4
Linkage with Healthy People 2010

Overarching Goals

Increased Quality and Terms of Healthy Life

The first overarching goal of Healthy People 2010 is to increase the quality and the years of healthy life. The focus on health status and quality of life deviates somewhat from earlier generations of Healthy People, which placed greater emphasis on reducing mortality and increasing longevity. For example, the five sentinel indicators for the first decade of Healthy People were targeted to reduce mortality among five different age cohorts. Commonly used measures of mortality are death rates, life expectancy, and years of potential life lost before age 75. Data are available for every death that occurs in the United States and can be analyzed for the total population, special population groups, and specific causes of mortality. Consequently, mortality measures have long been used in population health surveillance activities at the state, local, and community levels. However, since 1979 the life expectancy of the general U.S. population has increased significantly. This has shifted the emphasis on mortality to a broader view of health that includes mortality as well as attention to health outcomes and determinants such as prevention of disabilities, improvement of overall physical, social, and mental status, relief of pain, earlier detection and treatment of health conditions, and improved functional capacity at each stage of life.

The three proposed leading health indicator sets reflect this shift in emphasis away from simple mortality measures to the more complex topic of health-related quality of life. Two of the three sets the (Health Determinants and Health Outcomes Set and the Prevention-Oriented Set) incorporate only a single measure of preventable mortality, whereas the Life Course Determinants Set relies on no direct measure of mortality. Rather, the three proposed indicator sets incorporate factors that emphasize improvements in the quality of life as well as increases in the years of healthy life. These include measures of the physical environment, socioeconomic and educational factors, primary prevention of disease, societal factors, and health care system variables that ensure early detection and treatment of disease. This shift in focus away from measures of mortality reinforces the view that a wide variety of social, environmental, and behavioral factors play a major role in increasing the quality and years of healthy life.



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--> 4 Linkage with Healthy People 2010 Overarching Goals Increased Quality and Terms of Healthy Life The first overarching goal of Healthy People 2010 is to increase the quality and the years of healthy life. The focus on health status and quality of life deviates somewhat from earlier generations of Healthy People, which placed greater emphasis on reducing mortality and increasing longevity. For example, the five sentinel indicators for the first decade of Healthy People were targeted to reduce mortality among five different age cohorts. Commonly used measures of mortality are death rates, life expectancy, and years of potential life lost before age 75. Data are available for every death that occurs in the United States and can be analyzed for the total population, special population groups, and specific causes of mortality. Consequently, mortality measures have long been used in population health surveillance activities at the state, local, and community levels. However, since 1979 the life expectancy of the general U.S. population has increased significantly. This has shifted the emphasis on mortality to a broader view of health that includes mortality as well as attention to health outcomes and determinants such as prevention of disabilities, improvement of overall physical, social, and mental status, relief of pain, earlier detection and treatment of health conditions, and improved functional capacity at each stage of life. The three proposed leading health indicator sets reflect this shift in emphasis away from simple mortality measures to the more complex topic of health-related quality of life. Two of the three sets the (Health Determinants and Health Outcomes Set and the Prevention-Oriented Set) incorporate only a single measure of preventable mortality, whereas the Life Course Determinants Set relies on no direct measure of mortality. Rather, the three proposed indicator sets incorporate factors that emphasize improvements in the quality of life as well as increases in the years of healthy life. These include measures of the physical environment, socioeconomic and educational factors, primary prevention of disease, societal factors, and health care system variables that ensure early detection and treatment of disease. This shift in focus away from measures of mortality reinforces the view that a wide variety of social, environmental, and behavioral factors play a major role in increasing the quality and years of healthy life.

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--> Elimination of Health Disparities There can be no argument that equity of health status, health outcomes, and health quality of life does not exist among all of the diverse populations in the United States. The burden of illness and death is disproportionately greater in some racial and ethnic groups, among those with lower incomes, disabled populations, gender groups, and across the age spectrum. Higher disease incidence rates and poorer rates of survival for many illnesses, higher levels of exposure to adverse social and environmental risk factors, and decreased access to medical and preventive interventions all contribute to the disproportionate rate of negative health outcomes in diverse population groups. Healthy People 2000 attempted to address this issue by establishing an overarching goal of reducing disparities in health among the members of the U.S. population. Differential targets for specific objectives within the 22 priority areas of Healthy People 2000 were established for high-risk groups. These differential targets for different population groups had the effect of promoting attention to between-group differences but generally failed to move the health of high-risk groups to equity with the health of those populations who have benefitted from the best rates of morbidity and mortality from disease. In fact, data from the Healthy People 2010 Review, 1997 (National Center for Health Statistics, 1997) identified 95 objectives for which health disparities were equal to or greater than 25 percent or more between the general population and at least one target population group defined by racial or ethnic origin, socioeconomic status, disability, age, gender, and geographic location. The second overarching goal of Healthy People 2010 moves beyond the reduction of disparities in health to the elimination of such disparities for racial and ethnic minority groups, gender groups, socioeconomically disadvantaged people, disabled people, and people in specific age groups. One underlying motivation for this important conceptual change was the hope that it would focus even greater attention on health disparities and promote development and implementation of an increased number of effective interventions that would address health disparities and ensure equity in health outcomes. This emphasis on the elimination of health disparities is also consistent with the national commitment to the elimination of health disparities between racial and ethnic minority groups by 2010 in six areas: (1) infant mortality, (2) cancer screening and management, (3) cardiovascular disease, (4) diabetes, (5) human immunodeficiency virus infection and AIDS, and (6) childhood and adult immunizations. To meet the goal of the elimination of health disparities by 2010, a variety of changes to the manner in which research on health determinants and health interventions is conducted must be made. First, there must be an emphasis on epidemiological studies to determine disease factors that contribute to higher risk for specific diseases such as prostate cancer in African-American men, cervical cancer in Vietnamese women, breast cancer in white women of higher socioeconomic status, and diabetes in Hispanic subgroups. An expanded knowledge base about effective, culturally sensitive interventions for the prevention, detection, and treatment of disease must also be developed. The interventions must be responsive to the unique educational and motivational needs of different population groups. Correct identification of at-risk groups and evaluation of interventions targeted toward these groups will require improvements in the collection and monitoring of standardized data. Finally, all people must have equal levels of access to the health care system. Such enhanced access has the potential to increase the likelihood of disease prevention through patient counseling and education, early detection of disease through screening, and provision of state-of-the-art disease treatment and management. Each of the three proposed indicator sets addresses many of the above cited social, cultural, and economic issues that are critical determinants of the elimination of health disparities. For example, measures of income, educational attainment, and access to health care for disease prevention, detection, and treatment are included in one or more of the sets. An indicator that monitors the number of preventable deaths from unintentional and intentional injury is also included in two of the three sets. It is a particular strength that

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--> the three proposed indicator sets focus on some of the most significant determinants of health disparities as well as the six priority areas of the President's Initiative on Race (1997), and the U.S. Department of Health and Human Services' initiative, Eliminating Racial and Ethnic Disparities in Heath (U.S. Department of Health and Human Services, 1998a). The actual content and wording selected to express the indicators to many different groups will be of equal or greater importance to the elimination of health disparities. If the leading health indicators are to accomplish their three primary goals (promote awareness and understanding, motivate actions, and provide ongoing feedback about progress toward improving the status of the indicators), it will be of critical importance to express them in language that speaks directly to the general population and its many diverse population groups. Currently, the three sets of recommended indicators rely on phrasing that is more familiar to the professionals in the public and private health care systems as well as proponents of the general concept of Healthy People. Preliminary qualitative research that assesses consumers response to the proposed leading health indicator sets will be funded and conducted by a private health care foundation during spring and summer, 1999. The results of that work will specifically address the three primary functions of leading health indicators (noted above) and elicit consumer impressions of their ability to fulfill these functions. Participants in this research will at least include members of diverse age, gender, racial and ethnic, socioeconomic and geographic locales. Results from the initial data collection efforts on public reactions to the three proposed indicator sets will be provided to the U.S. Department of Health and Human Services by fall 1999 and would guide efforts to further refine for consumer evaluation and acceptance of the indicators within the selected set. This committee suggests that such work be conducted by the U.S. Department of Health and Human Services or its designee. This second level of evaluation should focus on the actual language and strategies that will be used to convey information about the leading health indicators to the target population groups established for Healthy People 2010. For example, results of this research might suggest the following action statements as the most effective language to communicate to the general population and diverse population groups about the indicators contained for the Life Course Determinants Set. 1.   Don't smoke; if you do smoke, quit. 2.   Get regular exercise. 3.   Explore employment and training opportunities in your community. 4.   Don't use alcohol or illegal drugs, especially when driving. 5.   Enroll your child in Head Start. 6.   Make sure your children get the immunizations they need to keep from getting sick. 7.   Make sure our young people don't die at a young age from accidents, violence, or suicide. 8.   Get health insurance, if you can, and find a doctor who knows you and can take care of you on a regular basis. 9.   Get help early from agencies in your community to help you handle any physical, mental, or developmental problems your or your family members might have. Alternative wording and presentation styles should also be explored and tested for the Health Determinants and Health Outcomes and Prevention Oriented Sets. This will help to ensure that the messages about each indicator in the selected leading health indicator set for Healthy People 2010 are conveyed in ways that elicit the public's attention and motivate them to act on their behalf and that of others. Integration of the proposed leading health indicators with the overarching goal of the elimination of health disparities will also be achieved by the process of data collection, analysis, and reporting. Specifically, data sets that provide information about indicators in the chosen set of leading health indicators

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--> for each of the five primary population groups that are targeted (groups stratified by race and ethnicity, gender, disability, socioeconomic status, and age) will be identified or their development will be recommended. Furthermore, all data analysis for the monitoring of changes in the indicators will include the total population and at least each of the five groups. It may also be necessary to recommend that the availability and quality of data be determined for a second tier of population groups currently under consideration by the U.S. Department of Health and Human Services including, educational attainment, geographic location, and sexual orientation. When data are available for these additional groups, they should be included in all subgroup analyses of the indicators within the chosen set. Methods for the reporting of results of these analyses should extend beyond traditional public health publications and public media to include communications strategies that are known or determined to be effective in disseminating messages to the general population as well as diverse population groups. Communications can be expanded through the following: (1) the popular print and electronic press; (2) national, state, local, and community publications; (3) various channels through which the important messages can be delivered (for example, interpersonal versus personal and print versus electronic media); (4) the publications of selected groups; and (5) identification of appropriate sources through which key findings can be disseminated, such as community leaders, ministers, businesses, schools, and institutions of higher education. Dissemination strategies for reporting on the leading health indicators are discussed in greater detail in Chapter 3. Enabling Goals Four enabling goals have been established for Healthy People 2010: (1) improve systems for personal and public health, (2) promote healthy behaviors, (3) prevent and reduce diseases and disorders, and (4) promote healthy communities. Integration of the proposed leading health indicator sets with each of these four enabling goals is readily apparent upon review of the indicators within each of the three proposed sets. For example, the Health Determinants and Health Outcomes Set includes three indicators directed to the improvement of systems for personal and public health (poverty, health insurance, and high school graduation). Promotion of healthy behaviors is exemplified by the tobacco use and weight indicators. Prevention and reduction of diseases and disorders includes the indicators preventable deaths, cancer screening and cancer detection. Finally, healthy communities are addressed by the physical environment indicator. Table 4.1 provides an overview of the relationship between indicators in the proposed Health Determinates, and Health Outcomes set and the four enabling goals of Healthy People 2010. Congruence with the enabling goals and the suggested indicators also exists for the Life Course Determinants Set. The health care access and poverty indicators are representative of systems for personal and public health, whereas substance abuse, exercise, and tobacco can be linked to the promotion of healthy behaviors. Prevention and reduction of diseases and disorders is represented by the low birth weight and disability indicators. The cognitive development indicator addresses the enabling goal of the promotion of healthy communities. Table 4.2 describes the specific indicators in the LCD set that match with each of the four enabling goals.

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--> Table 4.1 Congruence of Health Determinants and Health Outcomes Set With Four Enabling Goals Indicator Promote Healthy Behaviors Promote Healthy Communities Prevent and Reduce Disease and Disorders Improve Systems for Personal and Public Health Physical environment   X X X Poverty   X   X High School graduation   X   X Tobacco use X X X   Weight X   X   Physical activity X   X   Insurance X X X X Cancer detection     X X Preventable deaths due to injury X X X X Disability X X X X Table 4.2 Congruence of Life Course Determinants Set with Four Enabling Goal Indicator Promote Healthy Behaviors Promote Healthy Communities Prevent and Reduce Disease and Disorders Improve Systems for Personal and Public Health Substance abuse X X     Poverty   X   X Physical activity X   X   Health care access X X X X Cognitive development X X X   Violence   X X   Disability   X X X Tobacco use X X X   Low birth weight     X X Relationships between the four enabling goals and the indicators for the Prevention-Oriented Set can also be identified. Specifically, the health care access and poverty indicators link with systems for personal and public health. Tobacco use is representative of the second enabling goal of the promotion of healthy behaviors. Prevention and reduction of diseases and disorders will include the childhood immunization, hypertension screening, cancer screening, diabetes management, disability, and preventable death indicators. Finally, the indicator healthy communities is represented by the poverty indicator. Table 4.3 summarizes the relationships between the indicators of the Prevention Oriented set and each of the four enabling goals established in for Healthy People 2010.

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--> Table 4.3 Congruence of Prevention Oriented Set with Four Enabling Goals Indicator Promote Healthy Behaviors Promote Healthy Communities Prevent and Reduce Disease and Disorders Improve Systems for Personal and Public Health Poverty X X     Tobacco use X X X   Childhood immunization X X X X Cancer screening   X X X Hypertension screening   X X X Diabetes Management     X X Health care access   X X X Disability   X X X Preventable deaths due to injury     X X Healthy People 2010 Focus Areas, Measurable Objectives, and Developmental Objectives The three proposed indicator sets are intended to provide an ongoing assessment of the health of the U.S. population and its diverse population groups. However, it will also be important to ensure that the leading indicators are reflective of and coordinated with the overall Healthy People 2010 plan. In order to meet this challenge, indicators within each of the three proposed sets represent 1 or more of the 26 focus areas selected for Healthy People 2010. Whenever possible, selection of indicators has been coordinated with the quantifiable and developmental objectives established for each of the 26 focus areas. Routine analysis and reporting on the selected leading health indicator set will be supplemented by less frequent but more detailed levels of analysis and reporting for each of the 26 focus areas. In addition, the dynamic nature of the Healthy People 2010 plan must be recognized. As the decade is marked by advances in science, changes in the demographics of the U.S. population, social change, improvements in the health care delivery system, improvements in communications strategies, especially those for diverse population groups, and progress toward attainment of the quantitative and developmental objectives within the 26 focus areas, the U.S. Department of Health and Human Services must ensure that appropriate changes are incorporated into the relevant dimensions of the selected leading health indicator set.