Criteria for Measurability of Objectives
Each small group leader gave a short summary of his/her group. Edited versions of these summaries follow:
"It's important that the 2010 document come from the ground up and that the ultimate users, that's the public, must be at the planning table from the beginning. Having said that, our group offers the following template as a framework to better communicate HP 2010. The HP 2010 document would have two chapters. Chapter 1 would be entitled, "Life Stages" and that would cover everything from pre-birth to old age. And Chapter 2 would be called, "Community Health" and that would include core public health issues such as environmental health or food safety. HP 2010 would complement, not necessarily replace, the fine Healthy People 2000 effort."
"Our group decided that the current organizational structure actually works very well. Although we do feel that it might need minor modifications, we feel that current categorization, you know, has been two decades in the making and... that over 40 States and territories have adopted it as the format for their own Healthy People programs. We do feel that it does need minor modifications, but not a complete remodeling. And a couple of the recommendations I'm just going to mention and some of this is based on... some of you I think were at the meeting last week where there were State and local representatives who presented their views on what they felt was good and not so good about the current Healthy People 2000 objectives. And I would say the majority of them really actually enjoyed the comprehensiveness of the document. That they used it to select what was appropriate and applicable to their needs. And so we wanted to advocate keeping the comprehensiveness of it and also keeping it fluid and flexible so States and locals can select from a larger grouping of objectives. And the only other thing I want to say is that we also felt there needed to be, in the development of the objectives, a stronger connection with our three primary goals. We discussed greatly that most of the objectives really apply to the first goal which is to increase the span of healthy life. A little bit more so to reducing health disparity, but very little to achieving access to preventive services to all Americans."
"After a very lively discussion we decided that we think for Healthy People 2010 that the focus should be on health outcomes and risk factors and all of the objectives that we have right now that deal with strategies to achieve these objectives should be dropped as measured objectives. Now that didn't mean that you should drop the strategies. Obviously you need the strategies and people will still be measuring the strategies in different ways. But after a lot of discussion we determined that a lot of objectives that seem to haunt us the most are the ones which mainly fall in services and protection that are actually strategies to achieve some kind of health outcome. So that was our suggestion, that we would drop these as measured objectives, but they would still be strategies. They would be discussed in the document, but they would not be measured."
"What we did is give complete discussion to using the life stages, the age categories. We devoted a considerable amount of discussion to those and I think it will ultimately prove to be the one we think we'd choose. However, we also looked at something we phrased as "life settings." That looks at where we can find the population we are looking at, a particular time. That could be residences, which would include correctional centers, juvenile justice systems, nursing homes. Wherever you reside. It could be school. It could be workplace. It could also relate to your dealings with the health provider, be it a dentist, a physician. Then when looking at problems such as air pollution and pollution questions, we looked at an over-arching setting of community. What we would do with that is open to discussion right now. But we continue to have much concern about the public perception of Healthy People as it relates to them. This seemed to us to be the best way of keeping it simple. Obviously, I think it was a consensus that 22 priority areas were too many. And we preferred to see them phrased in a much more realistic and user-friendly sort of way."
"Don't tweak the existing structure too much. Too much effort, dollars, systems, and plans in States are based upon the existing Healthy People systems. We don't want to have the States say of us, 'Oh, it's just like the Feds'."
Criteria for Measurability of Objectives
The focus of discussion in the next session was the advantages of limiting the objectives to those that can be measured versus those that are actually being measured.
The advantage of using 'measurable' (versus 'measured') criteria are that more, and a broader range, of objectives can be included, "You could include all things that people thought were really important," and give flexibility in terms of how local entities use them. "There are different ways to get at the same objective. In one community they might decide to do it one way and in another community they might decide to do it another way."
A disadvantage of 'measurable' criteria is that if we put an objective up there, on the hope that it will be measured, the Federal agencies continue to feel like they are mandated to find a way to measure it. On the other hand, it can actually lead to the improvement of measurement systems.
As an aside, one member commented, "Sometimes because something is measurable, we think it's do-able. For instance, we can measure self-esteem, but we don't know really very much about how to increase it." Another replied that it's important to make broad statements about something that people and public health feel strongly about... "you don't want to lose out on addressing important issues that we don't have systems for or that we don't know how to measure." Another added that for some things we can't get comprehensive data, only data from sub-populations, such as for immunization. Having immunization as an objective serves an educational role, it makes a policy statement, holding specific groups accountable.
The advantage of limiting objectives to those that are already being measured by data systems, that you expect to be around for a while, is that you will be able to do this even in times of level or declining budgets. You don't need extra resources to make it happen and, further, you have good baseline data. The number of objectives will be lower and you restrict the number of sub-populations you can use.
One participant suggested having a measurability criterion that the higher and more political levels of the agencies would be held to as well as technical folks. It would allow us to measure progress. It increases the credibility of the objectives and the utility of the objectives for the health care delivery system. "It adds to the knowledge base. You can be sure that over time you will have learned something about how something is changing or not changing or in which direction, whereas if you start out and think you might get something in place and you can't do it... you end up saying, well, you know, I haven't learned anything. I don't know what to do about it and I don't know whether I've even possibly made an impact here or not." Another member added, "it's not just a matter of a baseline at a point in time, but you have some back data that give you historical trends so that you can tell whether or not even the changes that you are looking at are just secular trends or real changes." Another said, "You can more easily apply cost effectiveness analysis because you've at least got the effectiveness component of the equation in there."
If you have an objective that depends on a data system, it is going to encourage people to improve the data system because it's got an objective associated with it. If they're measured at the national level, that increases the likelihood that they will be at least measurable at the State and local level. At minimum there is a template and there may actually be data. It can help you generate objectives a little bit more creatively if you really start to mine the data that are already there.
One advantage of 'measured' is that the pinch of realizing that you can't put an objective in could lead to the creation of objectives which would be measurable and lead to questions about whether or not there were data systems in place.
Another woman replied, "Considering the kind of energy that has gone into attempts, multiple attempts to get data, I want to throw out one possible advantage... if you limit yourselves to objectives that you know can be measured, the energy of the Federal agencies can go into trying to achieve progress on those objectives rather than trying to find data for those objectives. So ... that's a different way to look at it."
In summary, the participants felt that the advantage of including 'measured' criteria is that it motivates the building as well as the improving of data systems. Many people were comfortable with the idea that there would be at least some objectives that would speak to the development of data systems to collect information on things we can't collect now.
Making sure that you have objectives for which there are data means that you have data today. It means that you're likely to set more realistic targets for where you want to go because you actually know where you are today.
Another comment was a caution not to assume that we will have the data for problems that don't exist yet. In 1980, it was not even known that there was a such a thing as HIV, let alone what kind of impact it was going to have or how they could measure it. In thinking about HIV, another comment was, "requiring that the objective be measured may lead to advocacy on the part of external interest groups for improved measurement... as opposed to just putting the objective in.
One man said, "the advantage is that [requiring the objectives to be measured] follows the philosophy of the whole process. Management by objective calls for rules and measurable objectives. And that's the philosophy of the whole system, the theoretical background for this process. Now, I think one of the things that maybe we deluded ourselves in was in having only three goals. In a sense we're talking about leaving certain things out because we don't have measures. We could have had more goals or some sub-goals. For example, a major goal or policy issue in HIV is to reduce the incidence of HIV. That can be a goal. One goal might be reduced HIV infection. Well, we can't measure that! So you have an objective about what can be measured. The things that you can't measure can be stated more broadly in terms of policy wishes as a goal which you have no intention of measuring because you can't measure it. We would set up a system with a few more goals and some sub-goals and then still keep true objectives as measurable."
The moderator, speaking to one of the participants, said "you used the term 'policy statements' earlier. Is that what you mean? That you can make a distinction between goal statements that do not have these stringent measurement criteria around them versus objective statements that do have these stringent measurement criteria around them. And that's one definition of what an objective is... that it's one or multiple ways to operationalize and measure a goal."
There followed a brief conversation about serving the needs of the States and about using new technology. It was suggested that new technology would allow a system in which there can be, in a sense, multiple alternative frameworks and architectures that someone can essentially design for themselves, if the data base is structured appropriately. One could search on age, on place, on risk factor, on population, disease, and on anything else. Many participants of the Retreat talked about the fact that the structure and the dissemination, especially, of Healthy People 2010 should take full advantage of the fact that our communications technology has changed dramatically.
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