Executive Summary

Since its inception in 1979, Healthy People has been a significant and innovative health initiative to guide the efforts of this nation to (1) address disparities in health status and health outcomes between diverse population groups and (2) improve the overall health of the nation. Healthy People identifies opportunities at the national, state, local, and community levels to remediate the most significant and tractable issues affecting the health of all people residing in the United States. With its goal statements, focus areas, and objectives, Healthy People suggests ways to improve the health of the nation's population while using the knowledge and skills of national, state, and local government agencies, individual and group participants in communities, members of health care delivery systems, voluntary groups, and public—and private-sector organizations and agencies.

Healthy People 2010 is the third generation of this health initiative that is intended to address the health problems of this nation as it enters the next millennium. Efforts to develop Healthy People for the decade from the years 2000 to 2010 have been under way since September 1996. Although the identification of overarching goals, enabling goals, focus areas, and related objectives for the full Healthy People 2010 guidance document has dominated these efforts, much attention has also been given to the development of a small set of leading health indicators.

Similar to the five key measures in the first decade of Healthy People and the 47 sentinel indicators established for Healthy People 2000, Healthy People 2010 may benefit from a small set of leading health indicators that will be of interest, importance and relevance to the general public, non-health organizations, and traditional public and private health organizations. Leading health indicators can focus on a small number of key health and social issues that can be brought to the attention of the nation, motivate actions to exert positive influences over these leading health indicators and provide feedback concerning progress toward achieving the targets set for each indicator. Furthermore, a small set of leading health indicators can create a national identity for the full-scale implementation of Healthy People 2010 and expand the traditional Healthy People community to include a wide variety of agencies, organizations, diverse population groups, community organizations, and individuals.

Charge to the Committee

The Institute of Medicine convened a committee to consider the issue of leading health indicators for Healthy People 2010 and to develop and recommend a minimum of two sets of indicators for consideration by the U.S. Department of Health and Human Services. The committee received its charge from the department with several opportunities for review and discussion. The initial charge emphasized that the



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--> Executive Summary Since its inception in 1979, Healthy People has been a significant and innovative health initiative to guide the efforts of this nation to (1) address disparities in health status and health outcomes between diverse population groups and (2) improve the overall health of the nation. Healthy People identifies opportunities at the national, state, local, and community levels to remediate the most significant and tractable issues affecting the health of all people residing in the United States. With its goal statements, focus areas, and objectives, Healthy People suggests ways to improve the health of the nation's population while using the knowledge and skills of national, state, and local government agencies, individual and group participants in communities, members of health care delivery systems, voluntary groups, and public—and private-sector organizations and agencies. Healthy People 2010 is the third generation of this health initiative that is intended to address the health problems of this nation as it enters the next millennium. Efforts to develop Healthy People for the decade from the years 2000 to 2010 have been under way since September 1996. Although the identification of overarching goals, enabling goals, focus areas, and related objectives for the full Healthy People 2010 guidance document has dominated these efforts, much attention has also been given to the development of a small set of leading health indicators. Similar to the five key measures in the first decade of Healthy People and the 47 sentinel indicators established for Healthy People 2000, Healthy People 2010 may benefit from a small set of leading health indicators that will be of interest, importance and relevance to the general public, non-health organizations, and traditional public and private health organizations. Leading health indicators can focus on a small number of key health and social issues that can be brought to the attention of the nation, motivate actions to exert positive influences over these leading health indicators and provide feedback concerning progress toward achieving the targets set for each indicator. Furthermore, a small set of leading health indicators can create a national identity for the full-scale implementation of Healthy People 2010 and expand the traditional Healthy People community to include a wide variety of agencies, organizations, diverse population groups, community organizations, and individuals. Charge to the Committee The Institute of Medicine convened a committee to consider the issue of leading health indicators for Healthy People 2010 and to develop and recommend a minimum of two sets of indicators for consideration by the U.S. Department of Health and Human Services. The committee received its charge from the department with several opportunities for review and discussion. The initial charge emphasized that the

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--> committee should recommend a minimum of two candidate indicator sets that would (1) elicit interest and awareness among the general population, (2) motivate diverse population groups to engage in activities that will exert a positive impact on specific indicators and in turn, improve the overall health of the nation, and (3) provide ongoing feedback concerning progress toward improving the status of specific indicators. In subsequent meetings between committee members and staff from the U.S. Department of Health and Human Services, this charge was reviewed and clarification sought where necessary. Specifically, the committee was informed that the charge also included the development of potential dissemination strategies to promote the leading health indicators to the lay public and traditional public and private health care communities. It was also established that clear linkages should be demonstrated between the proposed indicators and the existing full draft of Healthy People 2010, including the two overarching goals, four enabling goals and 26 focus areas. Finally, the committee received additional direction that the candidate indicator sets should contain no more than 10 indicators and that any proposed indicator set should be supported by a conceptual framework around which the specific indicators could be organized. Overview of Indicator Set Development This report provides a detailed discussion of the committee's efforts to develop leading health indicator sets that could focus on health and social issues as well as evoke response and action from the general public and the traditional audiences for Healthy People. Briefly, three sets of leading health indicators were developed through the standard Institute of Medicine committee process. The committee followed an iterative approach to guide selection of conceptual frameworks and specific indicators for potential indicator sets. These efforts resulted in consideration of 13 conceptual frameworks and more than 50 categories of indicators. The committee then followed a consensus-based approach to facilitate selection of conceptual frameworks and specific indicators. This resulted in three unique conceptual frameworks and 19 indicators unique to the three proposed sets. The diverse expertise and experience of the committee members strongly influenced the process of selection of the conceptual frameworks and indicators. However, the appointed committee is confident about the strengths of the three conceptual frameworks underlying each of the proposed sets and similarly, the ability of specific indicators within each set to meet the final set of six essential criteria. The committee is also confident that the three proposed indicator sets are responsive to every aspect of the committee's charge. The committee also focused on identification of a set of essential criteria to guide the selection of suitable indicators for each of the candidate indicator sets. Initially, the committee accepted the nine criteria that had been recommended by the Working Group on Sentinel Indicators for Healthy People 2010. The committee then decided to expand this initial set of nine to include five additional criteria. As the committee progressed in its efforts to select appropriate indicators, they shared a growing awareness of the need to select criteria that would be understandable to the lay public and traditional public and private health care professionals as well as feasible to implement. Ultimately the committee decided that 14 criteria were too numerous and therefore, not feasible to apply in the selection of specific indicators. Following an interactive process that also reflected the committee's best judgments and their consideration of relevant literature and public comment resulted in a smaller set of six essential criteria that were worded in the simplest and most understandable terms. These criteria then became the essential conditions used by the committee to guide selection of the final indicators in each of the three proposed sets. The final set of six criteria are presented in the following Table E.1.

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--> Table E.1 Final Criteria Guiding Selection of Leading Health Indicators   1.   Worth measuring—the indicators represent an important and salient aspect of the public's health 2.   Can be measured for diverse populations - the indicators are valid and reliable for the general population and diverse population groups 3.   Understood by people who need to act - people who need to act on their own behalf or that of others should be able to readily comprehend the indicators and what can be done to improve the status of those indicators 4.   Information will galvanize action - the indicators are of such a nature that action can be taken at the national, state, local and community levels by individuals as well as organized groups and public and private agencies 5.   Actions that can lead to improvement are known and feasible -there are proven actions (e.g., changes in personal behaviors, implementation of new policies, etc.) that can alter the course of the indicators when widely applied 6.   Measurement over time will reflect results of action - if action is taken, tangible results will be seen indicating improvements in various aspects of the nation's health Committee efforts then turned toward the identification of plausible, science-based conceptual frameworks around which sets of leading health indicators could be organized. In addition, the committee identified 50 categories from which indicators could be selected. These efforts resulted in development of three sets of leading health indicators including (1) a Health Determinants and Health Outcomes Set, (2) a Life Course Determinants Set, and (3) a Prevention-Oriented Set. Three conceptual frameworks provided an underlying logic that facilitated selection and organization of indicators within each of the three proposed sets. In addition, the committee considered issues relevant to dissemination strategies, data collection and analysis, health disparities, potential strategies for action, and strength and limitations associated with the proposed sets. Table E.2 provides an overview of the specific indicators within each of the three proposed sets. Description of Proposed Indicator Sets Health Determinants and Health Outcomes Set The Health Determinants and Health Outcomes Set is based on extensive research supporting the field model of determinants of health at the individual and population levels (Evans and Stoddart, 1992). In this conceptual framework, determinants of health are also considered predictors of health behaviors and health outcomes. Knowledge about how well the nation, a state, a community or an individual is doing on specific indicators clarifies factors associated with the current health status of this nation and suggests actions to be taken to further improve the nation's health status. In addition, the proposed set includes a small number of indicators to assess broad population health outcomes. This provides information about disease morbidity and mortality that require interventions to improve disease outcomes of diverse U.S. populations. The proposed Health Determinants and Health Outcomes Set includes eight indicators representative of health determinants: physical environment, poverty, high school graduation, tobacco use, weight, physical activity, health insurance, and cancer detection. These indicators have been chosen because they represent some of the most powerful determinants of health for which meaningful action can be taken at multiple jurisdictional levels, ranging from the national and state levels to individuals and families in neighborhoods and communities. There are two indicators to address health outcomes. The first focuses on prevention of mortality associated with intentional and unintentional injuries, while the second addresses the extent to which illness, injury or disability prevents people from performing important social roles. The indicator set

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--> Table E.2 Comparative Overview of Three Proposed Leading Health Indicator Sets Health Determinants and Health Outcomes Life Course Determinants Prevention Physical environment Poverty High school graduation Tobacco use Weight Physical activity Health insurance Cancer detection Preventable deaths Disability Substance abuse Poverty Physical activity Health care access Cognitive development Violence Disability Tobacco use Low birth weight Poverty Tobacco use Childhood immunization Cancer screening Hypertension screening Diabetic eye exam Health care access Disability Preventable deaths NOTE: Key: Bold = Unique to the set, Italic = Common to two sets, Underline = Common to three sets therefore recognizes that just as society has an effect on health, so too the health of the population has an effect on the functioning and productivity of society. Life Course Determinants Set The conceptual framework for the Life Course Determinants Set draws from two models regarding the primary determinants of health. This set integrates the field model, described above, and the life course health development model. The life course health development model reflects a growing body of evidence that health outcomes and health status follow a developmental process in which current health status and outcomes are the product of cumulative inputs across the course of life. This framework suggests that at strategic points throughout the life course, health determinants are susceptible to greatest influence and, in turn, can significantly affect the subsequent life course. For example, lifelong patterns of tobacco use may be most dependent upon smoking behaviors established in adolescence. To be most successful in the prevention of death and disability from diseases associated with tobacco smoking, the public and the health care system should focus efforts most intensely on prevention of smoking initiation and smoking cessation programs targeted to youth. Similarly, the long-term functional level of an adult who has had a stroke may be primarily determined by the physical rehabilitation and psychosocial support received in the first few months following the stroke. The Life Course Determinants Set includes indicators representative of health in a broad social and biological context including substance abuse, poverty, physical activity, health care access, cognitive development, violence, disability, tobacco use and low birth weight. Prevention-Oriented Set The third proposed set of leading health indicators is based on the Prevention Model, which relies on four basic constructs: current health status, primary prevention, secondary prevention, and tertiary prevention. The Prevention-Oriented Set uses a simple and conventional structure that encompasses both individual and community-based health activities and the prevention and disease management activities of the health care delivery system. The prevention orientation itself emphasizes that the general population, in collaboration with public and private health professionals, should take action to promote health and

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--> prevent disease in themselves and others. Approaches to the achievement of improvements in health behaviors and disease outcomes can be personal, familial or institutional. The four categories into which the nine indicators in the Prevention-Oriented Set have been given names that are intended to be comprehensible to the lay public and diverse population groups. Thus, instead of listing the first category as health status, the category is, "How are we feeling?" The category of primary prevention is associated with the question "How do we keep ourselves well?" Secondary prevention is described as "If we are sick, how can we find disease early?" Tertiary prevention is described as "When we are sick, how do we get the best medical care?" Indicators in the proposed set were selected with a particular emphasis on issues pertinent to ease of interpretation by the public, availability of data for national, state, local, and community jurisdictions, and the relation of the indicators to health promotion and disease prevention surveys as well as to morbidity surveys. The specific indicators include: disability, and preventable deaths as measures of current health status; poverty, tobacco use and childhood immunizations as primary prevention strategies; cancer screening and hypertension screening as representative of secondary prevention, and diabetes management and health care access as measures of tertiary prevention. Linkage of Indicator Sets to Healthy People 2010 The three proposed leading health indicator sets reflect a shift in emphasis away from simple mortality measures toward a more complex array that includes health-related quality-of- life, protective health behaviors, risk behaviors, social, and environmental factors consistent with one of two overarching goals of Healthy People 2010: to increase the quality and years of healthy life. This shift in focus away from measures of mortality reinforces the role of the proposed indicator sets in responding to such an expanded vision of health. Each of the three proposed indicator sets also addresses many of the social, cultural, economic and health care system issues considered by many to be critical factors in efforts to eliminate health disparities, which is the second of the overarching goals established for Healthy People 2010. For example, measures of income, education, and access to health care for disease prevention, detection, and treatment are included in one or more of the sets. In addition, the proposed sets include measures relevant to each of the six areas identified by the U.S. Department of Health and Human Services Initiative to Eliminate Disparities in Health. These include cancer screening, diabetes, immunizations, infant mortality, and risk behaviors for cardiovascular and other diseases. The suggested sets of indicators are also linked to the four enabling goals established for Healthy People 2010. These include promotion of health behaviors, promotion of healthy communities, prevention and reduction of diseases and disorders, and improvement of systems for personal and public health. For example, the poverty, health insurance, high school graduation and health care access indicators can be considered to be representative of a healthy community as well as improved systems for personal and public health. Similarly, immunization, tobacco, substance abuse, physical activity, and weight are associated with promotion of healthy behaviors, promotion of healthy communities, and prevention and reduction of disease and disorders. Crosscutting Data Issues The committee's selection of three sets of leading health indicators also relied on an analysis of crosscutting data issues. The committee believes it is essential that the DATA2000 Monitoring System be updated for Healthy People 2010 to ensure that it continues to be the leading source of comprehensive data

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--> for the ongoing monitoring of the proposed leading health indicators and reporting on the indicators on a timely and routine basis. Additional federal databases may also provide alternative sources of data to inform the three proposed sets of leading health indicators. In the absence of existing data collection efforts, new data collection efforts that will provide data on the indicators as well as permit multilevel analysis and reporting of key results at the national, state, local, and community levels will be required. This has particular relevance to data collection and analysis efforts for specific population groups defined by age, gender, race and ethnicity, disability, socioeconomic levels, geographic locale, sexual orientation, and levels of educational attainment. It will be essential to identify the need for new data collection efforts that will provide information about the three sets of indicators for diverse population groups prior to implementation of the full Healthy People 2010 plan and the selected set of leading health indicators. Further, analyses for the monitoring of changes in the indicators should include data for the total population as well as data for diverse population groups. Furthermore, to ensure that local or community-based initiatives are the most appropriate and effective to improve the status of the leading health indicators, data will be required for defined jurisdictional units as well as select population groups within those local jurisdictions. This reflects the committee's recognition of the importance of an individual's community in influencing the wide range of health-related behaviors, beliefs, practices, and outcomes considered in each of the three sets of leading health indicators. This is especially true as the focus of the recommended sets has been broadened to encompass a wider range of factors that influence health, such as social, educational, and environmental factors, preventive health behaviors, risk behaviors, to health care systems and other direct biological determinants of health outcomes. This report also identifies steps the U.S. Department of Health and Human Services can take to ensure the highest quality of data collection and management. This is of particular importance in cases in which new or expanded data sets will be established to measure the indicators and analyze the progress that has been made toward achieving the specific targets for each leading health indicator. The committee encourages particular attention be given to data quality limitations of self-reported data, data validity and reliability, periodicity and timeliness of data availability, representativeness of data and small-area analyses. Dissemination Strategies Experience with leading health indicators during the first two decades of Healthy People suggests that traditional methods of communication and dissemination are unlikely to be successful in communicating to the general public and motivating public actions to improve the status of specific indicators. This report includes the committee's suggestions for effective strategies for the communication and dissemination of information about the leading health indicators, with an emphasis on the role of the U.S. Department of Health and Human Services as the lead agency to assume responsibility for integration of traditional methods of dissemination of information with new communications channels such as electronic communication. The committee also suggests that research on communications and dissemination strategies should be completed before the department finalizes the language for specific indicators for the selected set of leading health indicators. This research should focus on determination of the most compelling language that will communicate to the diverse groups of the population and encourage those subgroups to take action. Similarly, traditional and innovative communications products and methodologies should be evaluated before their inclusion in the full dissemination protocol for the leading health indicators that will be undertaken by the U.S. Department of Health and Human Services and its collaborating agencies. The department is also strongly encouraged by the committee to establish an ongoing system of process evaluation, including audits of communications products and the use of target group profiles of diverse

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--> population groups. These should be developed prior to initiation of the leading health indicator component of Healthy People 2010 and continued for the duration Healthy People 2010. This will provide the U.S. Department of Health and Human Services with information about the implementation of different communication strategies as well as assessments of their effectiveness in motivating actions among individuals and communities to improve the status of specific indicators. This will provide ongoing feedback about the successes and failures of specific dissemination strategies for diverse population groups and will support modification of these strategies, if necessary, during the full course of Healthy People 2010. Conclusions and Recommendations Chapter 3 of this report recommends three sets of leading health indicators for consideration by the U.S. Department of Health and Human Services along with suggestions for effective dissemination of the selected indicator set to the general public, including diverse population groups, and the public and private health care communities. The chapter also includes information about potential action strategies for each of the proposed indicators, and a discussion of the general strengths and limitations of the three proposed indicator sets. The Committee recognizes the difficulty and complexity of the department's task of selecting a single set of leading health indicators for Healthy People 2010. In order to facilitate that process this committee makes a number of recommendations and suggested action steps to be taken by the U.S. Department of Health and Human Services. Selection of Indicator Set The committee recommends that the U.S. Department of Health and Human Services select a single set of leading health indicators from among the three proposed sets and commit to support fully the implementation of the selected indicator set for the duration of Healthy People 2010. The Committee recognizes that political and/or policy issues may motivate the U.S. Department of Health and Human Services to change indicators within the sets. The committee does not advocate for efforts by the U.S. Department of Health and Human Services to develop alternative sets of indicators comprised of different indicators selected from each of the three proposed sets. The three sets are based on unique conceptual frameworks and integration of indicators between sets would likely compromise the internal validity of each of the sets. If the U.S. Department of Health and Human Services must consider altering the indicators within a set, the committee strongly urges that it is done in such a manner that does not compromise the internal validity of the conceptual frameworks supporting each of the three sets. Achieving the laudable goals of the leading health indicator effort to promote the nation's health will be difficult unless department efforts to promote, evaluate, and disseminate the selected set of indicators are maintained and strengthened. The Committee offers five suggestions for steps necessary to support the leading health indicator initiative. Inter-Agency Collaborations Leading health indicators will be strengthened by continued collaborations of the U.S. Department of Health and Human Services with other federal agencies (e.g., Environmental Protection Agency, U.S. Department of Labor, U.S. Department of Education, U.S. Department of Housing and Urban Development),

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--> private sector agencies, businesses, labor and voluntary groups, state and local health agencies, and community-based groups and organizations with a shared goal of improving the health of their communities and thereby improving the health of the nation. Dissemination Strategies A comprehensive plan for communication and dissemination of information related to the leading health indicators should be responsive to the needs of diverse population groups and include both traditional and innovative communication and health behavior change strategies. Health Disparities Data must be available on a consistent, timely, and periodic basis to examine health disparities among the following population groups: 1) racial and ethnic minorities; 2) population groups defined by income; 3) population groups defined by age; 4) population groups defined by gender; 5) population groups with disabilities; 6) population groups defined by sexual orientation; 7) population groups defined by levels of educational attainment, and 8) population groups defined by geographic locale. Poverty/Socioeconomic Status Analysis of every indicator with socioeconomic status or income level as stratification variables will ensure that health disparities attributable to variations in socioeconomic status are identified, monitored, and corrected. Data Collection and Analysis Assuring the availability of appropriate data to monitor the selected leading health indicator sets will include the following actions: 1.   Evaluation of data sets for the following characteristics: quality of data, limitations of self-reported data, periodicity and timeliness of data availability, representativeness of data, and ability to provide small-area analyses, 2.   Technical assistance to communities to utilize small-area analysis data sets appropriately in the design, implementation, and evaluation of local interventions to improve the status of specific indicators, and 3.   Determination of the appropriate intervals for data collection, methods of analysis, and frequency of reporting of results for each of the indicators. The development of leading health indicators that provide a clearly understandable and recognizable face for the full Healthy People 2010 agenda has enormous potential to exert positive influences on the public's

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--> awareness and practice of health-promoting behaviors. This is especially true if the chosen set of indicators is meaningful to and can be acted upon by the lay public, with an emphasis on diverse population groups. This report contains a number of recommendations and suggestions for the Department of Health and Human Services that address issues relevant to the composition of leading health indicator sets, data collection, data analysis, effective dissemination strategies, health disparities, and application of the indicators across multiple jurisdictional levels. These recommendations and suggestions also reflect the committee's belief that achievement of the overarching and enabling goals of Healthy People 2010 is possible only when national, state, and local health agencies establish collaborative partnerships with members and organizations representative of a wide array of diverse population groups and communities. These partnerships can yield significant and sustained changes in the health behaviors and health outcomes of the public. In the presence of collaborative, community-based partnerships, leading health indicators for Healthy People 2010 can be used as tools to mobilize the lay public and health professionals to become engaged in making progress toward the health goals for the nation and to do so in a manner that prompts public understanding of and policy actions related to the important determinants of that progress.

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