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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