Leading Health Indicators for Healthy People 2010: First Interim Report (1998)

For more than two decades public health planning has been guided by the concept of establishing target health objectives and monitoring of those objectives to promulgate positive changes in health status. Tables 2-1 and 2-2 provide an overview of the Healthy People timeline and its associated products and activities. The first such effort began with the report from the Surgeon General on health promotion and disease prevention entitled Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (U.S. Public Health Service, 1979). Outlined in that report were a set of general goals for reducing preventable deaths and injuries in different age groups by 1990. The basic premise for that report was disease prevention and risk reduction through behavioral change. In turn, these behavioral changes were expected to result in reductions in the numbers of negative health events and increases in positive health outcomes in five age cohorts: infants, children, adolescents and young adults, adults, and older adults. Adherence to a set of recommended risk reduction and health promotion behaviors was advocated as the mechanism by which significant mortality reductions could be achieved in each of the five age cohorts by 1990. These included the following:

1. an overall 35 percent reduction in the rate of infant mortality;
2. a 20 percent reduction in the numbers of deaths of children ages 1 to 14 years to fewer than 34 per 100,000;
3. a 20 percent reduction in the numbers of deaths among adolescents and young adults up to age 24 to fewer than 93 per 100,000;
4. a 25 percent reduction in the number of deaths among adults ages 25 to 65; and
5. a 20 percent reduction in the average number of days of illness among those over 65 years of age.

Fifteen specific strategies were described as the primary methods by which these five goals would be achieved. Each of the 15 strategies, in turn, comprised a variety of subobjectives that could be grouped into three major categories: (1) preventive services delivered by health professionals; (2) interventions undertaken by governmental agencies, industries, and other agencies to prevent harm; and (3) activities at the personal and community levels to promote healthy lifestyles. For example, preventive health services addressed family planning, pre- and postnatal care for mothers and infants, childhood immunizations, services for the prevention of sexually transmitted diseases, and hypertension control. Measures to protect health addressed control of population exposures to toxins, occupational safety and health, reduction of accidental injuries, fluoridation of community water supplies, and methods to control exposures to infectious agents. Finally, health promotion objectives focused on healthy populations and promotion of health-protective behaviors such as smoking cessation, reduction or elimination of the use of recreational drugs and alcohol, nutritional changes especially reduced levels of intake of certain foods, increases in the levels of exercise and overall fitness levels, and finally, stress control and reduction.

Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (U.S. Public Health Services, 1979) was the impetus for publication of a second report entitled Promoting Health/Preventing Disease: Objectives for the Nation (U.S. Department of Health and Human Services, 1980). That report enhanced conceptualization of the five broad goals and 15 strategies for achieving those five goals through the use of specific actions. Development of the objectives was the result of a 1-year process involving more than 500 individuals and organizations recruited from the private sector and government arenas, who articulated a number of different objectives for each of the 15 strategies or target areas. These quantifiable objectives addressed public health policies, health care delivery, health care access, personal health behaviors and other, similar parameters.

The U.S. Department of Health, Education and Welfare (now DHHS) convened a conference in Atlanta, Georgia, in June 1979. Responsibility for conference coordination was shared by the Centers for Disease Control and the Health Resources Administration associated with the Office of Disease Prevention and Health Promotion of the Office of the Assistant Secretary for Health and Human Services. A total of 167 experts were invited to the conference to participate in 15 work groups consistent with each of the 15 areas outlined in the Surgeon General's 1979 report. These experts represented multidisciplinary academic and applied fields of expertise including private-and public-sector health care providers; academicians with expertise in epidemiology, behavior modification, and social science; state and local health organizations; community health groups; consumers; members from industry; voluntary health associations, and bench scientists.

Each panel of experts in the 15 work groups, drafted a set of quantifiable objectives that were published in the Federal Register in the fall of 1979 to elicit broad-based review and comments. Interim and final revisions were completed by the spring of 1980. These activities were in response to the National Health Planning Goals described in Section 1501 of Public Law 93-641 (which at the time was under the responsibility of the Health Resources Administration) and the Model Standards for Community Preventive Health Services required by Section 314 of Public Law 95-83, with implementation coordinated by the Centers for Disease Control. The overriding tenet of the

goals and objectives was to achieve a national impact in purpose and scope rather than one that was limited to a government or federal agenda for design, implementation, and evaluation. It was also required that both science and policy support each objective in such a way that actual achievement of the objectives was consistent with what one might consider feasible during the decade from 1980 to 1989, assuming that no major innovations, scientific breakthroughs, or policy changes occurred during that 10-year interval. Finally, achievement of the objectives was intended to require the participation and contribution of

A standard format was developed to describe each of the 15 prevention strategies and their related sets of quantifiable objectives. This included a discussion of each of the following topics:

1. the nature and extent of the health problem, including a review of health implications, status, and trends;
2. a description of plausible disease prevention and health promotion measures that might involve education, legislation, information dissemination, economic incentives, and social-behavioral interventions;
3. specific national objectives for improved health status, means of reducing behaviors that place a person's health at risk, improvements in public and professional awareness of relevant issues, and improvements in services including protective services to reduce exposures;
4. the principal assumptions that supported the basic parameters of each objective; and
5. the data required to monitor positive and negative changes in each objective.

objective within the 15 areas was necessary and essential. Specifically, a baseline rate for each objective would be required to provide an initial profile for each objective before any intervention or policy change could take place. Of equal or greater importance was the need for dynamic and sensitive surveillance systems for each objective to permit tracking of changes from the baseline. The ideal data system would provide reliable data on a continual reporting schedule, and the data would be coded according to universally determined operational definitions. It was recognized, however, that the data available for each of the 15 areas and their accompanying quantifiable objectives were likely to fail to meet the criteria for an ideal data system. This was attributed to factors such as the absence of baseline data, wide variability in both the operationalization of data collection and the methodology used for data collection, the poor reliability of data collection efforts, and variability in the methods of analysis. Acknowledgment of the flaws inherent in many of the database monitoring activities and behaviors in the 15 areas and their related objectives resulted in an additional emphasis in the report recommendations to focus efforts on improving the quality of data collection capabilities over the course of the decade.

In addition to the need for rigorous, consistent, and statistically adequate databases for each area and its related objectives, the report emphasized the need to base objectives and interventions on the highest-quality research framework available. It was acknowledged that for the 15 strategies such frameworks varied in their stage of development because of variations in the strength and quality of the theoretical and scientific bases for implementation of development, measurement, and intervention activities. It was also pointed out that ongoing research during the decade could, and most likely would, result in significant changes in the state of the science for the 15 areas and their related objectives. Consequently, changes in objectives, intervention strategies, and measurement strategies were likely to occur because of achievements in the areas of basic biomedical research, behavioral research, social science research, and legal and policy research. This was considered a potential weakness in the Healthy People effort primarily because of possible compromises in the consistency in the type of data collected, in the method of data collection, and in the means of data analysis. Despite this potential weakness, the authors of the report generally advocated for increased research efforts in each of the 15 areas simply because it was recognized that extant knowledge was in general, limited for each area, with more significant limitations evident for the specific target objectives.

The resulting document, Promoting Health/Preventing Disease: Objectives for the Nation (U.S. Department of Health and Human Services, 1980) has provided the framework for the design, implementation, and evaluation of public health activities for the ensuing three decades The initial document included 15 strategic areas and a total of 226 objectives focused on improving health status and reducing behaviors that place health at risk through the use of interventions to reduce mortality and morbidity, as well as to promote prevention and behaviors that protect health. Implementation of the specific objectives was facilitated by the establishment of work groups from each of the lead federal health agencies contributing to the development of the 1990 priorities and objectives. Members of these groups identified those objectives of highest federal priority and then

developed implementation plans for the intervention(s) that reflected available and potential program actions. These work groups then identified agencies at the federal, state, and local, levels, that represented both the public and the private sectors and whose cooperation in the implementation phase would be valuable and required. The implementation plans, along with the collaborating agencies, were published in 1983 in a special supplement of Public Health Reports (U.S. Public Health Service, 1983).

Evaluation of the Objectives for the Nation report occurred at two distinct levels, including periodic progress reviews and a midcourse review. First, a system of progress reviews was established, which consisted of briefings for the Assistant Secretary for Health and Human Services. These progress review sessions involved representatives from lead and collaborative agencies who presented to the Assistant Secretary summaries of activities and reprised the current status of the objectives in each of the 15 areas. These summaries included a discussion of the progress that had been made as well as shortfalls, problems with implementation and evaluation, and suggestions for modifications to the specific language of objectives or to the implementation plans. These detailed reviews were published in Public Health Reports (U.S. Public Health Service, 1983) and to facilitate public awareness of the major issues. In retrospect, it seems unlikely that publication of the progress reports in these two journals would have any likelihood of reaching the general population, although the scientific community would benefit from the updates. Two review sessions focusing on each of the 15 areas and their accompanying objectives were conducted with the Assistant Secretary for Health and Human Services by the spring of 1986.

A midcourse review was also planned as an evaluation strategy for the 15 areas and their 226 related objectives. This review was intended to be decentralized, comprehensive, collaborative, and preparatory for the development of objectives for the next decade (1990 to 1999). Briefly, results of the midcourse review for the five age cohorts for 1990 to 1999 documented significant progress toward the mortality reduction goals for infants, children, adolescents and young adults, and adults. Thirteen percent of the total number of 226 objectives had been achieved by 1985, with an additional 35 percent projected to be attained by 1990 given the stability of the trend data. Slightly more than one quarter (26 percent) were considered to be unlikely to be achieved by 1990, and data for an additional 26 percent were inadequate to permit appropriate monitoring. Examination of the data for the three major categories of objectives (preventive health services, health protection, and health promotion) revealed that 52 percent of the health promotion objectives were projected to be achieved by 1990, with 24 percent being unlikely to be met and the data sources for the remaining 24 percent being inadequate. A similar review of health protection objectives revealed that 46 percent were on target to be achieved by 1990. Unfortunately, data sources for an additional 35 percent were inadequate and 19 percent of the objectives were not expected to be achieved by 1990. Finally, the midcourse review for objectives related to preventive health services indicated positive achievement trends for 45 percent of the proposed objectives offset by almost 40 percent compromised by inadequate data and 15 percent unlikely to be achieved in the projected time frame. This midcourse review was anticipated to be followed by a final report describing the status of each of the 226 objectives in 1991 combined with modification and promulgation of objectives for the interval from 1990 to 1999.

The development of priority areas and objectives for the year 2000 followed a similar model for the design, implementation, and evaluation of priority areas and related objectives. Some significant differences were incorporated into the Healthy People 2000 plan, however (U.S. Department of Health and Human Services, 1991). For example, the mortality and morbidity reduction goals for the five age cohorts proposed for the 1990 report were replaced by the following goals:

1. increase the span of healthy life for Americans,
2. reduce health disparities among Americans, and
3. provide access to preventive health services for all Americans

In addition, the original 15 areas were expanded, renamed and reorganized to include 22 priority areas, and one or more U.S. Public Health Service agencies were designated to coordinate activities that would support the achievement of objectives for each of these 22 priority areas. Furthermore, the objectives themselves increased in number to 300. In addition, subobjectives included an emphasis on special population groups to be responsive to the second goal, which focused on reducing health disparities among Americans. Evaluation strategies included the periodic briefing summaries for the Assistant Secretary for Health and Human Services and a midcourse review. The periodic reviews were published as briefings in Public Health Service Progress Review Reports on Healthy People 2000, with the first such review published in 1992 (National Center for Health Statistics, 1992). Additional briefings were published in 1994 and 1997 and focused on the presence and absence of positive and negative changes noted since the 1990 publication of Healthy People 2000 (National Center for Health Statistics, 1994, 1997).

The midcourse review evolved into a 2-year process initiated in 1993 and resulted in publication of the Healthy People 2000 Midcourse Review and 1995 Revisions in the fall of 1995 (U.S. Department of Health and Human Services, 1995). All subsequent status reports to the Assistant Secretary were based on the revisions to the objectives that resulted from this intensive review process. Specifically, the proposed midcourse revisions were announced in the Federal Register on October 3, 1994, to solicit public review and comment (Federal Register, 1994). This effort yielded no changes to the three underlying goals or in the organization of the 22 priority areas. However, a number of modifications to the quantitative objectives within each of the 22 priority areas resulted from more than 550 public comments in response to the Federal Register publication. These included: (1) new objectives reflecting scientific advances, changes in policy, or availability of new information or data; (2) duplication of existing objectives shared across the 22 priority areas to increase awareness of the multidimensional relationships among health issues; (3) language revisions to increase the ability of the general population to comprehend the objectives and to clarify the intent of specific objectives as well as revisions to accommodate current issues and reflect data source and system improvements; (4) specification of target populations that were at the highest risk

of premature death, disease occurrence, or disability; and (5) revising the quantifiable targets for the year 2000 to increase the challenge of meeting the objectives. The impact of the proposed changes on the number of objectives was formidable. A new total of 319 nonduplicate objectives was created. Summing across all accepted modifications resulted in a total of 638 nonduplicate objectives and subobjectives (specific for target populations) and 805 objectives and subobjectives when the duplicate objectives were included in the total count.

In 1995, results of the midcourse review for the year 2000 based on the revised set of 319 objectives, excluding subobjectives and duplicate objectives revealed that only 8 percent of the quantified targets for the year 2000 had been reached or surpassed. This was an indication that significantly less progress has taken place compared with the amount of progress that had been noted in the midcourse review of the goals for 1980, which indicated that 13 percent of the objectives had been met or surpassed by 1985. Positive progress toward achieving objectives was reported for 40 percent of the objectives in the 1995 midcourse review, whereas the value was 35 percent in the 1985 midcourse review. Conversely, regression or negative progress was noted for 18 percent of the objectives in the 1995 midcourse review, demonstrating that movement was away from the quantifiable target. Mixed results were apparent for 5 percent of the objectives, and no change was noted for 3 percent of the objectives. For a striking number (75, or 20 percent of the objectives) inadequate data were available to document progress from the baseline measure in 1991, and baseline data for 6 percent of the objectives (19 objectives) were lacking.

The Healthy People 2000 Review: 1997 (National Center for Health Statistics, 1997) revealed some compelling results. Thirteen percent of the objectives were noted to have reached or superseded the target quantifiable measure, and continued progress toward the objectives was apparent for an additional 43 percent of the objectives. Data for 7 percent of the objectives demonstrated mixed results, and only 2 percent of the objectives no change from the baseline was indicated. Objectives for which only baseline data were available were reduced in number to 44 (14 percent), with baseline data established for 4 new objectives that had previously lacked such data. No baseline rates were available for 3 percent of the total number of objectives (11 objectives) which was a significant improvement over the 20 percent for the Healthy People 1995 report (U.S. Public Health Service, 1995).

It is notable that along with the midcourse review for Healthy People 2000, efforts were made to develop an electronic inventory of data sets relevant to the monitoring of Healthy People 2000 at the national level. These efforts began in 1990 and resulted in six primary deliverables. These included the following: (1) preliminary data set inventory based on draft objectives for 2000, (2) preliminary identification of gaps in available data relevant to monitoring the objectives for 2000, (3) draft data set descriptors, (4) first update to the database inventory, (5) development of the Dataset Quality Assessment Criteria, and (6) a second inventory update of data sources used to establish baseline measures and provide ongoing monitoring of the status of Healthy People 2000 priority areas and related objectives.

This inventory was intended to describe the various data sets used to establish baseline rates for each of the objectives in the 22 priority areas as well as suggest alternative data sets that had the potential to be effective monitors of progress toward achievement of the 319 objectives at the national level. This effort included special attention to data sets that would be representative of the designated special subpopulations. This database inventory was also intended to include descriptors

for cross referencing objectives with specific data sets and to provide an assessment of each data set regarding the level at which it was appropriate to measure the 319 quantifiable objectives.