Deborah R. Maiese, MPA

Claude Earl Fox, MD MPH

The first year of development of the national health objectives for Healthy People 2010 has been a time for listening. The Healthy People 2000 Consortium has asked representatives of a range of constituencies to evaluate what has been useful in Healthy People 2000 and should be preserved for Healthy People 2010 as well as what has not worked in the initiative and should be modified or deleted. Through focus group sessions, public meetings, and a website, people from across the country have been able to make their voices heard. This report summarizes the first year of activities to stimulate more people both to contribute to the national consultation and to replicate these efforts locally.

The Healthy People 2010 framework will be grounded in initiatives pursued over the past two decades. A Surgeon General’s Report: Healthy People provided targets to reduce premature mortality in four life-stage groups in the 1980s and was supported by objectives with 1990 endpoints. Healthy People 2000: National Health Promotion and Disease Prevention Objectives has guided efforts throughout the 1990s toward health targets for the year 2000. Like its predecessors, Healthy People 2010 will involve a broad consultation process and will be a decade-long action agenda.

In the 18 years since the Healthy People initiative began, the scope of activities using this framework at the state and local levels has demonstrated the value of shared health targets. Forty-four states, the District of Columbia, and Guam have published their own versions of health promotion and disease prevention objectives. In 1996-1997, New York and Hawaii completed plans; Maryland, Ohio, and Virginia updated their objectives; and Maine, Rhode Island, and Vermont published midcourse assessments. These documents are being used to shape local and statewide health initiatives.

Since its inception in 1987, the Healthy People 2000 Consortium has more than doubled in size, from 157 national membership organizations to 342. Among the newest members are the Society for Academic Emergency Medicine, the National Association of Local Boards of Health, and Shape Up America!

The activities that have been pursued in support of the Healthy People initiative include groundbreaking research, service innovations, targeted program initiatives, and far-reaching public awareness campaigns. As the Healthy People framework is included in textbooks and college courses, it is being used in educating the next generation of health professionals. Together, these activities are integrating the efforts of the public health community with private health care providers. The scope of the objectives goes beyond personal health care and traditional health settings to encompass the health-promoting activities of schools, worksites, and other community organizations.

The distribution of Healthy People materials may be another measure of the broad constituency that is engaged in using the objectives. More than 100,000 copies of the Healthy People 2000 documents are in circulation. The 20,000 copies of the Healthy People 2000 Midcourse Review and 1995 Revisions were distributed within the first year, requiring a second printing. Some 12,000 copies of Healthy People 2000 Review, the annual statistical abstract produced by the National Center for Health Statistics (NCHS), are placed in circulation each year. These documents can be accessed through the Healthy People 2000 home page--odphp.osophs.dhhs.gov/pubs/hp2000. This website receives more than 8000 contacts a month.

Because Healthy People 2000 is so widely used, the framers of Healthy People 2010 are seeking to engage their "customers" of the past 18 years to shape the scope of the initiative for the next decade. In addition, they are redoubling their efforts to bring more people into the development process. The feedback received over the next two years will have a profound effect on the shape of the Healthy People activities in the new millennium.

Consortium members. A series of seven focus group sessions were conducted with members of the Healthy People Consortium. Led by professional facilitators from the Center for Health Outcomes Improvement Research (CHOIR) of the George Washington University Medical Center, representatives of national membership organizations, state governments, managed care organizations, and private businesses have examined the value and functions of Healthy People objectives, both current and future. The group reviewed the major changes in health status and health care and gave opinions about how best to adapt the Healthy People framework to these trends. They agreed on the need for Healthy People 2010 to be relevant to a wider audience of health care purchasers and private sector employers.

Several suggestions emerged from the group meetings: a plan to create multiple versions of the 2010 document and thus offer products adapted to the needs of a wide range of users; a commitment to writing the documents in a way that would be understandable for an audience beyond public health professionals; the suggestion that measures be incorporated that describe health improvement as well as disease reduction, which will help ensure broader use of the document by people undertaking community health improvement efforts.

Healthy People Steering Committee members. The Department of Health and Human Services’ Healthy People Steering Committee is comprised of representatives from all of the operating divisions of the DHHS and meets on a quarterly basis. Work group coordinators, who represent the lead agency for each Healthy People 2000 priority area, also participate in these sessions. In focus groups led by the CHOIR staff, the coordinators have discussed options for restructuring the Healthy People framework, the criteria for determining priority areas, and the number of objectives within each priority area as well as data issues. Reorganizing the document by life stages (infants, children, adolescents, adults, and older adults) was considered as a means for moving away from disease specific/categorical priority areas. While this format would make the document more understandable, the need to repeat objectives (for example, nutrition objectives are relevant to every age group) would make the document cumbersome. All agreed that the newest in information technology should be applied to make the Healthy People 2010 document versatile. Key word indexes in the electronic version of the documents would enable users to customize their listings of objectives.

Focus group input on number of objectives. Both the Consortium and DHHS focus groups discussed the number of objectives in Healthy People 2000. Six of the seven Consortium member focus groups felt that the encyclopedic nature of the document provides something for everyone to use. The breadth and depth of the objectives was regarded as useful as long as the Federal government does not require grant recipients to report on all of these measures. Consortium members cited various uses for the objectives--in making the case for legislative changes in their states or localities, in requesting funding from both public and private sources, and in benchmarking their health improvement activities against national statistics.

The final focus group, comprised of medical directors of managed care organizations and benefits managers of private employers, questioned the utility of having so many objectives. They raised the question of how there so many areas can be priorities. Their recommendation was that the 2010 document be more focused. Participants in the DHHS Steering Committee favored fewer objectives. These divergent perspectives emerged in the first year’s consultation.

"Building the Prevention Agenda for 2010: Lessons Learned" was the theme of the Healthy People 2000 Consortium’s 1996 annual meeting. Attended by 185 Consortium members representing states, businesses, and voluntary membership organizations, the day provided an opportunity to address several issues. Dr. Ilona Kickbusch from the World Health Organization set the stage for framing health broadly by asking three strategic questions: "Where is health created? Which investment creates the largest health gain? Does this investment help reduce the health gap and ensure human rights?" Dr. Kickbusch then suggested that five groups of health determinants be addressed in national objectives: "biological factors, the physical environment, the social environment, lifestyle factors, and health care services." She challenged the United States to frame Healthy People 2010 objectives broadly.

Involvement of the business community in the development and implementation of Healthy People 2010 was considered at the annual meeting. The Executive Director of the Wellness Councils of America, David Hunicutt, described a history of corporate involvement in worksite and community health promotion activities. In an afternoon session, Consortium members discussed whether individual businesses should join the Healthy People Consortium. Concerns were expressed about the criteria that would be applied for business entry and the potential proprietary uses of this affiliation. The consensus was to limit the Consortium to national membership organizations, including trade associations to represent certain industries.

DHHS has created a Healthy People Business Advisory Council separate from the Healthy People 2000 Consortium. The purpose of this Council is to make Healthy People a valuable tool for both worksite and community health promotion. In July 1997, the Robert Wood Johnson Foundation awarded the Partnership for Prevention, a Consortium member that pursues prevention activities, funding for an 18-month period to engage the leaders of America’s businesses, both large and small, in Healthy People 2010 development.

Presentations on Healthy People 2010 have been made at numerous conferences, symposia, and meetings sponsored by Consortium members and other groups. These speaking engagements have offered an opportunity to describe the Healthy People 2010 development process to thousands of people in the public health community. Questions from the audience have provided an opportunity for an exchange of ideas that has helped refined the process, concepts, and content of the initiative.

Presentations to visiting health ministers and foreign delegations have focused on the value of having an framework of objectives not only for internal management purposes but also for collaboration with other sectors: education, agriculture, and environmental health. A U.S. Agency for International Development project was initiated in 1997 to collaborate with the Egyptian Ministry of Health in developing a set of 2010 objectives to unify that country’s many health improvement projects into a solid measurement approach with targets. This project holds great promise for demonstrating the value of objective-setting in a country that is seeking to enhance its data systems. It could also serve as a model for other countries to use in responding to the World Health Organization’s call for "Renewing Health for All."

At its inaugural meeting, the Secretary's Council, a group that includes former Assistant Secretaries for Health and the current heads of operating divisions in DHHS, reviewed the history and accomplishments of the Healthy People initiative with a view toward applying the lessons learned to the development of Healthy People 2010. The Council examined the proposed 2010 chapter framework and endorsed the concept of putting the proposed goals and focus areas out for public comment.

The Council also supported the proposal that two overarching goals be created for Healthy People 2010. The first goal of Healthy People 2000--"Increase Years of Healthy Life"--would be retained. The second goal, "Reduce Health Disparities," would be strengthened to "Eliminate Health Disparities."

The Council agreed that the chapters in the 2010 document be called focus areas, abandoning the term "priority area," which implied prioritization. The Council members asked us staff to diagram the proposed goals and focus areas so that the words would be connected through an image that could help demonstrate their interrelationships. The image of a fan with underlying goals at its base emerged as a way to convey the breadth of the Healthy People initiative.

Four enabling goals were proposed to connect the overall goals of the initiative with the proposed focus areas. The proposed enabling goals are: promote healthy behaviors; protect health; assure access to quality health care; and strengthen community prevention.

Language was added to expand the scope of the health services focus area to include long-term care. A footnote to convey the importance of considering special population groups in each focus area chapter was also added. A document titled Developing Objectives for Healthy People 2010 emerged from these discussion to explain the who, what, when, and how of the 2010 development process.

Improving the capacity to monitor health trends and progress has been both a tool and a purpose of Healthy People 2000. Monitoring and reporting on changing health status, emerging risks to health, and service delivery has been one of the major contributions of setting national disease prevention and health promotion objectives. While baseline data were lacking for 91 of the 300 objectives when Healthy People 2000 was published, today all but 11 of these data gaps have been filled.

The objectives have driven the development of new data collection mechanisms. Through the Primary Care Provider Preventive Care Survey, the extent to which clinicians are inquiring about, counseling, and providing clinical preventive services can be estimated. The School Health Program and Practices Survey provides information on school health curricula and the number of schools offering daily physical activity. The Worksite Health Promotion Survey has documented the scope of health promotion provided by private sector employers.

To lay the foundation for the collection of timely and reliable data to be used in setting measurable objectives for the year 2010, NCHS hosted a three-day meeting of Committee 22.1 in September 1996 with a theme of "Uses of Healthy People 2000 at State and Local Levels--Lessons for 2010." Committee 22.1 was established by the National Center for Health Statistics in 1991 to develop a set of health status indicators appropriate for measurement at all levels of government. The name of this committee refers to the first objective in the Healthy People 2000 "Surveillance and Data Systems" priority area.

Initially composed of members from key public health associations and academia, in 1996 the Committee 22.1 was expanded to include participants representing both state and local public health perspectives from Ohio, South Carolina, Minnesota, Oregon, Kansas, Virginia, and Texas. Participants reviewed existing survey data collection instruments, the availability of published statistics from national and state surveys, and the importance of developing uniform data measures to monitor community health status. Committee 22.1 also approved changes and enhancements to previously published Priority Data Needs.

The culmination of the year’s consultation was the opening a new website: www.health.gov.hpcomments. On September 15, 1997, as specified in a Federal Register notice of September 5, DHHS opened the proposed 2010 framework for public comment. In addition to commenting on the proposed vision statement, goals, and focus areas, the public is invited to comment on Healthy People 2000 objectives, making recommendations for deletions or modifications for 2010 or proposing new objectives.

By harnessing the power of the information superhighway, DHHS is making Healthy People 2010 a participatory process. The hope is that the public draft circulated in the fall of 1998 will already begin to reflect a consensus about the shape of the nation's health agenda.

While much of the consultation with various stakeholders and constituencies has been focused on the development of Healthy People 2010, DHHS and the Healthy People Consortium members continue to pursue achievement of the Year 2000 targets. During this past year, there have been eight progress reviews with the Assistant Secretary for Health. Cross-cutting reviews on the status of people with disabilities, Hispanic Americans, and Asian Americans and Pacific Islanders have focused on developing 2010 objectives.

The first year has seen just the beginning of the public outreach for Healthy People 2010. Year two will be focused on work groups drafting the initial set of objectives and structuring the draft document based on the public comments received. In the spring of 1998, the Healthy People Steering Committee and the Secretary's Council will synthesize the framework and the objectives into a draft document that will be posted for public comments in the fall of 1998. Efforts will begin in 1998 in collaboration with the National Academy of Sciences to identify a sentinel set of objectives and to plan for regional hearings on the draft objectives. Work will continue within DHHS and other Federal agencies to synthesize various performance measurement activities with Healthy People 2010 objectives. The United States will actively contribute to the efforts by the World Health Organization and the Pan American Health Organization toward renewing the Health for All strategy. By continuing to consult at local, state, national, and international levels, Healthy People 2010 will emerge as a consensus document that can guide this nation's health agenda for the 21st century.

This article was published in Public Health Reports, January /February 1998, Volume 113, pages 92-95. 

Deborah R. Maiese is a Senior Prevention Policy Advisor with the Office of Disease Prevention and Health Promotion (ODPHP), Washington DC. Claude Earl Fox, formerly the Director of ODPHP, is the Acting Administrator of the Health Resources and Services Administration, Washington DC.

Address correspondence to: Ms. Maiese, ODPHP, HHH Bldg., Rm. 738G, 200 Independence Ave. SW, Washington DC 20201; tel. 202-401-5809; fax 202-205-9478; e-mail dmaiese@osophs.dhhs.gov.

The Healthy People 2000 home page can be accessed on the Web at odphp.osophs.dhhs.gov/pubs/hp2000. The Healthy People 2010 home page is at www.health.gov/hpcomments.