Conclusions and Recommendations
The committee has drawn upon the diverse experiences and expertise of its members to provide the U.S. Department of Health and Human Services with three leading health indicator sets including the Health Determinants and Health Outcomes Set, the Life Course Determinants Set, and the Prevention-Oriented Set. The committee has made every effort to ensure that these proposed indicator sets were responsive to the original charge from the Department as well as the comments and suggestions received through the mail, electronic mail, regional meetings, and public hearing. The committee strongly endorses the need for a single, small set of leading health indicators that could reflect progress toward the health goals of the nation.
Such a small set of leading health indicators has the potential to significantly increase the impact of Healthy People 2010 by establishing a focus for national attention, generating cues to action, and providing feedback concerning progress toward achievement of improvements in the status of each leading health indicator. Leading health indicators can be considered focal points that direct efforts to improve the health of all of the many populations of the United States and that also serve as barometers of change in the major areas of health behaviors, health outcomes, and health disparities. Selection of a leading health indicator set will allow the public and members of the public and private health care communities to focus on a limited number of issues that have meaning and relevance to the general public, public and private policymakers, and health and science professionals. Furthermore, a small set of leading health indicators can create a national identity for the full-scale implementation of Healthy People 2010 and expand the traditional Healthy People community to include a broad membership of population groups and community organizations.
The committee recommends that the U.S. Department of Health and Human Services select a set of leading health indicators from among the three proposed sets and fully support the implementation of the selected indicator set for the duration of the decade.
The committee recognizes the difficulty of the task to select a single set of leading health indicators for Healthy People 2010. Political and/or policy issues may motivate the U.S. Department of Health and Human Services to change indicators within the three proposed sets to form a different set of leading health indicators. The committee does not advocate for efforts by the U.S. Department of Health and Human Services to develop alternative sets of indicators especially those that might be comprised of different indicators from each of the three proposed sets. The three sets are based on unique conceptual frameworks and integration of indicators between sets would likely compromise the internal validity of each of the sets. If the U.S. Department of Health and Human Services must consider altering the indicators within a set, the committee strongly urges that it is done in such a manner that does not compromise the internal validity of the conceptual frameworks supporting each of the three sets.
Achieving the laudable goals of the leading health indicator effort to promote the health of the U.S. population will be difficult unless department efforts to promote, evaluate, and disseminate the leading health
indicator set are maintained and strengthened. The committee offers five suggestions for steps to be taken by the department that will support the implementation of the leading health indicator effort. These include
Leading health indicators will be strengthened by continued and expanded collaborations between the U.S. Department of Health and Human Services with other federal agencies (e.g., the Environmental Protection Agency, U.S. Department of Labor, U.S. Department of Education, U.S. Department of Housing and Urban Development), the business and labor communities, private-sector agencies, voluntary organizations (e.g., the American Diabetes Association, the American Heart Association, and the American Lung Association), state and local health departments, and community-based groups with a shared goal of improving the health of their communities and thereby improving the health of this nation's population. In the absence of such a commitment by the department, it is highly likely that the leading health indicator effort will be unsuccessful as it has been in the two previous decades of Healthy People.
Commitment of Adequate Resources and Effort for Dissemination of Indicator Set
The committee strongly urges the U.S. Department of Health and Human Services to carry forward this concept of leading health indicators for the duration of Healthy People 2010. Achievement of the full potential for the selected set of indicators will rest squarely on the shoulders of the department and will require allocation of sufficient resources to (1) disseminate knowledge about the leading health indicator set to the general population and its diverse population groups; (2) support efforts at the national, state, local, community, and individual levels to intervene upon the suggested indicators; and (3) ensure ongoing data collection efforts at the national, state, local, and community levels that will permit the monitoring of changes in the indicators through the course of the decade. The committee urges the department to develop a comprehensive plan for the communication and dissemination of information related to the leading health indicators. Such a plan should be responsive to the needs of diverse population groups and should include both traditional and innovative communications strategies to bring about changes in health behaviors. The committee reiterates the imperative for the Department to select an indicator set and fully commit to design and implementation of communications and dissemination plans, implementation of interventions, and monitoring progress toward each indicator target within the chosen set.
Enormous disparities in health status and disease outcomes continue to exist between various population groups in the United States. For example, there is overwhelming evidence that racial and ethnic minority groups are more likely to suffer from certain diseases (e.g., some cancers), and when they are diagnosed with these conditions, they are more likely to die prematurely or suffer untoward consequences at a greater rate than the population as a whole. The critical problem and the opportunity for the United States in this regard are to fully understand the dimensions of the disparities that exist and then to make the appropriate commitments to act to reduce those disparities. Furthermore, in reducing and eliminating health disparities, the essential thrust of the nation's efforts must be to raise everyone to the highest standard of health rather than to seek some lower common denominator.
The concept of leading health indicators is one that can capture the imagination of the nation as a whole and lead to actions at the federal, state, local, and community levels to improve the overall health status of the nation's populations. The committee believes, however, that it can be equally effective in bringing attention to and action to bear upon the disparate experiences of certain population groups. This is consistent with the commitment by the Clinton Administration as a whole and the U.S. Department of Health and Human Services to address the issues of disparities in the health of the population as a major policy focus in the coming decade. To be useful to this larger initiative of the administration, the committee strongly urges that the selected set of leading health indicators be tracked and measured in such a way as to ensure that sufficient information is collected to yield valid and reliable results that describe disparities in the health of the population and monitor changes in these disparities over the course of the decade.
Plans are currently underway to track all objectives established for Healthy People 2010 and the leading health indicators in such a way as to obtain data for the nation as a whole and for certain subgroups of the U.S. population. The committee applauds this effort and urges the U.S. Department of Health and Human Services to ensure the availability of meaningful data on a consistent, timely, and periodic basis to examine disparities among the following population groups: (1) racial and ethnic minorities, (2) population groups defined by income, (3) population groups defined by age, (4) population groups defined by gender, (5) population groups with disabilities, (6) population groups defined by sexual orientation, (7) population groups defined by educational attainment, and (8) population groups defined by geographic locale.
Racial and Ethnic Minorities
As a minimum standard, data on census-defined racial and ethnic groups should be collected with particular attention given to African Americans, Hispanic Americans, Caucasians, Native Americans, Pacific Islanders, and Asian Americans. Strong consideration should be given to further breaking down the data for some of these groups to detect evidence of clear health status differences among subgroups of these racial and ethnic populations. For example, differences in rates of practice of high-risk behaviors such as tobacco use or substance abuse could be examined for Hispanic Americans as a whole as well as for groups of Hispanic origin from Cuba, Central America, Mexico, South America, and Puerto Rico. Similarly, differential rates of cervical cancer incidence could be determined for women from various regions of Asia.
Populations Defined by Income
As a minimum, data should be collected to distinguish between those with total family incomes that fall below 100 percent of the federal poverty level. It might also be informative to examine income differentials at 150 and 200 percent of the federal poverty level since these cut off points are often used as criteria for determination of eligibility for social services and subsidized health care. In addition, the committee believes that strong consideration should be given to distinguishing between those with and those without health insurance coverage for analyses of all indicators.
Populations Defined by Age
Data should be collected to assess disparities and trends across standard, census-defined age categories. In particular, indicators that apply to children, youth, and elderly people should capture any disparities that exist between these age cohorts and the general population. This particular focus on these three age groups reflects the importance of examining disparities in specific indicators for population groups that are often dependent on others for their daily well-being and care.
Populations Defined by Gender
When appropriate, gender-specific disparities should be analyzed, with particular attention given to disparate rates of disease incidence, management, and survival as well as gender-based variations in the practice of specific health behaviors that could increase or decrease the risk of certain health conditions.
Populations with Disabilities
Data should be collected to assess disparities and trends across populations with disabilities. In particular, indicators that apply to health care access, health insurance, health promotion and risk reduction behaviors, and health outcomes should be examined for population groups with different levels and kinds of disabilities. Comparisons of the status of specific indicators should also be made to the general population. Inclusion of people with disabilities is important to provide analyses of disparities in specific indicators for population groups that are often dependent on others for their daily well-being and care.
Populations Defined by Sexual Orientation
Some indicators address issues that may be closely linked to sexual orientation. For example, among teenagers who commit suicide, a high proportion occurs among homosexual teenagers. When such disparities exist, the committee strongly urges that data be collected to ensure a full understanding of the factors that contribute to the differences between heterosexuals and homosexuals.
Populations Defined by Educational Attainment
As a minimum, data should be collected to distinguish between those who have and those who have not graduated from high school. Analysis of the indicators according to census-defined educational categories is suggested. In addition, the committee believes that analyses should examine the degree of correlation between educational attainment, socioeconomic status and indicators reflective of risk behaviors.
Populations Defined by Geographic Locale
Data should also be collected to identify disparities in health determinants, behaviors, and outcomes that occur on a regional basis throughout the United States. This level of analysis will have particular relevance to indicators associated with health care access, socioeconomic status, and certain risk behaviors such as tobacco use and substance abuse. As a minimum, analyses of geographic disparities should permit comparisons of urban and rural areas.
Exclusion of Specific Indicators of Health Disparities
In making its selection of candidate indicators for each of the three proposed sets, the committee debated the wisdom of including separate indicators that would focus on health disparities in the general population. It chose not to do so and, instead, urges that every indicator that it has proposed be tracked, as appropriate, for each of the population groups noted above. The committee members agree that the latter approach will more effectively address efforts to eliminate health disparities.
Poverty as a Leading Health Indicator
Committee members agreed unanimously that socioeconomic status and that poverty in particular are critical determinants of health and disparities in health behaviors and outcomes. Committee members had differing opinions, however, about whether a measure of poverty or socioeconomic status should be included in the proposed sets of leading health indicators. This represented an awareness that social issues such as poverty are outside the purview of the public and private health communities.
The committee recognizes that inclusion of a direct measure of poverty in each of the three proposed sets of leading health indicators may fall beyond the scope of the efforts of the U.S. Department of Health and Human Services. In the absence of a leading health indicator reflective of socioeconomic status, the committee strongly urges analysis of every indicator with socioeconomic status or income level as stratification variables. This will ensure that health disparities attributable to variations in socioeconomic status are identified, monitored, and corrected, if possible.
General Data Issues and Analysis at Multiple Jurisdictional Levels
General Data Issues
Significant work needs to be undertaken by the U.S. Department of Health and Human Services following its selection of a set of leading health indicators for Healthy People 2010. First, data sets that will be appropriate for the measurement of each of the indicators within the chosen set must be selected and evaluated on the basis of a number of dimensions including the quality of the data, limitations of self-reported data, data validity and reliability, periodicity and timeliness of data availability, representativeness of the data, and the ability of the data to be used for small-area analyses. Of equal importance will be the determination of appropriate intervals for data collection, methods of data analysis, and frequency of reporting on results for each of the indicators. It would be best if the collection of data on each of the indicators were to occur on an regular basis rather than to be tied to surveys that obtain data at only single points in time. Furthermore, methods of data analysis should be defined at the outset and should be adhered to during the course of implementation of the selected leading health indicator set. Consistency of analysis will help to ensure that the same information about each indicator is available to be reported to the public. Careful consideration of the appropriate time intervals of reporting on the indicators to the public will also be required. Reporting at intervals that are too frequent may make it difficult for the public to perceive any significant or meaningful change in the indicators. In contrast, delayed reporting on the indicators to every 1 or 2 years may increase the likelihood that the public will lose awareness of the indicators and motivation to act on them.
Analysis at Multiple Jurisdictional Levels
One of the four enabling goals used to organize the objectives in Healthy People 2010 is the promotion of healthy and safe communities. This is an important goal and one that is increasingly recognized in activities and publications such as the Healthy Communities 2000: Model Standards, and in the Community Health Improvement Process (CHIP) recommendations in the Institute of Medicine's recent report Improving Health in the Community (American Public Health Association, 1991; Institute of Medicine, 1997). The work of these groups suggests that communities respond to data that reflect their own particular situation. Most communities, however, have local data on only a few health issues, such as mortality, hospitalizations, childhood immunization rates, and cases of reportable diseases. Unless the local community has organized and funded special surveys or research, it will typically have no information about local rates of health protective or risk-taking behaviors, the prevalence of mental illness or disabilities, or even the number of people in the community without health insurance or a regular source of primary care.
This lack of local information can cause two serious problems. First, in the absence of such information about their own community, citizens and policymakers are far less likely to see something as important enough to merit the use of their resources or tax dollars. For example, local school officials or parents generally do not find national data on drug use among adolescents to be sufficiently convincing to prompt them to develop a substance abuse intervention program for their own high school. The second problem is that even if a community is concerned about a particular issue such as substance abuse, it often lacks the specific information necessary to develop a program targeted to the specific needs of the community. This is further complicated by the absence of baseline and impact evaluation data for assessment of the community-wide effectiveness of any programs that might be implemented.
There is increasing recognition of the importance of an individual's "community" in influencing a wide range of health-related behaviors, beliefs, and practices. This is especially true as the focus shifts from health care to the wider range of factors that influence health, such as those considered in the three proposed indicator sets. In fact, there is increasing evidence and understanding among the general public that health is an outcome of many psychosocial, educational, and environmental factors, in addition to health care and other direct biological determinants. For most people, their health behaviors and knowledge are affected most directly by the people immediately around them, including their family, friends, coworkers, and others whom they identify as peers. In some instances, the "community" may in fact be the city, town or county in which they live. In other cases, the community that is important for consideration may be a neighborhood or an extended network of persons of the same ethnic or racial group. For local programs to be most appropriate and effective for these diverse communities, data on each of the indicators in the selected set will be needed not only for defined jurisdictional units but also for the major racial, ethnic, educational, and economic subgroups within these jurisdictions.
Given the absence of good local data, communities have shown a variety of responses. Perhaps the most common response is a lack of interest or failure to implement programs that will address the most serious of the community's concerns about health. A few communities, such as those with greater resources or greater levels of initial interest, have sponsored local research or surveys to assess issues of concern. However, a community's ability to interpret its data is hindered by not having similar data from other similar localities for comparative purposes. In addition, communities frequently cannot sustain the commitment of resources to collect at regular intervals the data that would allow monitoring of the effects of intervention programs. Communities in which there is interest but not the resources to collect local data must often resort to the use of state or national results and must use those results as if they were valid for their particular small communities. For example, they may calculate the number of local cases of a condition or disease by applying the national rates of the condition or disease. This can lead to erroneous assumptions about local needs and provides no way to monitor outcomes, but these communities believe they are doing the best they can in the absence of valid data about their local jurisdictions.
During the course of development of the three proposed indicator sets and the review of relevant data issues, the committee came to recognize the imperative for resources to ensure that data are available for small jurisdictional regions throughout the United States. In addition, technical assistance will be essential at the local community level to ensure that these data are appropriately analyzed and interpreted.
Summary of Issues Relevant to Data Collection and Analysis
In light of these issues relevant to data collection, analysis, and reporting, the committee makes several suggestions.
Data sets should be evaluated for the following characteristics: quality of data, limitations of self-reported data, periodicity and timeliness of data availability, representativeness of data, and ability to provide small-area analyses and analyses for multiple jurisdictional levels.
Technical assistance should be provided to ensure appropriate use of small-area analysis data sets representative of multiple jurisdictional levels in the design, implementation, and evaluation of local interventions to improve the status of specific indicators.
Appropriate intervals for data collection, methods of data analysis, and frequency of reporting on results for each of the indicators will also need to be determined.
Development of leading health indicators that provide a clearly understandable and recognizable face for the full Healthy People 2010 agenda has enormous potential to exert positive influences on the public's awareness and practice of health promoting behaviors. This is especially true if the chosen set of indicators are meaningful to and can be acted upon by the lay public, with an emphasis on the inclusion of diverse population groups. This report contains a number of recommendations to the U.S. Department of Health and Human Services that address issues relevant to the composition of leading health indicator sets, data collection, data analysis, effective dissemination strategies, health disparities, and effective use of interagency collaborations to support the full implementation of the leading health indicator set. These recommendations reflect the committee's belief that achievement of the Healthy People 2010 overarching and enabling goals is possible, but only when national, state, and local health agencies establish collaborative partnerships with members and organizations representative of a wide array of diverse population groups and communities. These partnerships can yield significant and sustained changes in the health behaviors and health outcomes of the public. In the presence of collaborative, community-based partnerships, leading health indicators for Healthy People 2010 can be used as tools to mobilize efforts by the lay public and health professionals to become engaged in progress toward the health goals for the nation and to do so in a manner which prompts public understanding and policy actions related to the important determinants of that progress.