnesses. (~698)
Other particular data needs are discussed elsewhere in
this report.
An existing data source that could be used better
In setting objectives, according to Patrick O'Malley
and Lloyd Johnston of the University of Michigan, is
the National High School Senior Survey, "one of the
county's major sources of epidemiological informa-
tion on substance abuse among American adolescents
and young adults." It serves as a valuable source of
trends on drug and alcohol abuse, the potential for
accidents, and physical fitness and nutrition, and
should be used in setting and tracking objectives and
teen behavior. (~419)
Special Leeds of Minority Populations
Minority groups in the population have special data
needs. First, data on minorities as groups are often
lacking. Furthermore, as a number of testifiers point-
ed out, individual minority populations are themselves
heterogeneous, which calls into question even the
available data for groups such as Blacks, Hispanics,
and Asians.
For example, according to Sandral Hullet, Director
of West Alabama Health Services, there are no
characteristics shared by all minority subgroups.
Furthermore, speaking of the Black populations that
OCR for page 25
she selves, Hullet says that health research policies
and programs fail to differentiate among the special
needs of subgroups within racial, ethnic, and social
communities, which accounts for the disproportionate
burden of illness among minorities. More informa-
tion on the determinants of health and illness in each
subgroup is necessary to account for the different
susceptibilities and resistance of these groups to risk
factors. (~671J
Similarly, David Hayes-Bautista of the University of
California, Los Angeles suggests that basic data about
health promotion and disease prevention are lacking
for Latino populations. The problems arise from (1)
lack of uniformity~ome surveys are coded to names,
others to national origin, others to nationality, so it
is difficult to find homogenous populations for
comparison purposes; (2) lack of uniform definitions
and procedures; and (3) lack of data to get a baseline
profile of the Latino population. Hayes-Bautista also
says that a conceptual model for looking at Latino
health is lacking-the Black model simply does not
apply. With more than one linguistic group, more
than a single cultural or economic group, and not
solely an immigrant population, the Latino community
has unique characteristics and structural elements that
must be understood to develop appropriate interven-
tions, he says. (#679J
Michael Watanabe, representing the Asian Pacific
Planning Council, suggests that the Asian-Pacific
community also requires special attention because it
is not homogeneous. There are 17 distinct ethnic
groups with different norms and problems, including
a large refugee component. According to Watanabe,
Asians are often represented as a model minority, but
when subgroups are examined, problems with poverty,
education, crime, and delinquency arise, which are not
always represented in official statistics. Major health
problems also emerge in subgroups: high stomach
cancer rates among the Japanese and lung cancer
among the Chinese. f#683)
Information Resources
A number of testifiers identified the need for more or
better information to help implement the Year 2000
Health Objectives. This information included techni-
cal assistance about the objectives process for states
and local areas, better information about the costs
and benefits of disease prevention, and research to
support the objectives.
Milne called for more technical assistance to help
states and local areas implement the objectives.
(#328J Similarly, Kinsman suggested an addendum to
the publication of the Year 2000 Health Objectives
giving methods and tools needed to use objectives.
(#699)
According to Harmon, one of Missouri's main
recommendations for the Year 2000 Health Objectives
is to centralize technical resources at national, state,
and local levels. This requires establishing a technical
resources office at the national level to provide
technical assistance and training to states and local
areas involved in using the national objectives and the
Model Standards. This office could (1) establish a
library and clearinghouse for data and technical
information, (2) operate an electronic bulletin board
to disseminate information and encourage communica-
tion between states and local areas, and (3) make a
uniform national data set available through the
clearinghouse or bulletin board. (~085)
Those implementing the objectives at the state or
local level also require more information on the
effectiveness of prevention interventions. "All too
often," says Michael Eriksen of the Society for Public
Health Education, "the marketplace drives the availa-
bility of effective interventions. If money can be
made, programs will be marketed and sold, irrespec-
tive of need, quality, and effectiveness. Special efforts
need to be made to assure that effective health
promotion programs are diffused to the annror~riate
target groups." f#309)
--r Hi- - - r ~
_ _ ~ . ~
David Lawrence of the Kaiser Foundation Health
Plan of Colorado points out that employers and other
purchasers of health care, as well as "buncllers~ of care
such as health maintenance organizations and other
managed care organizations, are increasingly con-
cerned with the quality and appropriateness of the
health care they purchase. Many, however, are still
not sure which preventive programs are suitable at the
worksite, which are most effective, and how to evalu-
ate success. The national objectives can be a guide
for purchasers to determine how well bundlers (those
who put together the pieces necessary to deliver care
within systems) are doing in the areas of disease
prevention and health promotion. For this to work,
however, Lawrence says that data commissions or
other data collection and analysis entities must be
developed to evaluate the bundlers' effectiveness at
health promotion and disease prevention. (#3 75J
Similarly, the Business Roundtable suggests that a
public-private data consortium be organized early in
the objectives-setting process to help develop baseline
data and assist in the collection, retrieval, and analysis
of follow-up data. The absolute and relative expenses
Implementing the Objectives at State and Local Levels IS
OCR for page 26
associated with each goal should be estimated to
facilitate planning and prioritizing. (#465J
To use the national objectives well, information
about successful programs and the strategies used to
implement them must be shared. According to
Spengler:
To achieve objectives and strive for improving
health, it is essential that monitoring and evalu-
ation efforts be supported throughout any pro
REFERENCES
ject. A greater emphasis must be placed on
agencies/organizations with principal responsibi-
lities being held accountable for monitoring and
evaluation. The same agencies/organizations
should be held accountable for determining
efficacy, effectiveness, efficiency, cost-benefits,
and transferability of program activities. There
also needs to be more interstate data sharing
and comparison of intervention strategies and
evaluations. (~458J
1. Model Standards Work Group: Model Standards: A Guide for Community Preventive Health Services (2nd
Edition). Washington, D.C.: American Public Health Association, 1985
2. U.S. Department of Health and Human Services: The 1990 Objectives for the Nation: A Midcourse Review.
Washington, D.C.: U.S. Government Printing Office, November 1986
TESTIFIERS CITED IN CHAPTER 3
020 Bernstein, Robert; Texas Department of Health
026 Breslow, Lester; University of California, Los Angeles
071 Givens, Austin; American Occupational Medical Association
076 Gurian, Gary; City of Allentown Bureau of Health (Pennsylvania)
085 Harmon, Robert; Missouri Department of Health
098 Heydinger, David; West Virginia Department of Health
104 Hyslop, Thomas; Harris County Health Department (Texas)
106 Isman, Robert; The Association of State and Territorial Dental Directors
125 Larsen, Michael; Mississippi State Department of Health
129 Halpin, Thomas and Evans, Karen; Ohio Department of Health
149 Michael, Jerrold; University of Hawaii School of Public Health
156 Easley, Michael; American Association of Public Health Dentistry
198 Sheps, Cecil; American Public Health Association
204 Spain, Carol; Health Officers Association of California
225 Welch, Dick; Minnesota Department of Health
260 Samuelson, Caroler Jefferson County Department of Health (Alabama)
280 Goldston, Stephen; University of California, Los Angeles
309 Eriksen, Michael; University of Texas Health Science Center at Houston
315 Berg, Alfred; University of Washington
320 Nicola, Bud; Seattle-King County Department of Public Health
328 Milne, Thomas; Southwest Washington Health District
340 Lipsher, Julian; Hawaii State Department of Health
355 Jacobson, Miriam; Washington Business Group on Health
364 Frissell, Nelson; City-County Health Department, Casper, Wyoming
365 Biers, Richard; Kansas City Health Department
375 Lawrence, David; Kaiser Foundation Health Plan of Colorado
387 Richards, N. Mark; Pennsylvania Department of Health
405 Myers, Jr., Woodrow; Indiana State Board of Health
419 O'Malley, Patrick and Johnston, Lloyd; University of Michigan
432 Rader, Herbert; The Salvation Army in the United States
26 Healthy People 2000: Citizens Chart the Course
OCR for page 27
448 Warshaw, Leon; New York Business Group on Health
454 Yaffe, Bertram; New England Conference for Disease Prevention, Health Protection and Health
Promotion (NECON)
458 Spengler, Robert; Vermont Department of Health
460 Addiss, Susan; Quinnipiack Valley Health District (Connecticut)
461 Scott, H. Denman; Rhode Island Department of Health
465 Entmacher, Paul; Metropolitan Life Insurance Company
473 Jones, Tom; Northwest Portland Area Indian Health Board
476 Schmidt, William; Wisconsin Division of Health
518 Blockstein, William; University of Wisconsin-Madison
523 Nitzkin, Joel; Monroe County Health Department (New York)
527 Freedman, Mary Anne; Association for Vital Records and Health Statistics
542 Weiner, Lyn and Morse, Barbara A; Boston University
572 Williams, Corinne; California Dietetic Association
619 Schramm, Carl; Health Insurance Association of America
629 Kinsman, Katherine; South Dakota Department of Health
671 Hullet, Sandral; West Alabama Health Services
679 Hayes-Bautista, David; University of California, Los Angeles
683 Watanabe, Michael; Asian Pacific Planning Council (Los Angeles)
698 Lafferty, William; Washington State Department of Public Health
709 Rockwell, Bruce; The Colorado Trust
747 Grieder, Karen; Texas Association of Community Health Centers
750 Richland, Jud; Association of State and Territorial Health Officials
756 Reeves, Philip; American Public Health Association
786 Roemer, Milton; University of California, Los Angeles
Implementing the Objectives at State and Local Levels 27
Representative terms from entire chapter:
model standards
