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Background and Significance

Healthy People: The First Decade

Healthy People has evolved over the past 20 years to become the nation's health agenda. It encompasses health promotion and disease prevention efforts that are intended to achieve and sustain significant improvements in the health of all people in the United States. The conceptual underpinnings of Healthy People were first described in a 1979 report from the Surgeon General entitled Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (U.S. Public Health Service, 1979). That report outlined a set of 5 national health goals that would guide health promotion and disease prevention activities during the decade 1980 to 1990. The primary purpose of establishing these health goals was to advance a small set of measures that could be tracked on a routine basis to monitor the general status of the health of the public (U.S. Department of Health and Human Services, 1998a). These five goals were established for five distinct age cohorts and 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 among 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 numbers 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 age 65 (U.S. Public Health Service, 1979).

    The report described 15 strategies by which these five goals could be achieved by 1990. Each of the 15 strategies, in turn, were supported by objectives that could be grouped into one of following categories: (1) preventive services delivered by the health care system, (2) interventions undertaken by governmental and private sector agencies to prevent harm to the public, and (3) personal and community level activities to promote healthy lifestyles.

    The U.S. Department of Health, Education and Welfare (now known as the U.S. Department of Health and Human Services) convened in June, 1979 a conference in which recognized experts addressed each of the 15 strategic areas for intervention. Fifteen panels of experts drafted sets of quantifiable objectives that were then published in the Federal Register in fall of 1979 to elicit broad-based review and commentary from the public and private health care system. Interim and final revisions to 226 objectives representing each of the 15 strategic areas were completed by the spring of 1980. A target outcome was identified for the



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    --> 1 Background and Significance Healthy People: The First Decade Healthy People has evolved over the past 20 years to become the nation's health agenda. It encompasses health promotion and disease prevention efforts that are intended to achieve and sustain significant improvements in the health of all people in the United States. The conceptual underpinnings of Healthy People were first described in a 1979 report from the Surgeon General entitled Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (U.S. Public Health Service, 1979). That report outlined a set of 5 national health goals that would guide health promotion and disease prevention activities during the decade 1980 to 1990. The primary purpose of establishing these health goals was to advance a small set of measures that could be tracked on a routine basis to monitor the general status of the health of the public (U.S. Department of Health and Human Services, 1998a). These five goals were established for five distinct age cohorts and 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 among 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 numbers 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 age 65 (U.S. Public Health Service, 1979). The report described 15 strategies by which these five goals could be achieved by 1990. Each of the 15 strategies, in turn, were supported by objectives that could be grouped into one of following categories: (1) preventive services delivered by the health care system, (2) interventions undertaken by governmental and private sector agencies to prevent harm to the public, and (3) personal and community level activities to promote healthy lifestyles. The U.S. Department of Health, Education and Welfare (now known as the U.S. Department of Health and Human Services) convened in June, 1979 a conference in which recognized experts addressed each of the 15 strategic areas for intervention. Fifteen panels of experts drafted sets of quantifiable objectives that were then published in the Federal Register in fall of 1979 to elicit broad-based review and commentary from the public and private health care system. Interim and final revisions to 226 objectives representing each of the 15 strategic areas were completed by the spring of 1980. A target outcome was identified for the

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    --> 226 objectives and these were then published in a second document, Promoting Health/Preventing Disease: Objectives for the Nation (U.S. Department of Health and Human Services, 1980). The overriding premise for that report was the need for improvement of the health of all people in the U.S. during the decade of 1980 to 1990 through the implementation of intervention plans by governmental bodies and private sector agencies at the national, state, local, and community levels. Evaluation of progress toward achieving the 226 objectives outlined in Promoting Health/Preventing Disease: Objectives for the Nation relied on periodic progress reviews and a midcourse review. Both reviews included discussions of the progress that had been made toward achievement of each of the objectives and the five overarching goals, analysis of shortfalls and problems associated with implementation of the interventions, and suggestions for modifications to the specific language of objectives or the methods of intervention. Five periodic progress reviews and the midcourse review were completed by 1996 (National Center for Health Statistics, 1992, 1994, 1995, 1996, 1997). A final report summarized the progress that had been made in achieving the five overarching goals as well as each of the 226 objectives (Journal of the American Medical Association, 1992). That final review revealed that among the five overarching goals, positive changes had been achieved for infants, children, and adults whereas the goals for adolescents and the elderly had not been met. Of equal importance, this final report set the stage for development and modification of goals and objectives for the next decade of the Healthy People including the years from 1990 to 2000. Healthy People 2000 The development of priority areas and objectives for the decade from 1990 to 2000 was enhanced by lessons learned during the first decade of Healthy People. Several significant changes were incorporated into the Healthy People 2000 plan as a result of those lessons (U.S. Department of Health and Human Services, 1991). Specifically, the five age-based mortality and morbidity reduction goals were replaced by the following three 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 strategic areas were expanded, renamed, and reorganized to include 22 priority areas. The entire national public health community was invited to contribute to the process of determining the priority areas, objectives, and targets for Healthy People 2000. The total number of objectives increased to 319. Of greater significance was the inclusion of subobjectives to ensure that efforts to reach special population groups in the United States were emphasized, with a particular focus on reduction in disparities of health status and disease outcomes. Special targets were set for population groups at heightened risk of morbidity and mortality from disease including people in certain racial and ethnic minority groups and disabled people. Another innovation that emerged during planning efforts for Healthy People 2000 was the identification of a smaller set of 47 "sentinel" indicators selected from among the full set of 319 objectives. These sentinel indicators were thought to provide a succinct measure of the health of the general population and special populations. These 47 indicators were similar in purpose to the five overarching goals established for the first decade of Healthy People. These sentinel indicators were conceptually linked to the goals, priority areas, objectives and subobjectives of Healthy People 2000. The intent was for sentinel indicators to monitor

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    --> the status of the health of the general population on a regular basis and inform those federal, state, local, and community agencies involved in Healthy People 2000. Of equal significance, however, was the idea that the sentinel indicators could be presented to the general public and non-health care professionals to increase their awareness of, and involvement in, Healthy People 2000 activities (Journal of the American Medical Association, 1995, U.S. Department of Health and Human Services, 1998a). It was also notable that Healthy People 2000 included a special objective, Objective 22.1, that addressed issues related to health and disease surveillance and data systems (U.S. Department of Health and Human Services, 1991). The Centers for Disease Control and Prevention convened the Committee for Objective 22.1 to accomplish several tasks. First, the committee developed a set of 18 health status indicators that would allow comparisons of data used by public health officials at the federal, state, and local levels of government. An electronic inventory of data sets that could be used to monitor Healthy People 2000 at the national level was also established. This inventory described the various data sets used to establish baseline rates for each of the objectives in the 22 priority areas in Healthy People 2000. It also suggested alternative data sets that had the potential to be effective monitors of progress toward achievement of all of the Healthy People 2000 objectives. Particular attention was given to the identification of data sets that were representative of special population groups. Finally, the committee recommended priority data needs and modifications to existing data collection systems to ensure the availability of measures of outcomes, risk factors, and processes that could be used in the planning of prevention programs that would support the Healthy People 2000 objectives. Evaluation strategies for Healthy People 2000 were similar to those described for the first decade of Healthy People. Periodic briefing summaries were provided to the assistant secretary for health and human services and were then published in Public Health Service Progress Review Reports on Healthy People 2000 (National Center for Health Statistics, 1992, 1994, 1997). In addition, a midcourse review was conducted as a 2-year effort initiated in 1993. That midcourse review resulted in publication of the Healthy People 2000 Midcourse Review and 1995 Revisions (National Center for Health Statistics, 1995). A summary analysis of Healthy People 2000 results indicated that 13 percent of the 319 objectives had reached or superseded the target quantifiable measures and an additional 43 percent of the objectives had achieved positive progress toward these measures. The values for only 2 percent of the objectives remained unchanged from the 1990 baseline values. The proportion of objectives for which only baseline data were available was reduced to 14 percent. Only three percent of the total of objectives lacked baseline rates, which was a significant improvement over the 20 percent reported in the midcourse review (National Center for Health Statistics, 1995, 1996, 1997). Progress toward achievement of the targets for the 47 sentinel objectives was disappointing. The set did not generate focused interest and attention in the general population or the national public and private health care communities, for that matter. Nor did the establishment of 47 sentinel objectives prompt intensified intervention efforts by agencies to achieve the projected targets. This lack of success was suggested to be due to the fact that 47 measures were too many, that they may not have been of significant interest, especially at the levels of state and local governments, and that they may have lacked political appeal (U.S. Department of Health and Human Services, 1998a). Healthy People 2010 Attention was directed toward the third generation of Healthy People even before the final review of accomplishments of Healthy People 2000 were disseminated (National Center for Health Statistics, 1997). Experiences from the previous two decades played a major role in establishing a methodology and time frame for the development of the Healthy People 2010 plan. The selection of 26 priority or focus areas and

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    --> their related objectives and subobjectives, drew heavily upon results from the periodic summaries of Healthy People 2000 (National Center for Health Statistics, 1992, 1994), the midcourse review of Healthy People 2000 (National Center for Health Statistics, 1996), and the final Healthy People 2000 report (National Center for Health Statistics, 1997). It was also recognized that implementation of Healthy People 2010 would best be considered a dynamic process in which changes to the plan would occur over time on the basis of the occurrence of one or more of the following events indicated in Table 1.1. Recognition of the anticipated complexity of the Healthy People 2010 development process prompted the establishment of the Secretary's Council on National Disease Prevention and Health Promotion Objectives for 2010 in September 1996. In addition, the Healthy People Consortium began to plan for Healthy People 2010. This consortium includes an alliance of diverse organizations committed to the nation's prevention agenda including state and territorial, public health, mental health, substance abuse, and environmental agencies and national organizations representative of the professional, voluntary, and business sectors. A meeting of the Healthy People Consortium was convened on November 15, 1996, which resulted in publication of Building the Prevention Agenda for 2010: Lessons Learned (U.S. Department of Health and Human Services, 1996). Activities heightened in 1997, with the secretary of health and human services' first briefing on objectives for Healthy People 2010 followed by a meeting of the Secretary's Council on National Disease Prevention and Health Promotion Objectives for 2010. This meeting provided an opportunity to discuss in greater detail the objectives to be established for 2010. The U.S. Department of Health and Human Services published a focus group report on the utility of Healthy People 2000 in July 1997 (U.S. Department of Health and Human Services, 1997). Shortly thereafter, in September 1997, a notice calling for comments on the framework, goals, enabling goals, focus areas, and objectives of the first draft of Healthy People 2010 appeared in the Federal Register. This resulted in more than 700 comments from private consumers of health care services, Healthy People Consortium members, members of the U.S. Congress, agencies of state and local governments, health care agencies, and health professional groups, individual health care professionals, and other diverse groups and organizations. The Healthy People Consortium reconvened in November 1997 with the specific intent of discussing health disparities and reviewing the degree of progress in reducing these disparities that the nation had made. Work groups were established for each of the 26 focus areas to discuss objectives, data issues, and disparities in health among diverse population groups. This work continued through 1997 and 1998 and focused primarily on identification of the Healthy People 2000 objectives to be continued into Healthy People 2010, and identification of new objectives to be developed. The first draft of objectives for Healthy People 2010 were available for internal review by March 1998. This was presented to the Secretary's Council on National Disease Prevention and Health Promotion Objectives for 2010 in April 1998 and the Notice of Call for Public Comment on 2010 draft was appeared in the Federal Register in October 1998. The public comment period extended through December 1998 and occurred simultaneously with five regional workshops convened by the U.S. Department of Health and Human Services to elicit comments on the Healthy People 2010 draft from the health care community, members of special population groups, and interested consumers. A meeting of the Healthy People 2010 Consortium was held in November 1998 to discuss the implications of results from the public comment period and regional meetings. A third meeting of the Secretary's Council on National Disease Prevention and Health Promotion Objectives for 2010 will convene in April 1999 and will be followed by a Healthy People Consortium meeting in June 1999. Efforts to finalize the Healthy People 2010 plan, including the overarching goals, enabling goals, focus areas, and objectives, will continue through the remainder of 1999 with the anticipated release of Healthy People 2010 scheduled for January 2000. At present, Healthy People 2010 includes two overarching goals (increase quality and years of healthy life and eliminate health disparities), four enabling

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    --> Table 1.1 Factors Stimulating Changes to the Healthy People 2010 Plan   1.   Analysis and dissemination of significant findings in the data 2.   Improvements in data collection methods and systems 3.   Enhancements to the science base, especially in the areas of health promotion and disease prevention 4.   Growing awareness of health promotion and disease prevention among traditional health care agencies and health professionals 5.   Activities of the general population at the community level 6.   Ongoing efforts to monitor the quality of health care services 7.   Greater specificity and sensitivity of epidemiological knowledge about disease risk factors and methods of effective intervention 8.   The changing demographic profile of the U.S. population that will evolve over the decade 9.   Changes in availability and access to health care services goals (promote healthy behaviors, promote healthy and safe communities, improve systems for personal and public health, and prevent and reduce diseases and disorders), 26 focus areas, objectives, and "developmental objectives" that are associated with each focus area but for which current surveillance systems and databases do not yet provide the requisite quantitative measures. The inclusion of developmental objectives in Healthy People 2010 is intended to identify new focus areas that are important and to encourage the development of national data systems through which they can be monitored. It is anticipated that 30 percent of the objectives for Healthy People 2010 will be developmental. During the past two decades Healthy People has become entrenched within the national, state, and local public health communities as the driving force behind the nation's health promotion and disease prevention agenda. It has fostered efforts to effect changes in health status, identify emerging health challenges, and facilitate the development, implementation, and evaluation of interventions to respond in a timely manner to key and emerging health issues. The full set of Healthy People objectives has been particularly useful to federal, state, and local public health agencies as they do long-range planning and prioritize programs that are appropriate for their target populations. Multilevel comparisons of commonly available data foster understanding of those populations at greatest risk and can suggest priorities for resource allocation. Such multilevel comparisons can also provide cross-sectional and longitudinal analyses of the health of the nation, highlighting these populations at higher risk of disease and poor health outcomes. Analysis at the level of detail of specific population groups is imperative if the nation is going to achieve the desired changes in specific objectives within each of the 26 focus areas for all people in the United States. The 26 focus areas, objectives and developmental objectives, without question, will continue to guide efforts to plan, implement, and evaluate health promotion and disease prevention interventions for the entire population of the United States. Leading Health Indicators The breadth of Healthy People 2010, however, has the potential to overwhelm and perhaps, discourage individuals, voluntary organizations, community organizations, and businesses from participation. 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 will 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

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    --> public and private health care communities. Leading health indicators have the potential to significantly increase the impact of Healthy People 2010 by establishing a small number of key health topics that can (1) be brought to the attention of the nation, (2) motivate actions to promote positive changes in these topics, and (3) provide ongoing feedback about progress toward achieving the desired changes in these topics. Such a set of leading health indicators can focus national attention on a limited number of measures that have relevance to, and can be acted upon by, the general public, public and private policymakers, and health and science professionals. Furthermore, a set of leading health indicators can create a national identity for Healthy People 2010 and can expand the traditional Healthy People community to include a wide variety of agencies, organizations, diverse population groups, community organizations, and individuals from outside as well as within the health care community. To achieve their full potential for success, communications strategies for leading health indicators must be appropriate and effective for the general population and diverse population groups, especially those that may not be reached by traditional health care communications campaigns such as elderly people, members of racial and ethnic minority groups, members of socioeconomically disadvantaged groups and disabled people. In preparation for the development of a set of leading health indicators, the U.S. Department of Health and Human Services convened a work group in 1997 whose members included 22 individuals from its Office of Public Health and Science, U.S. Public Health Service agencies and other agencies of the U.S. Department of Health and Human Service 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 such indicators (U.S. Department of Health and Human Services, 1998a). In addition, this document provided an overview of existing sets of leading health indicator sets, discussed the theoretical underpinnings for these sets, suggested nine criteria to guide selection of potential indicators, and reviewed issues concerning data availability and analysis. The U.S. Department of Health and Human Services then asked the Institute of Medicine to convene a committee to consider the issue of leading health indicators and to propose a minimum of two sets of indicators from which the department could choose the leading health indicator set for Healthy People 2010.