3
Proposed Leading Health Indicator Sets

The public health community has drawn on its collective wisdom and experience to develop a set of objectives and benchmarks intended to improve the overall health of this nation. These are under preparation for publication in the full Healthy People 2010 plan. Identification of a set of leading health indicators has the potential to significantly enhance the impact of Healthy People 2010. Leading health indicators can provide a face for Healthy People 2010 that will be recognizable to the lay public, especially diverse population groups, and the private and public health care communities in partnership with other interested stakeholders. In addition, a small set of leading health indicators lends itself to identification of a discrete set of actions that will lead to improvement in the status of each indicator and that can be acted upon by the diverse audiences of Healthy People 2010.

An effective set of leading health indicators will fulfill a number of functions. First, such indicators will be exemplary measures of key health behaviors and related outcomes that are known and understandable by the general population including socially and demographically diverse population groups. Second, these indicators will be the object of routine data collection and analysis efforts at the national, state, local, and community levels, with the potential for the availability of comparable data across these levels for diverse population groups from 2000 to 2010. Third, a set of leading health indicators can motivate positive changes in knowledge, health behaviors, and health determinants at the level of the individual and will also guide the development of policy and action plans within communities to ensure the maintenance of efforts at making changes in these areas. Fourth, a set of leading health indicators will address primary, secondary, and tertiary prevention issues as well as environmental and social determinants of health. Finally, the Healthy People 2010 vision of eliminating health disparities and increasing quality and years of healthy life will be integrated into the selection of leading health indicators.

The Institute of Medicine committee followed an iterative process to guide the selection of conceptual frameworks and specific indicators for potential indicator sets. These efforts involved consideration of a total of 13 conceptual frameworks and more than 50 broad categories from which indicators could be chosen. These categories encompassed social, environmental, institutional, and individual factors associated with health status, health determinants, and health outcomes. The committee then adhered to a consensus-based approach in the final selection of conceptual frameworks and specific indicators. This resulted in development of three sets of leading health indicators, each with a unique conceptual framework and each consisting of no more than ten indicators. Given that there is some overlap between sets in the selection of specific indicators, a total of 19 unique indicators were chosen by the committee.

Committee choices about specific indicators and conceptual frameworks were significantly influenced by the scientific literature in the areas of epidemiology, clinical medicine, health policy, and theories of health behavior change. In addition, the diverse expertise and experience of the committee members strongly



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--> 3 Proposed Leading Health Indicator Sets The public health community has drawn on its collective wisdom and experience to develop a set of objectives and benchmarks intended to improve the overall health of this nation. These are under preparation for publication in the full Healthy People 2010 plan. Identification of a set of leading health indicators has the potential to significantly enhance the impact of Healthy People 2010. Leading health indicators can provide a face for Healthy People 2010 that will be recognizable to the lay public, especially diverse population groups, and the private and public health care communities in partnership with other interested stakeholders. In addition, a small set of leading health indicators lends itself to identification of a discrete set of actions that will lead to improvement in the status of each indicator and that can be acted upon by the diverse audiences of Healthy People 2010. An effective set of leading health indicators will fulfill a number of functions. First, such indicators will be exemplary measures of key health behaviors and related outcomes that are known and understandable by the general population including socially and demographically diverse population groups. Second, these indicators will be the object of routine data collection and analysis efforts at the national, state, local, and community levels, with the potential for the availability of comparable data across these levels for diverse population groups from 2000 to 2010. Third, a set of leading health indicators can motivate positive changes in knowledge, health behaviors, and health determinants at the level of the individual and will also guide the development of policy and action plans within communities to ensure the maintenance of efforts at making changes in these areas. Fourth, a set of leading health indicators will address primary, secondary, and tertiary prevention issues as well as environmental and social determinants of health. Finally, the Healthy People 2010 vision of eliminating health disparities and increasing quality and years of healthy life will be integrated into the selection of leading health indicators. The Institute of Medicine committee followed an iterative process to guide the selection of conceptual frameworks and specific indicators for potential indicator sets. These efforts involved consideration of a total of 13 conceptual frameworks and more than 50 broad categories from which indicators could be chosen. These categories encompassed social, environmental, institutional, and individual factors associated with health status, health determinants, and health outcomes. The committee then adhered to a consensus-based approach in the final selection of conceptual frameworks and specific indicators. This resulted in development of three sets of leading health indicators, each with a unique conceptual framework and each consisting of no more than ten indicators. Given that there is some overlap between sets in the selection of specific indicators, a total of 19 unique indicators were chosen by the committee. Committee choices about specific indicators and conceptual frameworks were significantly influenced by the scientific literature in the areas of epidemiology, clinical medicine, health policy, and theories of health behavior change. In addition, the diverse expertise and experience of the committee members strongly

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--> influenced the final selection of conceptual frameworks and indicators. However, the appointed committee is confident about the strengths of the three conceptual frameworks underlying each of the proposed sets of leading health indicators and similarly, the ability of each of the specific indicators to meet the six requisite criteria for inclusion in a set. Affirmative responses to each of the six criteria were required before a specific indicator could be included in one or more of the three proposed indicator sets. The committee is also confident that the proposed indicator sets are responsive to every aspect of the committee's charge as defined during the course of the project by the U.S. Department of Health and Human Services The committee does acknowledge that political and/or policy issues may motivate the department to change indicators within proposed sets or even to make changes to the conceptual frameworks underlying the sets. The committee does not advocate efforts by the department to develop alternative sets of indicators based on revisions to the three proposed conceptual frameworks or development of alternative sets comprised of different indicators selected from each of the proposed sets. The three proposed sets are based on sound conceptual frameworks unique to each set and integration of indicators between sets would likely compromise the internal validity of the proposed sets. If the Department must consider alterations to indicators within a set, the committee urges that it does so in such a manner that will not compromise the integrity of the conceptual frameworks for each of the sets. The remainder of this chapter focuses on the three sets of leading health indicators that the Institute of Medicine committee has recommended for the consideration of the U.S. Department of Health and Human Services. These three sets are the Health Determinants and Health Outcomes Set, the Life Course Determinants Set, and the Prevention-Oriented Set. The presentation of each of the 3 sets includes a description of the conceptual framework underlying the set and a brief description of the proposed indicators and measures as operationalized by the committee. This is followed by a discussion of suggested actions to change the status of indicators, a discussion of strengths and limitations of the three proposed sets, and a discussion of general strategies for dissemination of the selected indicator set to the lay public and the more traditional audiences for Healthy People including public and private health care agencies and professionals; national, state, and local government agencies and staff; businesses; community-based organizations and groups; and other major stakeholders. Health Determinants and Health Outcomes Indicator Set Conceptual Framework The Health Determinants and Health Outcomes Indicator Set has its conceptual basis in the field model of determinants of health at the individual and population levels (Evans and Stoddart, 1994; Institute of Medicine, 1997). This model asserts that disease status and the health and well-being of individuals and populations are a product of individual or population risk factors and the role of medical care. Alternatively, the field model suggests that current health status and disease outcomes associated with disease states in individuals or populations are determined by multiple factors that are both internal and external to the individual or population. These factors include the: (1) physical environment, (2) social environment, (3) genetic endowments, (4) prosperity, (5) individual behaviors, (6) individual biology, (7) health and function, (8) disease, (9) health care systems, and (10) overall well-being. The schema for the field model also defines directions of influence and interaction among these various factors. The schema acknowledges the complexity of interrelationships and interactions among multiple factors that are determinants of health but not necessarily limited to traditional predictors or determinants of health. Furthermore, the field model seeks to move health policy beyond being simply health care policy

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--> to include health, social, political, and environmental policies as well as characteristics and behaviors inherent in individuals and populations. The relationships among these many determinants of health status and disease outcomes suggest strategic intervention points that an individual or a community can take to effect change in health status or disease outcomes. The field model is represented graphically in Figure 3.1. FIGURE 3.1 A model of the determinants of health. Source: Reprinted from R.G. Evans and G.L. Stoddart, 1990, Predicting Health, Consuming Health Care, Social Science Medicine 31:1347–1363, with permission from Elsevier Science Ltd., Kidlington, United Kingdom. In the proposed Health Determinants and Health Outcomes Indicator Set, all the major categories of determinants with the exception of genetic endowments are considered. In proposing the field model as the underlying conceptual framework for the Health Determinants and Health Outcomes Set of leading health indicators, particular emphasis is placed on the term leading. According to the field model, determinants can also be predictors: How well the nation is doing on specific indicators informs not only about where the nations stands today, but where the nation and its diverse population groups are headed. The specific indicators chosen for the Health Determinants and Health Outcomes Set represent some of the most powerful determinants of health on which the nation is capable of taking meaningful action at multiple levels, including the nation as a whole, states, local jurisdictions, and individuals and families living and working in neighborhoods and communities. In addition, the Health Determinants and Health Outcomes Set includes two measures of broad population health outcomes, reflecting the field model premise that it is important to know about and make improvements in the current status of the health of the nation and its diverse population groups. With respect to outcomes, the committee chose one indicator that focuses on preventable mortality attributed to intentional and unintentional injuries while the second encompasses a broad definition of morbidity associated with disability that includes physical, mental, or developmental illnesses or injuries that might interfere with the performance of important social roles. The proposed indicator set therefore recognizes that just as society has an effect on health, so too the health of its populations will effect the functioning and productivity of society. Table 3.1 describes the specific indicators included in the Health Determinants and Health Outcomes Indicator Set.

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--> Table 3.1 Health Determinants and Health Outcomes Set of Leading Health Indicators Indicator Measure 1. Physical environment Percentage of population living in areas where air quality meets or exceeds all National Ambient Air Quality Standards and whose community water systems receive a supply of drinking water that meets the Safe Drinking Water Act Regulations 2. Poverty Percentage of population with in household incomes less than 100 of the federal poverty limit 3. High school graduation Percentage of population ages 18 to 24 who have completed high school 4. Tobacco use Prevalence of any use of tobacco products among youth up to age 17 5. Weight Percentage of population whose body mass index is no more than 20% lower and no more than 20% higher than that recommended for their age and gender 6. Physical activity Percentage of population whose participation in physical activity with significant cardiovascular benefits meets or exceeds recommended levels with respect to the number of times per week and the number of minutes per time 7. Health insurance Percentage of population under age 65 who report that they currently have health insurance coverage 8. Early detection of cancer Percentage of uterine/cervical, colorectal, and breast cancers detected at an early stage 9. Preventable deaths from injury Percentage of preventable deaths attributed to intentional and unintentional injury 10. Disability Average number of days per year lost to school, work, homemaking, and other social roles (e.g., volunteering) for a defined population Proposed Indicators The proposed indicators in the Health Determinants and Health Outcomes Set were chosen because there is substantial and credible evidence that they are significantly related to health problems that are important today in the United States, that are likely to persist or worsen in the general population or diverse population groups unless action is taken, and against which it is, in fact, possible to make improvements. In addition, each of the indicators were considered to meet the six criteria considered essential for inclusion of an indicator in a set and the selection of the indicators was guided by the conceptual framework described above. The following sections discuss the 10 indicators in the proposed Health Determinants and Health Outcomes Set.

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--> Physical Environment. Percentage of population living in areas where air quality meets or exceeds all National Ambient Air Quality Standards and whose community water systems receive a supply of drinking water that meets the Safe Drinking Water Act Regulations. Poor air quality is known to exacerbate a wide range of respiratory ailments including asthma, chronic obstructive pulmonary disease, and certain allergic reactions. similarly, water quality has a significant impact on a wide range of waterborne diseases, many of which affect the gastrointestinal tract (e.g., giardiasis, cryptosporidiosis, and Campylobacter enteritis). Note that one of the earliest triumphs of public health that led to significant reductions in deaths from illnesses such as cholera and typhoid was a result of making the water supply safe. The Environmental Protection Agency may have data that can be used to track this indicator. Poverty. Percentage of population with household incomes less than 100 percent of the federal poverty level. There is an extensive epidemiological literature documenting a positive and almost linear correlation between income and health. Those at the lowest end of the income spectrum, that is those with total family incomes at or below the federal poverty level, have significantly greater burdens of illness and negative disease outcomes. In some cases illness can lead to poverty, but far more frequently, poverty is associated with higher rates of a wide range of social and behavioral risk factors for disease as well as poor health outcomes. The pathways between poverty and ill health have not been fully specified, but they are likely to include poor nutritional status, poor housing, lower levels of educational attainment, residence in neighborhoods with higher rates of crime and violence, and reduced access to and utilization of health care services. Data from the U.S. Department of Labor supplemented by state and local economic indicators and Vital Statistics may provide information about this indicator. High School Graduation. Percentage of population ages 18 to 24 who have completed high school. As with poverty, level of educational attainment is highly correlated with a wide range of social and behavioral risk factors and poor health outcomes. This indicator focuses on young people, because society can indeed intervene to improve their high school graduation rates, whereas society does little to increase the educational attainment of older adults. Education level affects people's ability to understand how their own behavior can influence their health, how the health care delivery system works, and how to use the health care delivery system to maximize personal benefit. In addition to the independent effects of education on health, educational level is also related to income and employment opportunities, with lower incomes associated with lower rates of high school completion and more restricted opportunities for jobs. Data on high school graduation rates can be obtained from local Departments or Boards of Education, the U.S. Department of Education, and possibly, the Youth Risk Behavior Survey. Tobacco Use. Prevalence of any use of tobacco products among youth up to age 17. Tobacco use has been identified as a leading cause of death in the United States and has effects on many forms of cancers and respiratory ailments and results in poor birth outcomes. Other effects of tobacco use include injuries, deaths and environmental damage caused by fires (McGinnis and Foege, 1993). The proposed indicator encompasses all forms of tobacco use, including cigarette and cigar smoking and use of smokeless tobacco. It also focuses in particular on the school-age population for two reasons. First, school age is the developmental stage at which tobacco products are first tried and when addictions to tobacco products are often established. Risk factors for the initiation of tobacco use at this age include lower socioeconomic status, environmental conditions such as lower cost and ease of access to tobacco products, and perceived social norms that tobacco use is acceptable. Youth with poor self-images, low self-esteem,

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--> and lack of feelings of self-efficacy are significantly more likely to use tobacco products. Reductions in tobacco use would arise both from delays in the age of initiation of tobacco use and from an overall reduced prevalence of use. Second, although there has been steady progress in reducing the rates of tobacco use among adults, the picture is less optimistic when it comes to youth with increased levels of use noted for adolescent females and some racial and ethnic minority groups. At the same time, a wide variety of strategies address not only the prevention of tobacco use among youth and improvements in the rates at which youthful smokers quit. The Youth Risk Behavior Survey may be a significant source of data for this indicator, perhaps supplemented by cost and purchase data provided by the Internal Revenue Service. Weight. Percentage of population whose body mass index is no more than 20% lower and no more than 20% higher than that recommended for their age and gender. Obesity typically reflects a diet that is higher in fat and lower in more healthful foods such as whole grains, fruits and vegetables. Certain eating patterns are associated with cardiovascular disease and, to some extent, cancer. In addition, obesity is directly associated with both the prevalence and the sequelae of diabetes On the other hand, an extremely low weight sometimes reflects the presence of dangerous and potentially life-threatening eating disorders such as anorexia and bulimia. Unfortunately, research documenting the precise relationships between dietary habits and disease incidence and outcomes is still in an exploratory phase with an emphasis on bench research with animals. Exercise is an important aspect of weight control, but the relationship between the two can be reciprocal. It is often the case that people who are significantly over- or under-weight may be more resistant to initiating and sustaining a regular program of physical activity, perhaps because of a poor body image or poor dietary habits that cannot sustain a regular program of physical activity. The National Health and Nutrition Examination Survey, the Behavioral Risk Factor Surveillance Survey, the Youth Risk Behavior Survey and the National Health Interview Survey may serve as potential sources of data concerning body mass index. Physical Activity. Percentage of population whose participation in physical activity with significant cardiovascular benefits meets or exceeds the recommended levels with respect to the number of times per week and the number of minutes per time. Regular and sustained physical activity has documented beneficial effects on cardiovascular functioning (e.g., reducing hypertension and hypercholesterolemia) but also on the prevention of osteoporosis and its sequelae (e.g., hip fractures), the effects of osteoarthritis, and on such mental conditions as depression. Physical activity is also an important element of weight control. This indicator addresses physical activity across the age spectrum. Children who acquire the habit of engaging in regular physical activity tend to maintain the habit throughout their lives. At the same time, a regular program of physical activity has some of its most salubrious effects on conditions faced by older persons. The Youth Risk Behavior Survey, the Behavioral Risk Factor Surveillance Survey, the National Health Interview Survey, and the National Health and Nutrition Examination Survey might all be useful in measuring the status of this indicator during the course of Healthy People 2010. Health Insurance. Percentage of population under age 65 who report that they currently have health insurance coverage. Almost 20 percent of the United States population does not have health insurance with particular racial and ethnic minority groups being at even greater risk of having no insurance. The unmet need for health insurance coverage creates significant social, structural, system, and personal barriers to the receipt of appropriate health care services in appropriate settings at appropriate times. In particular, it reduces the

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--> ability of the medical care delivery system to provide important clinical preventive services, to encourage healthy behaviors, to intervene early and effectively in the course of acute illnesses, and to effectively and efficiently manage chronic health conditions. Data on health insurance status may be available from the Behavioral Risk Factor Surveillance Survey, the National Survey on Family Growth, and the National Health Interview Survey. Early Detection of Cancer. Percentage of uterine/cervical, colorectal and breast cancers detected at an early stage. The cancers included in this composite indicator (uterine/cervical, colorectal, and breast cancers) share an important characteristic: if they are detected early, they are more likely to be cured and less likely to lead to long-term illness or death. In addition, they are among the most prevalent cancers in this country. This indicator uses the actual rate of detection at the early stage rather than the rate of screening. The indicator thus serves as an intermediate health outcome that reflects the ability of the health care system to provide screening examinations, the effectiveness of the health care delivery system at ensuring that individuals are recommended at the proper intervals to obtain these screening examinations, as well as whether individuals avail themselves appropriately of such examinations. Information about the stage of disease at the time of diagnosis will best be provided by population-based cancer registries but may be supplemented by the National Hospital Discharge Survey and Medicare and Medicaid records. Preventable Deaths Due to Injury. Percentage of preventable deaths attributed to intentional and unintentional injury. This indicator addresses a significant cause of mortality that affects a wide range of populations defined by age, income, gender, race of ethnicity, geographic locale, job or profession, etc.: intentional and unintentional deaths due to injury. Intentional injury deaths include those from suicide and homicide and thus capture important elements of the emotional, psychological, and social environments of diverse population groups. Deaths attributable to unintentional injuries include motor vehicle accidents (which can, in turn, reflect behaviors such as drinking or substance abuse) and occupational injuries and unintentional deaths from fire, falls and drownings. This indicator focuses on mortality attributed to intentional and unintentional injury but actions taken to reduce mortality from these causes are also likely to reduce morbidity consequent to injury. Vital Statistics will likely be a primary source of information about this indicator. Disability. Average number of days per year lost to school, work, homemaking, and other social roles (e.g., volunteering) for a defined population. As noted earlier, disability is included in this set as a signal of the effects that health has on social functioning and economic productivity. Almost 20 percent of the U.S. population has one or more disabilities, including physical, psychological, and developmental disabilities. Furthermore, the inability to perform important social and family roles has profound consequences on individuals and their families, such as diminished self-esteem and self-efficacy, the increased burden on families because of the need to provide care, and decreased potential to contribute financially to the household. The focus of this indicator is not on one particular kind of disability but rather is inclusive of all kinds (physical, mental, emotional, and developmental). Potential sources of data regarding these types of disabilities might include the National Health Interview Survey, and the National Disability Survey.

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--> Life Course Determinants Set Conceptual Framework The theoretical framework for the Life Course Determinants Set draws from two related models that explain how multiple factors determine health status and outcomes. These include the field model outlined above in the description of the Health Outcomes and Health Determinants Set, and the life course health development model (Halfon et. al., 1999; Halfon, et. al., 1997). Both of these models view health in broad social and biological contexts. Both models also array different determinants and their interactions in a way that suggests how interventions occurring at different points in the life course would yield greater potential health benefits than some of the current standard approaches to disease management or prevention. As described above, the field model argues that the primary determinants of health include the physical environment, social environment, genetic environment, prosperity, individual behaviors, individual biology, health and function, disease, health care, and well-being. The life course health development model builds upon the field model by using development as an integrating principle to explain how health is established and transformed through a process of sequential and incremental changes over time in the life-course. The process of human development provides a framework that enables one to understand the patterns of relationships between genetic factors and functional biological systems, between neurobiology and behavior, and between individual (phenotypic) characteristics and social and environmental influences (Halfon, et. al., 1999). The life-course health development model has three key components. First, multiple determinants of health have different magnitudes of effect at different stages of the life course, with certain types of determinants having special relevance at certain stages. In young children, for example, family factors appear to be much more important than individual patterns of behavioral response, whereas such behavioral patterns appear to exert a greater effect as determinants of health in the adult and elderly populations. Second, health and disease status are considered to be the result of the cumulative effects of risk factors and determinants across the life course, as well as from the particular effects of factors during certain critical periods. Health development can be attributed to the observed cumulative and latent effects that are described in a growing empirical literature on the life course epidemiology of chronic disease and in development of psychopathology. Third, the depiction of life course health development in terms of a health development trajectory incorporates the differential effects of determinants across the life-course and the effects of determinants on the attainment of health states and long-term health outcomes. Such a trajectory demonstrates how early experience affects later health status and decline and how such experiences have important implications for the way in which the role of health promotion and disease prevention is conceptualized across the life course. This trajectory incorporates and synthesizes the previous two points. The life course health development model suggests that health-related quality of life is a function of a variety of developmental inputs. The concept of health-related quality of life is often illustrated as a maximum potential level of health and well-being that gradually begins to decline when some stage in the life course is reached. The health development trajectory recognizes that individuals begin life with different endowments that influence the initial rate of rise in their personal trajectory. This suggests that it is important to conceptualize that individual's greatest attainable health-related quality of life as something that can be enhanced through strategic interventions in childhood and that then continues to be maximized through strategic interventions throughout the adult years. This means that both the greatest attainable level

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--> of health-related quality of life and the timing and rate of decline can be influenced by health promotion and risk reduction efforts that occur during childhood and further modified as one grows older. The life-course health development trajectory also provides a meaningful analysis of population-based health. Entire populations of individuals can demonstrate different health development trajectories. Thus, many of the ethnic, economic, and gender disparities in health status and disease states that are observed can be explained in terms of this construct and the role of differential risk and protective factors across the life course. The initial endowment at birth, presence of risk factors, and presence of health protective factors can have population-level effects as can health promotion and other health care interventions that affect the development and maintenance of the trajectory. Therefore, from a community or population perspective, the potential long-term impact of different health promotion and disease prevention strategies can be considered. Proposed Indicators Table 3.2 describes the specific indicators included in the Life-Course Determinants Indicator Set. As noted above for the Health Determinants and Health Outcomes Indicator Set, the selection of the indicators was guided by three factors: (1) development of a sound conceptual framework for the set, (2) ability of the specific indicators to meet the six essential criteria for inclusion in a set, and (3) presence of substantive research demonstrating that each of the indicators are related to important health challenges in the nation and that actions can be undertaken to improve the status of each indicator. Tobacco Use. Percentage of households in which one or more members use tobacco. The scientific literature provides extensive documentation that the use of tobacco products and exposure to secondhand smoke are associated with significantly increased risk of disease and other types of adverse health outcomes across the lifespan such as heart disease, many cancers, poor pregnancy outcomes, respiratory illnesses, and oral health problems. Annually, an estimated 3,000 nonsmoking persons in the United States die of lung cancer and up to 300,000 children are affected by lower respiratory tract infections. This indicator incorporates several aspects of the effects of tobacco use on the user and on others. In addition to serving as a measure of the prevalence of overall tobacco use, the focus of this indicator on households provides a potential measure of the level of exposure of nonsmokers to second hand smoke. It also captures the relationship between family tobacco use patterns and the likelihood that a child or adolescent will initiate use of tobacco. Potential data sources for household tobacco use include the Youth Risk Factor Survey, Behavioral Risk Factor Surveillance Survey, the National Health Interview Survey, and the National Survey on Family Growth. Health Care Access. percentage of population with a specific source of ongoing primary care. Unlike many other developed countries, a significant proportion of the U.S. population does not have access to appropriate, readily available health care. Access to primary care is one of the most important factors in ensuring that people at any age receive basic preventive and early intervention services as well as counseling about health protective and risk reduction behaviors. For children in particular, as well as anyone with a chronic disease or disability, improvements in the quality and efficiency of health care can be achieved when services are obtained from a consistent provider (Starfield, 1999). Access to timely and appropriate health care services is a particular problem for different population groups such as the elderly, lower income and racial and ethnic minority groups, and this problem thus contributes significantly to some

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--> Table 3.2 Life Course Determinants Set of Leading Health Indicators Indicator Measure 1. Tobacco use Percentage of households in which one or more members use any tobacco product 2. Health care access Percentage of population with an ongoing source of primary care 3. Low birth weight Incidence of low birth weight (less than 2,500 grams) 4. Physical activity Percentage of persons ages 12 and older who engage in sustained physical activity for 30 minutes at least 5 days per week 5. Poverty Percentage of children ages 18 and younger living in households with incomes less than 100° of the federal poverty level 6. Cognitive development Percentage of eligible children enrolled in Head Start programs 7. Substance abuse Percentage of youth ages 12 to 17 who have used alcohol or illicit drugs during the previous 12 months 8. Violence Prevalence of physical assaults among youths and young adults ages 12 to 24 9. Disability Percentage of population with limitations of activity due to a physical, mental, or developmental conditions of the major health disparities among members of the U.S. population. Even when health care services are available in a community, barriers to the utilization of such services continue to exist. These include financial, cultural, structural, system, and personal barriers. One significant impediment to access to health care services is a lack of insurance which affects almost 20° of the total U.S. population. Racial and ethnic minority groups and groups of lower socioeconomic status are especially likely to lack health insurance and, consequently, fail to receive adequate preventive care and other health care interventions. The committee suggests new or expanded data collection strategies for data on this indicator. Low Birth Weight. Incidence of low birth weight (less than 2500 grams). Although there have been dramatic decreases in rates of infant mortality over the past several decades, the percentage of low birth weight births has not declined proportionately. Low birth weight births are associated with disparities in a number of risk and protective factors ranging from poverty, utilization of appropriate prenatal care, and exposures to stressful environments. From a life course health development perspective, low birth weight is associated with a more fragile entry into the world and the need for a range of ongoing medical and social interventions that may require ongoing application through adolescence. For some individuals the sequelae of low birth weight births may include lifelong disabilities and dysfunctions. This is a widely available measure. Vital Statistics may be a potential source of data for this indicator, as may be the National Hospital Discharge Survey.

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--> Physical Activity. Percentage of persons ages 12 and older who engage in sustained physical activity for 30 minutes at least 5 days per week. The specific recommendations and measures regarding physical activity have changed over time. Nonetheless, studies consistently affirm the overall benefits of frequent periods of moderate physical activity for all age groups. Furthermore, regular performance of aerobic physical activity has been demonstrated to reduce the risk of cardiovascular disease, diabetes, depression, osteoporosis, and even some cancers. A lack of physical activity is also strongly correlated with obesity. Patterns of physical activity for high school students are highly predictive of their patterns of physical activity later in life. Thus, initiation of a program of regular physical activity in the adolescent years may well exert a positive and sustained impact on the overall life course trajectory. Data from the Youth Risk Behavior Survey, Behavioral Risk Factor Surveillance Survey, and the National Health Interview Survey may contribute to the monitoring of this indicator. Poverty. Percentage of children ages 18 and younger living in households with incomes less than 100 percent of the federal poverty level Although poverty negatively correlates with health status for all age groups, the effects of poverty in childhood persist throughout life, even when the individual experiences greater affluence at later stages of life. Children who live in households whose incomes are below the federal poverty level are more likely to experience a range of exposures to adverse risk factors such as poor nutrition, poor housing, decreased access to enrichment programs, and have lower levels of access to health care services. As a result, they will experience acute and chronic health conditions at significantly higher rates and of greater severity. For many childhood health outcomes such as low birth weight, infant mortality, meningitis, and child abuse, the rates for children living in poverty can be two- and threefold times greater or more when compared to children living in households with greater affluence. Sources of data for this indicator might include the U.S. Department of Labor and local sources of information about economic development. Cognitive Development. Percentage of eligible children enrolled in Head Start programs. The first few years of life are critical for cognitive and emotional development and for the establishment of developmental pathways that are associated with subsequent success in school. Head Start programs have been shown to be an effective intervention for improving and sustaining cognitive and emotional development and academic success. In the process of ensuring that eligible children are identified and enrolled in Head Start, communities may be more likely to develop additional interventions that will benefit other groups within the community who are also at risk of reduced cognitive development, such as homevisiting programs for mothers with newborns who have risk factors for delayed or impaired cognitive and emotional development. Examples of such risk factors might include maternal smoking or substance abuse during pregnancy and low birth weight births. Head Start programs also have the potential to be available in all communities in the United States and consequently can reach diverse population groups. Likely sources of data about Head Start enrollment rates will be local surveys of social service agencies supplemented by data from the U.S. Department of Education. Substance Abuse. Percentage of youth ages 12 to 17 who have used alcohol or illicit drugs during the previous 12 months. Substance abuse and related problems are among the most pervasive and intractable among all health and social concerns. For each man, woman, and child in the United States the annual per person costs associated with the care for patients with substance abuse problems are $1000.00. Furthermore, substance

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--> Substance Abuse Use of drugs and alcohol by adolescents is problem that requires a multifaceted and long-term approach involving all aspects of a local community, including schools, recreation programs, parent groups, and the faith community, as well as the judicial system, and health care providers. State and national involvement can provide funding to support research to develop effective substance abuse prevention programs and help influence the media messages and role models presented to adolescents. In many communities, the use of drugs and alcohol by adolescents may also be associated with educational attainment, current economic conditions, and future economic opportunities. Thus, partnerships with the business and economic sectors of a community will be important. Drug and alcohol use prevention efforts should also be connected to other risk reduction interventions for adolescents and should encompass pregnancy prevention, sexual responsibility, reduction of the levels of violence, and the elimination of drunk driving. Violence It has too often been left to law enforcement and the courts to solve the problems of violence in communities. Adolescents and young adults adopt violent behaviors for a wide range of reasons, for example, because of peer pressure, because their role models exhibit violent behaviors, and because of emotional or mental illness. Violence cannot be addressed as an isolated behavior problem, and requires interventions beginning in early childhood, continuing throughout adolescence, and reinforced throughout all aspects of the life of the community. Successful efforts at reducing community violence could involve the educational, recreational, mental health, and social service systems at the state and local levels. Childhood Immunization Many professional organizations are responsive to the childhood immunization indicator. Specific public programs devoted to immunization will use data on this leading health indicator to promote interest in and compliance with childhood immunization recommendations. Because vaccines are administered largely in the clinical setting, in either private or public clinics, this indicator can become a touchstone for the delivery of effective primary care with a prevention orientation. In addition, community-based efforts can be undertaken to inform and motivate populations at risk of non-compliance with the recommended vaccination protocols for young children. Examples of such efforts might include integration of immunization information into childbirth preparation classes, worksites, schools, religious communities, and descriptions of covered benefits in health insurance plans. Effective use of local media to promote awareness of the importance of immunizations and highlight the availability of free or low-cost services might also be considered. National or state mass media campaigns involving credible and motivating spokespeople could also serve as effective interventions for this indicator.

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--> Cancer Screening There are several important points of action to improve cancer screening rates. This indicator will motivate community organizations devoted to cancer control and care to take action. It will also motivate actions among those involved in the delivery of primary care and the medical subspecialty groups in which the more technological aspects of cancer screening are practiced. In addition, the health education sector could support cancer screening efforts that enhance self-care, such as breast self examination, and the development of communications skills of health care providers to make effective referrals for screening examinations. Availability of free or low-cost screening programs can reduce or eliminate financial barriers to screening. Additional promotional efforts might involve media campaigns, enhanced access to screening services at the community or neighborhood level, and effective education and outreach programs to reduce attitudinal barriers to screening such as fear, embarrassment, and inaccurate perceptions of risk and personal susceptibility. Hypertension Screening Many constituencies for hypertension screening could be motivated to take action. Specifically, many federal and state governmental programs could receive an impetus to increase the level of effort in this area as could community organizations dedicated to the control of hypertension and its consequences. Other constituencies might include providers of primary care and several medical subspecialties are already involved in the screening and management of hypertension. Individuals can take action on their own behalf by asking their health care providers to routinely measure their blood pressure and inform them of their results. Individuals can also take steps to monitor their own blood pressures at pharmacy-based screening stations and becoming informed about the symptoms of elevated blood pressure levels. Those concerned with the health of African Americans and other racial or ethnic minority groups and the health of the elderly population could also be motivated to take actions to educate the public and provide no or low-cost screenings. Diabetes Management Diabetes management will resonate most closely with the professional and patient communities interested in diabetes and its sequelae. However, preemptive screening and management of diabetic retinopathy for the prevention of blindness have many other constituencies, including those involved in medical subspecialties, technology development, disease management, health care quality evaluation, and self-care for chronic conditions. Employers might also support diabetic eye exams to help maintain the health and functional status of their diabetic employees. Inclusion of this indicator is intended to serve as a model indicator for several complex and overt conditions for which clinical interventions can significantly improve the quality of life and prevent disability and death.

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--> General Discussion of Issues Relevant to the Proposed Indicator Sets The committee would like to bring a number of issues to the attention of the U.S. Department of Health and Human Services to ensure that the proposed sets of leading health indicators remain responsive to their three primary functions to generate awareness, motivate action, and provide ongoing feedback. Issues of particular relevance to the committee include: (1) modifications to the proposed indicator sets, (2) operationalization of measures for the specific indicators; (3) clarification of the role and functions to be filled by the leading health indicators; (4) rationale for inclusion or exclusion of specific indicators within the three sets; (5) suggestions of indicators for future development; and (6) general points of clarification. Each of these issues is addressed below Modifications to Indicator Sets The committee is confident that each of the three sets of indicators are based upon conceptually sound and unique frameworks. The Health Determinants and Health Outcomes Set is based on the tenets of the field model in which health is based on a variety of determinants (Evans and Stoddart, 1992). The final set of indicators selected for the Health Determinants and Health Outcomes Set reflects these various determinants. The Life Course Determinants Set relies on both the field model and the life course health development model in which the role of the life course trajectory is considered to be an additional factor in determining when and how interventions should be applied to different age cohorts in an effort to maximize the effectiveness of such interventions. For example, cognitive development is an indicator for which interventions should occur during the first five years of life in order to exert a positive and sustained effect on a child's developmental trajectory. The Prevention-Oriented Set bases selection of leading health indicators primarily on the three processes of prevention: primary, secondary, and tertiary. Two or three indicators in the Prevention-Oriented Set have been selected as representative of each of these three domains. The committee feels strongly that integration or 'mixing and matching' of indicators between sets could violate the basic tenets of these three conceptual frameworks. Consequently, the committee recommends that an intact set be selected as the leading health indicator set for Healthy People 2010. It is recognized, however, that the actual operationalization of measures for specific indicators within a set might be modified by the U.S. Department of Health and Human Services. The committee also recognizes that political and policy factors may influence the department's final selection of a single set in its entirety, regardless of the committee's recommendation. The committee suggests that changes to specific indicator categories (e.g., replacing cognitive development in the Life Course Determinants Set with an indicator of dietary habits) in the selected set or switching indicators between sets might result in compromises to the three conceptual frameworks and their associated indicator sets. Operationalization of Indicator Measures The committee acknowledges that the operationalization of measures for the indicators in the three proposed sets may change during the course of the decade in response to changes and advances in medical knowledge and technology. For example, identification of new screening examinations for the detection of cancers other than breast, colorectal, and uterine/cervical in their earliest, most treatable stages might require

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--> modification of the cancer detection indicator in the Health Determinants and Health Outcomes Set and the cancer screening indicator in the Prevention-Oriented Set. Similarly, if new evidence supports the expansion or reduction of the age range for a target screening activity, the indicator could be similarly adjusted. As new vaccines or vaccine schedules are recommended for universal or large population use, the childhood immunization indicator could be appropriately modified. Health care reform efforts during the decade may also precipitate a substantive change in the measures related to health care access and health insurance. As these reforms are put into place, the measure for the health care access and health insurance indicators may require revisions or the indicators themselves may even be dropped from inclusion in the selected set of leading health indicators. The committee also recognizes that there are differences in the operationalization of measures for some instances in which sets share a common indicator. For example, physical activity is included in two of the three sets but the suggested measures for this indicator are slightly different between the two sets. Similarly, the measures for tobacco use are operationalized in a slightly different format between each of the three proposed sets. The committee chose to include different operational definitions for the measures of indicator for two reasons. First, the focus of the three conceptual frameworks underlying the proposed indicator Sets strongly influenced the committee's selection of specific measures for shared indicators. For example, the Life-Course Determinants Set emphasizes measures that are targeted to younger populations for whom interventions will yield some of their most beneficial effects by modifying behaviors early in the life course and thus, preventing or delaying the onset of disease morbidity and mortality. Thus, the measure of tobacco use for the Life Course Determinants Set focuses on assessment of household tobacco use to serve both as a predictor for initiation of use of tobacco products among youth and as a proxy measure for exposure of children and youth to secondhand smoke. Alternatively, a measure for the tobacco use indicator chosen for the Prevention-Oriented Set encourages assessment of changes in the prevalence of the use of tobacco products for the general population and throughout the life course. Similarly, the measure for the Poverty indicator in the Life-Course Determinants Set focuses on the percentage of children living in households with incomes below the federal poverty level. In comparison, the Health Determinants and Health Outcomes and Prevention Oriented Sets include a measure of Poverty that encompasses the general population which is consistent with the orientation of these two sets to include all U.S. populations and diverse population groups. Second, the committee included variations in operational definitions for indicators shared between sets in order to present the department with different measurement choices. While the committee is opposed to changing indicators within or between the three proposed sets, there is consensus that the department will select the operational definitions of the measures for each indicator that will be most effective in reaching the general population and diverse population groups. Thus, disability is presented as a rate in the Health Determinants and Health Outcomes Set whereas it is a number or count in the Prevention-Oriented Set. The committee recognizes the possibility that these two ways of measuring the impact of disabilities will evoke different reactions among the various target population groups for the leading health indicators for Healthy People 2010. The committee expects that final decisions about the actual measures for all indicators in the chosen set of leading health indicators should be based on results from the quantitative and qualitative research suggested in Chapter Four of this report. This will ensure that the language selected for the measure for each indicator is most effective in communicating with diverse populations and motivating the public to take actions to improve the status of those indicators.

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--> Role and Functions of Leading Health Indicators The committee also emphasizes that the proposed sets of leading health indicators are not to be interpreted as mechanisms by which the health care delivery system in the United States can be monitored or evaluated. Reporting on the leading health indicators will not inform the public about the quality of health care in the United States. Rather, the selected indicator set will serve as a means for monitoring the health of the U.S. population and its diverse population groups and will be used to motivate interventions at the national, state, local, community, and individual levels. Changes in the status indicator measures during the course of the decade will be used to assess the impact of such interventions. It is also important to acknowledge that the three proposed sets are not inclusive of all health behaviors, risk factors, and health conditions. In fact, such an all-inclusive set would fall beyond the scope and intended functions of a set of leading health indicators as described in the Executive Summary and Chapter One of this report. It was not possible to include every health threat or condition that will be recognized in the full Healthy People 2010 plan for several reasons. To do so would require that the size of the sets be significantly increased beyond the recommendation of no more than 10 indicators per set. Furthermore, inclusion of more health issues within each set would complicate the process of dissemination of the sets to the general public and the public and private health care communities and undermine the likelihood that the sets would generate interest and galvanize action in these populations. Obviously, the indicators in each of the proposed sets will not satisfy all of the many health and disease-specific advocacy groups. However, the proposed sets are the result of thoughtful consideration of relevant literature combined with the multidisciplinary expertise and considered judgment of the Institute of Medicine committee. Rationale for Inclusion or Exclusion of Specific Indicators Poverty There was consensus among committee members that availability of timely, comprehensive quality medical care is an absolute requisite for the coordination and implementation of a national public health initiative that addresses health care delivery, protection from environmental exposures, coordination of social services, and effective health promotion at the community and individual levels. This point of view is clearly expressed in each of the three proposed indicators sets by the inclusion of the poverty indicator. This indicator underscores the absolute necessity of efforts directed toward elimination of disparities in health status and health outcomes associated with socioeconomic status. Furthermore, the health care access indicator, included in the Life Course Determinants and Prevention-Oriented Sets and the health insurance indicator in the Health Determinants and Health Outcomes Set are intended to focus attention on social and health care system factors associated with the delivery of care for preventive health as well as urgent and chronic conditions. Increased public awareness and commitment toward change such as increasing access to care, elimination of barriers associated with socioeconomic status, and increasing general availability of insurance coverage are considered by the committee to be requisite for the achievement of sustained improvements in the health status of the general population and diverse population groups.

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--> Tobacco Use As noted above, inclusion of indicators to address each and every risk factor, prevention strategy, and/or disease state is not feasible, logical, or consistent with the intended scope and function of a set of leading health indicators. The committee feels strongly, however, that inclusion of an indicator of tobacco use in each of the three proposed sets is essential to reflect the tremendous impact of tobacco use on the health of the nation's many diverse populations. In fact, the committee believes that improvements in the status of the tobacco indicator has the greatest potential for achieving significant and sustained improvements in the health of all people of the United States. Tobacco is a leading risk factor for many cancers, cardiovascular disease, stroke, asthma, and other severe respiratory conditions. The committee argues that efforts to modify tobacco use patterns as well as effect change in laws, regulations, and policies relevant to tobacco use will yield the most significant and positive effects on current and long-term health status of diverse populations in the United States. Furthermore, efforts to prevent smoking initiation among children and youth have the potential to reduce incidence of some cancers, cardiovascular disease, and respiratory illnesses in their lifetimes. The committee asserts that an indicator of tobacco use should be included in the final set of leading health indicators for Healthy People 2010. Diet and Nutrition The exclusion of diet and nutrition from the three proposed sets of indicators is based on the committee's consideration of measurement issues associated with this indicator. Dietary behaviors present considerable measurement challenges, particularly efforts to establish baseline dietary profiles and monitor changes in these profiles over time. These measurement difficulties can be particularly troublesome to efforts to assess the dietary patterns in diverse population groups such as racial or ethnic minorities, income-defined groups, and the elderly. Recall bias, social desirability response bias, and the reliance on self-report data are only a few examples of such measurement challenges. The committee feels that the state-of-the-art of dietary measurement has not yet achieved a level that would provide regular, timely, valid and reliable measurement for each indicator, for diverse population groups, and at multiple jurisdictional levels. Consequently, dietary patterns are not included as a leading health indicator in the three proposed indicator sets It should be noted, however, that the Health Determinants and Health Outcomes Set includes weight and appropriate body mass index as a proxy measure for dietary habits. The suggested indicator addresses both underweight and overweight and is considered by the committee to be an indirect reflection of dietary choices and eating patterns. The committee also assumes that weight measured as body mass index will lend itself to regular, timely, and valid measurement by individuals and their health care providers. Suggested Indicators for Future Leading Health Indicator Sets Inevitably, a list of no more than ten indicators can only address some of the nation's most important health problems. The committee's suggestions concerning modifications to proposed indicators and suggestions for new indicators for future development as leading health indicators are discussed in the following narrative.

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--> High School Graduation High school graduation rates are relatively crude estimates of educational attainment. It would be valuable to develop a more sophisticated approach to assess not only how many individuals graduate from high school but how many graduate with competencies in key areas that permit them both to play important social roles and to take action to maintain and improve their own health and the health of their families. Violence It would also be valuable to invest resources in the development of an additional broad measure of the social environment, specifically, a measure of the fear of violence. An example of such an indicator might be the percentage of the population who report that concerns about violence interfere with their ability to pursue activities of daily living or life goals or to perform important activities. It is possible to develop such a measure, but it appears that new data collection efforts would be required to support this measure at multiple jurisdictional levels and for diverse population groups. Social Support and Isolation Social and emotional aspects of health are increasingly recognized as fundamental to the health status of individuals and communities. The committee suggests that an indicator of social support and social isolation might merit consideration for inclusion in a future set of leading health indicators. These could be measured with a validated social support scale. There is increasingly strong evidence for the impact of social support and social isolation on health status and health behaviors across the life-course (Berkman, 1980). Social support and isolation are suggested as indicators for consideration in future sets of leading health indicators in part because of the complexity of collection of information about these issues across multiple jurisdictional levels and diverse population groups. Furthermore, at this time there is a lack of well-defined, feasible, and effective intervention strategies that would sustain an increase in the levels of social support and a decrease in the levels of social isolation. Mental Health Another indicator that would address the social and emotional aspects of health is the proportion of the population with a diagnosed mental health problem(s) or (for children up to age five) developmental problems who are receiving care. Although many aspects of the mental health status of a community are not encompassed in this indicator, the committee suggests that it would be an important first step toward ensuring appropriate care systems for those already diagnosed with mental health or developmental problems. If such a step were taken, communities might be more able and more likely to address issues related to ensuring the early detection of mental health or developmental problems and establishing programs for prevention and early intervention.

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--> Foster Care The committee also suggests that the proportion of children in foster care might serve as a meaningful indicator in the future. The number of children reported and confirmed to be abused and neglected has dramatically increased over the past decade. Children generally arrive in the foster care system because of family violence or family neglect or both and both of these conditions can be caused by and can aggravate social disruption. A measure of involvement in foster care could serve as a sentinel for community levels of violence, substance abuse, and social disruption and might call attention to a group of children at particularly high risk for a variety of serious short-term and long-term developmental problems. The number of children enrolled in foster care programs could also provide a measure of the availability of community intervention services for endangered children. Substance Abuse The committee suggests development of a more comprehensive measure of substance abuse than that included in the Life-Course Determinants Set. A possible measure for this indicator might be the percentage of households in which someone uses drugs or uses alcohol inappropriately. Data on this proposed indicator are not currently collected and are likely to be more difficult to collect in detail at the local level but it would be an important measure for communities. There are a number of useful reasons to focus on households, especially to identify potential impacts on children and others in the family, such as increased risks of domestic violence, child abuse, and exposure to role models who may increase the likelihood that children in the household will adopt the same alcohol or drug use patterns. This indicator would also provide some measure of the service needs for the adults in the community. Physical Environment The Health Determinants and Health Outcomes Set includes a limited measure of the physical environment that focuses on air and water quality. However, many other components of the physical environment have a significant effect on health. It would be desirable to assess the general or overall quality of the physical environment in which an individual lives or in which a community is located. Many specific measures are available for single aspects of the environment, such as air or water quality, but the committee is not aware of any composite measures of environmental quality. This would be a fruitful area for further study and for recommendations from experts. Genetic Screening Genetic screening is a subject with many medical, political, social, and legal complexities and one for which some guidelines and measures of quality would be valuable for use in future indicator sets. The availability and use of genetic screening for a wide variety of health conditions are rapidly increasing and could be expected to increase exponentially in the next few years. Some data indicate that there are considerable disparities in the availability and access to current genetic screening services and these

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--> disparities have implications for future access trends. The potential use of genetic screening to improve immediate and long-term health through early identification of diseases or of susceptibilities is tremendous. There is, however, the potential for significant misuse. For example, health insurance plans might move to deny coverage for people known to be at increased genetic risk for some health condition(s). This may be the area in which society can anticipate the greatest changes between current practices and knowledge and those of the year 2010. Consequently, consideration of this as a future leading health indicator is warranted. Suggested Dissemination Strategies for the Leading Health Indicator Set A well-designed, well-implemented, and well-evaluated dissemination and communication plan is essential to achieving the goal that leading health indicators will capture the interest of the public and will encourage actions that will lead to advances in health. Effective communication of health information depends on a scientific approach informed by the fields of behavioral science, communication theory, consumer research, social marketing, advertising, and public relations. Strategic communications about the selected set of leading health indicators can build on the momentum of the Healthy People 2010 program and can place the leading health indicators on the media and public agenda. Leading health indicators can also stand apart from Healthy People 2010 activities and become an integral part of the U.S. Department of Health and Human Services' programming, field work, and press activities. From the moment the department begins discussions that lead to the selection from this committee's report of a set of leading health indicators, planning must begin for a strategic, time-phased, multistep process for promotion of the understanding, use, and evaluation of the leading health indicators. This committee offers suggestions for how the department can optimize traditional and innovative communication strategies to achieve the goals that they set forth for the leading health indicators. If expertise in the development and implementation such a comprehensive plan is not resident in the U.S. Department of Health and Human Services, it should be accessed through other means. The communication plan should use research tools to inform the development and execution of the project as well as explore the use of new partnerships and networks. The formative research and message design for leading health indicators described in Chapter Four should consider models of behavioral change (e.g., Prochaska and Di Clemente, 1992, Bandura, 1986), communications theory, and diffusion of innovations theories (Rogers, 1996) in order to develop a realistic strategy to encourage the nation's diverse populations to adopt the leading health indicators. A science-based plan of communication for the leading health indicators will also involve regular assessment of the results of the communications activities to make adjustments and provide feedback to further heighten awareness of, interest in, and appropriate actions on the leading health indicators. Historically, federal health initiatives have relied on traditional channels of communication, such as radio, television, and print media (Chamberlain, 1996, Rogers and Storey, 1987). However, the effectiveness of these channels is sometimes offset by the cost of using them. Television, radio, and newspapers often are attractive tools to public health programs because they reach the largest audience. However, they do not necessarily reach the most important audiences with messages that are relevant to and salient for those populations. The development of specialized media, marketing, and public relations efforts targeted to diverse population groups would be consistent with the overarching goal of Healthy People 2010 to eliminate health disparities. Even if the public health campaign designer has identified a number of audiences and knows that these audiences should be approached differently, it is often difficult to derive such an approach. It is also sometimes too expensive to develop different strategies and tactics to produce many different

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--> versions for a variety for population groups by using traditional communications channels. These traditional channels need not be abandoned, but should be complemented by specialized or innovative communications strategies. Given that the leading health indicator set will carry efforts to improve the health of the U.S. population through the new century, it is only appropriate that dissemination and communications plans should maximize the use of new technologies such as the next generation of the Internet and interactive health communication technologies. Use of innovative approaches along with more traditional tactics should be integrated into the communications and dissemination plans at the outset to maximize the potential impacts of the leading health indicators on the public. The entire spectrum of dissemination materials for the leading health indicator set that are going to be released should fit among a strategic and tactical plan that is implemented by the U.S. Department of Health and Human Services and that outlines the short and long-term objectives, press strategies, public affairs plans, approach (activities, channels, formats), time lines, responsibilities, costs, expected outcomes, and assessment activities. Although it is anticipated that the general public will be a primary target population for information about the leading health indicators, it is likely that the principal audiences for early adoption of the indicator set will be the leadership in the general public health, health service delivery, and health care policy communities. The initial development of communications and dissemination plans for the selected indicator set should include communication audits and target group profiles to describe the preferred dissemination mechanisms for a group and their subsequent expected use for the dissemination of the leading health indicators. For example, a "VIP" health leadership profile might be useful to tailor the message for diffusion in the policy community. This likely will differ from that for an audience of health care practitioners. "Push-and-pull" electronic technology applications, in which a recipient can obtain automatically customized information that includes the latest statistics and support documents in his or her area of interest or need, could also prove useful. Other examples for consideration include print and electronic publications, for example, a Leading Health Indicators at-a-glance or a how-to guide describing how to develop activities to improve the status of the leading health indicators. These should be short, concise, and tailored for different audiences. Each one should be tested for message, format, channel, and source. For example, there may be one for community health planners, members of the Association of State and Territorial Health Officials, American Public Health Association, National Association of City and County Health Officials, media sources, health professional students, lay health care workers, specific demographic and social groups, and so forth. Each of these could be mass produced with the potential for joint sponsorship and distribution of such information for their memberships and audiences. A variety of traditional and innovative communications products should be tested with diverse audiences. Some traditional examples of such products include conferences and workshops for health care and public health professionals, public service announcements, newsletters, articles in professional medical and health journals, speakers' bureaus, and op-ed pieces prepared by nationally recognized health experts. Some more innovative communications strategies for consideration and evaluation might include interactive computer programs, video programming, electronic messaging, hyperlinks to and from other reputable health care-related sites on the World Wide Web, and aggressive collaborations with community organizations. Depending on the goals of the campaign and the materials and events to be promoted, an appropriate mix of such tools can be designed to help release and promote the leading health indicators. This mix can be designed and modified from the results of the ongoing communications audits.

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