The overall reporting statement was "Don't tweak the existing structure too much. So much effort, money, systems, State plans [are] based upon the existing Healthy People systems."
Other topics of discussion in this group were:
Change only with reason.
Life stages or life phases are not good alternatives to the current categorization of Healthy People.
Prioritize objectives in terms of "degree of disparity of health," identifying where the major problems are and for what sections of the population.
Speak to the health care needs and problems of the "disenfranchised" and special population targets, or keep strictly measurable objectives and national goals, leaving sub-population objectives at the local level.
Include overarching non-health outcome objectives that lead to higher health care standards for the nation, e.g. monitoring health insurance coverage, and the quality of managed care.
Develop system of exclusion of an objective.
Change with reason, no need to reinvent
One woman stated, "I personally like the categorical organization... one of the underlying principles is that you know it allows flexibility for States and communities to select and develop their own priorities from these Federal priorities. A man agreed pointing out that "the model that we are using now has been widely accepted by... almost all State and local governments... If we use an entirely different model, everything that's been done by the States to this point is going to have to be radically changed. So basically I think unless there is a reasonably strong reason to change the model we should try to use as much of the model as we can ... that's already in place." This idea of retaining as much of Healthy People's current structure as possible was a major theme throughout the group's discussions and "flexibility for States" was determined as an overarching principle of Healthy People.
Don't reorganize by life stages
One woman commented, "Maybe there's a way of simplifying that structure and then adding a component or two, sort of at the overarching end of it. Rather than disassembling it and creating something new that ... at least for me it would take a long time for me to even figure out for example, this life phase thing." Everyone agreed that minor changes should be made but that Healthy People 2010 should be "built upon the existing model". Organization by life stages or phases was not an appealing alternative to the present categorization for this group. One woman felt that using life stages or phases would involve "artificially forcing things into categories." The main concern of the group members was to improve Healthy People but not change it dramatically "so as to not disrupt state efforts/funding."
In discussing organization one woman said, "I think choosing priority areas matters... going back to the book, it's a chapter system, not a priority system... If we had real priority areas, we could be flexible with what the objectives wereΒΌ and how many there were" A man added, "Objectives should reflect not only outcome objectives ..but objectives for policy and an ecological model as well as health status outcome objectives."
Prioritize by issues having overall health impact
The group discussed prioritization of objectives as a way of simplifying Healthy People "at the overarching end." One woman suggested that prioritization be dependent on where "our major public health problems are today," and another woman suggested it be determined by the degree of disparity in health: "Between the healthiest among us and those at the bottom of the curve. And the objectives that you have now even, with the data, help you find some of those questions to answer without changing the questions so much." The group came up with a strategy to reduce the number of priority areas to 19 by taking out (4)Substance Abuse: Alcohol and Other Drugs, (8) Educational and Community-Based Programs, and (22) Surveillance and Data Systems, and putting them under other priority areas "as they are appropriate." There was no real explanation for this but everyone seemed to agree with the idea, and one woman added that mental health should also be dealt with "under the appropriate priority areas."
One woman stated that "maybe there should be an emphasis more on where... when you say [all] citizens, you know, I mean there are definitely some that are [left] out here, that aren't getting the benefits of a lot of this." She later stated that "the structure should be one that includes key health issues for disadvantaged or disenfranchised populations... And I guess by 'disenfranchised' I mean... people who don't have health insurance, people who don't have access to any of the current [health care services]." Other group members agreed with this point but argued that the difficulty in accurately keeping track of sub-populations and special conditions over time made it unrealistic to prioritize Healthy People objectives in terms of special target groups.
Include overarching non-health outcome objectives such as insurance coverage and managed care
One woman wondered, "could these health objectives possibly be constructed or even used.... so that they would start to set standards of basic health status in this country... that managed care or any other providers could eventually be held to in some sort of official or quasi-official manner?"
System of exclusion of Healthy People objectives
The group members presented several criteria for setting priority areas and objectives. Measurability, multi-agency buy-in and consensus, and public believability were each important criteria according to the group. Also, one man stated that for an issue to become a Healthy People priority area, it is imperative that "there is an intervention, infrastructure and stakeholder structure around the problem." Another man emphasized the need for infrastructure behind a priority area, commenting that "the availability of resources and whether or not there is an infrastructure in place capable of dealing with the issues" should in large part determine the inclusion of a priority area. In order to scale down the number of objectives for 2010, the group suggested the establishment of a system of exclusion for Healthy People objectives based on measurability, feasibility, and a defined "cut-off point" of importance and funding. The group also discussed limiting the number of objectives per priority area to approximately 7, pushing agencies to include only the most crucial and data-accessible measures.
Another idea was to throw out the disease chapters and approach things through behaviors. Bringing up the survey of the population, someone added that, "The Congress represents the people. They think in terms of diseases. That's why we have disease Institutes".
"The categories as they stand now are confusing to the public. There is health promotion here and health preventive services there. It's doubly confusing because they're so similar. It appears that there are no services in some areas."
One man said, "I think that we have to live with the priority areas. Because we wanted to make something that was all encompassing in terms of disease. I would just as soon live with the priority areas. But I would rather see us think in terms of how we could address them from the age perspective. Because there are things that you can do behavior-wise as well as risk-assessment wise, at different ages, that impact these priorities to a greater extent by doing it that way. And, like immunization for instance, or even sexually transmitted diseases, when it comes to adolescents and young adults. Cancer more in old age and things like that. And things like physical activity, tobacco and alcohol use should be very early on-- should be at the elementary school, K to 12 levels, where you can really... when you set your behavior in life. So, I mean, there are... we can address it from those perspectives and I think we could do it well."
One participant felt that not everything could fit under life stages, "That can't be the only framework, there are things important to the area of health protection... that has to be a special section, the community health section." Another added, "..by making community health a separate entity in a group of four, you put actually more emphasis on it than you would if it were a separate entity."
There was some conversation about the public as an audience. One person thought it was important to be able to explain the framework to the public. Another said, I don't think of the public as a player. "I don't need to know how a car works to buy one." It was suggested that the public could know the "Top 25 Health Problems" without knowing the indicators. You could also interface with the providers this way. You could ask, 'are they going up or down?' and focus on them. Someone else added, however, "I still like the life stage idea of clinical preventive services. People think in life stages." A woman added, "If you do life stages, you can do just four or five most important things to do when you are at that age."
One woman suggested that you could say, "The health community wants every American to have a healthy childhood, healthy adulthood, healthy elder life... and these are the ways by which you can have a healthy childhood... etc."
One man felt that, "we have failed to communicate what Healthy People 2000 is all about to anybody outside of the Public Health Service." A woman added, "we may have failed in two different aspects. One of them is organization...and the other one might be that the objectives weren't relevant."
Restate criteria for inclusion of objectives
Suggestions for criteria were the following: Objectives should be measurable if there is a target but they can also be deliberately non-measurable without a target. They should be able to be applied locally, with local priorities based on severity or prevalence by population or locality. An effective intervention should be available. They should have scientific validity and a balance between outcome and process. They should be comprehensible to the public and reasonable and do-able at the local level.
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