4
Development of Leading Health Indicator Sets

During the past three decades, the concept of Healthy People has become entrenched within the national and state public health communities as an essential element of the nation's prevention agenda and public health focus. It has also provided the opportunity to monitor changes in health status, identify emerging health challenges, and facilitate the development, implementation, and evaluation of interventions that can be effective in responding to key health issues. As planning for Healthy People 2010 unfolds, it is apparent that the basic foundation of Healthy People 2010 will be further enhanced by establishing a small set of leading health indicators that could be presented and marketed to the general public. Thus, the Healthy People 2010 audience has been expanded to include the general population and community-based efforts rather than remaining in the domain of the public health system, as have the previous iterations of Healthy People.

The goal of such a leading set of target indicators is intended to increase the usefulness of Healthy People 2010 as a focus of national attention and a tool for monitoring America's health (U.S. Department of Health and Human Services, 1997b). Unquestionably, the full set of focus areas and related measurable and developmental objectives will continue to play a major role in the planning, implementation, and evaluation of public health interventions for all members of the U.S. population. However, it is now understood that recognition of and actions associated with the full compendium of focus areas and objectives have been limited largely, if not solely, to the health care community, especially the public health community. Development of a small set of leading indicators with a focus on measures that have meaning and relevance to the general public, public and private policymakers, and health and science professionals, however, has the potential to create a national identity for Healthy People and expand the Healthy People community to include a broader membership of diverse population groups and community agencies. In short, the leading indicators would promote health and serve as the “face” of Healthy People 2010 (Suzanne Stoiber, personal communication, 1998).

In preparation for the development of a leading set of health indicators, DHHS convened a work group whose members included 22 individuals representative of the Office of Public Health and Science, U.S. Public Health Service agencies, and other DHHS agencies. This work group was charged with preparing a background paper that would include information on the history of the Healthy People initiative, provide the rationale for identifying and using leading health indicators, and describe the potential uses and applications of leading sets of indicators. In addition, the work



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--> 4 Development of Leading Health Indicator Sets During the past three decades, the concept of Healthy People has become entrenched within the national and state public health communities as an essential element of the nation's prevention agenda and public health focus. It has also provided the opportunity to monitor changes in health status, identify emerging health challenges, and facilitate the development, implementation, and evaluation of interventions that can be effective in responding to key health issues. As planning for Healthy People 2010 unfolds, it is apparent that the basic foundation of Healthy People 2010 will be further enhanced by establishing a small set of leading health indicators that could be presented and marketed to the general public. Thus, the Healthy People 2010 audience has been expanded to include the general population and community-based efforts rather than remaining in the domain of the public health system, as have the previous iterations of Healthy People. The goal of such a leading set of target indicators is intended to increase the usefulness of Healthy People 2010 as a focus of national attention and a tool for monitoring America's health (U.S. Department of Health and Human Services, 1997b). Unquestionably, the full set of focus areas and related measurable and developmental objectives will continue to play a major role in the planning, implementation, and evaluation of public health interventions for all members of the U.S. population. However, it is now understood that recognition of and actions associated with the full compendium of focus areas and objectives have been limited largely, if not solely, to the health care community, especially the public health community. Development of a small set of leading indicators with a focus on measures that have meaning and relevance to the general public, public and private policymakers, and health and science professionals, however, has the potential to create a national identity for Healthy People and expand the Healthy People community to include a broader membership of diverse population groups and community agencies. In short, the leading indicators would promote health and serve as the “face” of Healthy People 2010 (Suzanne Stoiber, personal communication, 1998). In preparation for the development of a leading set of health indicators, DHHS convened a work group whose members included 22 individuals representative of the Office of Public Health and Science, U.S. Public Health Service agencies, and other DHHS agencies. This work group was charged with preparing a background paper that would include information on the history of the Healthy People initiative, provide the rationale for identifying and using leading health indicators, and describe the potential uses and applications of leading sets of indicators. In addition, the work

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--> group undertook a review of examples of sets of current health indicators and focused attention on both theoretical models and criteria essential to those models to develop a substantive set of leading health indicators. A detailed discussion of the work of that group can be found in the publication Leading Indicators for Healthy People 2010: A Report for the HHS Working Group on Sentinel Objectives (U.S. Department of Health and Human Services, 1997b). DHHS then turned to the Division of Health Promotion and Disease Prevention of IOM to convene a committee to consider the issue of leading indicators and to suggest a minimum of two sets of indicators for consideration by the Secretary of Health and Human Services as the leading health indicators for Healthy People 2010. The remainder of this report focuses on the activities of the committee as it discussed essential functions for potential leading health indicators, considered the strengths and weakness of proposed criteria to substantiate the selection of leading health indicators, and prepared for the future challenges of public comment and review. Functions of Leading Health Indicators The development of one or more sets of leading health indicators requires consideration of the functions to be served by the indicators. This issue was addressed only peripherally by the leading health indicators work group and resulted in the recommendation of the nine criteria (see below) that are essential for any individual or set of leading health indicators. To meet the larger goals established for Healthy People 2010, however, it is important to establish broader, interrelated functions for sets of leading indicators: (1) promotion of awareness, (2) motivation to action, and (3) feedback and assessment. These functions establish the cyclical nature of the leading indicators by establishing broad, population-based awareness of the indicator set and its quantitative targets. This awareness, in turn, would foster actions at the community and individual levels. Such actions precipitate a degree of change or movement addressing the cause and effect related to each of the individual leading indicators as well as the set as a whole. The cycle would be complete when the public received assessments in the form of regular and relatively frequent reports to update them on the status of the efforts toward achieving the targets for the leading set of indicators. Such feedback would then precipitate changes or increases in awareness, motivate additional action, and generate additional assessments to modify awareness and actions during the entire course of Healthy People 2010. A more detailed description of each of the functions is provided below. First, the leading set of indicators should achieve a level of awareness of, attention to, and recognition of leading health issues by the general U.S. population. Such awareness, attention, and recognition can be achieved only through the development, implementation, evaluation, and modification of a comprehensive plan for health communication and the dissemination of information. The importance of generating community and population commitment to the set of leading health indicators cannot be over-emphasized. Previous Healthy People efforts have effectively reached only federal, state, and local health agencies. Successful change in the behaviors of the general population can only be accomplished by inclusion of the general population in the process of change. This will be achieved only if the Healthy People 2010 leading health indicator initiative is supported by effective strategies to initiate, sustain, and maintain community and population involvement in every stage of implementation of the dissemination plan for the leading

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--> health indicators. An effective plan must also include delineation of communication strategies that will be appropriate and effective for diverse populations, especially those that may not have been reached by other health communication campaigns such as elderly and socioeconomically disadvantaged individuals. Furthermore, the proposed health communication plan must be dynamic and responsive to changes in the level of the population's awareness of the leading indicator set from 2000 to 2010. A strong evaluation plan will provide an ongoing assessment of progress, which in turn, will promote changes in dissemination strategies to ensure that the message about Healthy People 2010 and the leading health indicator set becomes firmly established in the awareness of the general population. The second key function of the leading health indicators for 2010 requires that the indicators, individually and as a whole, serve to prompt positive health actions by the general population. Again, this requires a stringent plan to assess behavioral responses to the individual and collective messages of the leading indicator set. This assessment plan will rely, in part, on the monitoring strategies established for the 20 focus areas and related objectives of Healthy People 2010. However, an ongoing evaluation plan directed at specific elements of the leading indicator set will be essential for monitoring behavioral responses provoked by the leading indicator set among both the general population and subpopulations of Americans. The third and final essential function of the set of leading health indicators will be the development and implementation of an assessment component to serve as a feedback loop by which the general population remains informed of the status of the individual and composite elements of the set. This requires adherence to a regular schedule of publication of “progress summary reports” for each of the leading indicators and the composite set. These reports would highlight the progress and the lack of progress that have occurred in specific areas. The dissemination plan would address the issue of creating expectations for routine reports by the American public and all of its subpopulations. It would also be used to motivate interest in activities that would address indicator set areas in which progress toward the expected target has not been achieved. This communication effort would complete the functional cycle of the leading indicator set by providing feedback that would increase the level of awareness by the general population and motivate action at the community and individual levels to proactively make progress toward the targets. It is important to recognize that the assessment of progress toward the leading health indicator goals will be monitored routinely by information readily available at the national, state, and local levels. Mechanisms will be established to ensure timely communication of this information to the general population and community organizations. Some of this information will be available at the beginning of the year 2000 while other information will begin to be collected during the interval of 2000 to 2010. This latter type of information will be considered developmental in nature but will still play in important role in monitoring progress and changes in awareness and actions associated with the leading health indicator set. Review of Criteria to Support Selection of Health Indicators The original DHHS working group also recommended that selection of the leading health indicator set for Healthy People 2010 be based on a set of criteria that would support a conceptual

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--> model of health promotion and disease prevention. The initial DHHS working group for leading health indicators established nine criteria that should be considered in the selection of individual leading indicators as well as the full set of indicators: the general public, opinion leaders, and the health and medical communities can easily interpret and understand the indicators; they reflect issues that affect the health profile of the nation's population in important ways; they address a problem that has a substantial impact on prospects for the health of the nation's population; they can be linked to one or more of the full set of Healthy People 2010 objectives; they are generally reliable measures of the state of the nation's health (or that of a subpopulation) to ensure that the problem is not reflective of the perspective of a relatively small part of the population aspect or population group; data on the indicators are available from an established source on a regular (at least biennial) basis; they have multilevel trackability to ensure that data can be anticipated at multiple levels and for multiple groups; they are reflective of a balance in the selection of targets that does not overemphasize any one group or condition; and they have utility in directing public policy and operational initiatives. The IOM committee has very little disagreement with these criteria but would elaborate as follows. Interpretability would be more clearly understood with words such as “relevance to the public including measures of understandability, salience, and interpretability by the general public.” Applicability, to the target population should be expanded to include national efforts to make the indicators applicable to broad groups of people in terms of geographic and demographic variables. The impact of the problem requires no further elaboration. However, it was suggested that the links of the leading indicator set to the full Healthy People 2010 publication is not limited only to specific objectives but also includes linkage with national policy through collaboration with DHHS. The committee suggested that use of the descriptor “representative” rather than “reliability” is a more accurate means of expressing equitable or balanced resources as defined by the DHHS working group. Similarly, the concept of measurable data can be substituted for the concept of data availability and multilevel trackability, and measurable data can be expanded to include data reliability and validity. Two additional criteria were also considered by the committee: sensitivity to change over a reasonable period of time and the ability to motivate action across multiple levels of the general population, including families, individuals, and community groups. These refined criteria will be discussed in greater detail at the next committee meeting and will be applied to the indicator sets that will be reviewed at that meeting.

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--> Future Directions and Challenges Phase two of this IOM project will result in a second interim report. The major components of that report will be examination of potential sets of leading health indicators, including a review of strengths and weaknesses. The public will then be able to comment on these through the internet, at a public forum, through written communication, or through email to the project Web site. The results of the public commentary will facilitate the committee's efforts to select and provide adequate justification for at least two sets of leading health indicators to be published in the third and final report during phase three of this project. The IOM committee has already noted several challenges that it must address in collaboration with DHHS. Specifically, the data available from national, state, and local sources raise concerns about the committee's ability to accomplish subpopulation-level analyses. Of equal or greater importance will be the reliability and validity of the data, especially data that are derived from multiple sources. Committee members also raised concerns about the ability to meet the second vision goal, elimination of health disparities. Their primary concern focused on the possibility that such a goal might be attained only if the health of the general population progresses or regresses toward the mean; that is, health and health behaviors would be improved among those who are disadvantaged but would be relaxed among those who have achieved or exceeded the objective target for 2010. This is a problem of considerable significance and concern to the committee, which is committed to developing a leading health indicator set that will support the visionary goal for Healthy People 2010, stating the importance of elimination of health disparities in subpopulations including those representative of different groups defined by gender, race and ethnicity, socioeconomic status, educational attainment, and age. The committee also raised concerns about the integration of the leading health indicator set with Healthy People 2010. Specifically, what plans are in place to disseminate the full Healthy People 2010 set of objectives to those populations defined as targets for the leading indicator set? How will these be coordinated with Healthy People 2010? Furthermore, will ODPHP or a special commission be responsible for release of data relevant to the leading health indicator set for 2010? How will these data be analyzed and reported to the nation? Furthermore, any changes in the existing methods of data collection or in the data content during the decade will undermine the validity, reliability, and credibility of data for the leading health indicator set. Dissemination of information about both Healthy People 2010 and the leading health indicators for 2010 will require two distinct dissemination plans adjusted to the various target populations. The diversity of the general population, which is defined as an audience for the leading health indicators for 2010, raises issues and concerns about communication and dissemination plans that are language appropriate, culturally appropriate, and generally responsive to the unique informational needs of the five target groups categorized by: age, gender, race and ethnicity, socioeconomic status, and educational attainment. Finally, the committee has begun to consider the issue of allocation of resources sufficient to support the data-gathering and dissemination functions, as well as intervention activities or initiatives at the local or community level. It is not clear whether funds will be available to support such activities or whether communities and individual constituents will be required to find adequate resources to conduct activities that might positively affect one of the leading health indicators. Such

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--> resources would not be limited to financial means but would also include technical assistance, training in data utilization and comprehension, and mechanisms that would promote the creation of an expanded network of individuals who are aware, action oriented, and responsive to data feedback. It is acknowledged that the charge to the committee did not include specific requirements for the development of strategies to integrate the leading health indicator set with full set of Healthy People 2010 objectives. Nor did that charge specifically request development of plans for data and information dissemination. It is the opinion of the committee however, that these issues are critical to the successful achievement of the leading health indicator objectives and must be addressed adequately in order to ensure the success of the Healthy People 2010 effort. Previous efforts to disseminate and achieve broad population commitment to discrete sets of leading health indicators have been unsuccessful largely because these and other issues were inadequately addressed. It is the intention of this committee to recommend additional actions to ensure successful implementation, dissemination, and evaluation of the leading health indicator set for 2010. These issues and more will be addressed in the second interim report in which potential indicator sets will be presented and critiqued.