Phase I Report
Recommendations for the Framework and Format of Healthy People 2020

Section V. Guidelines for Implementation of Healthy People 2020

The Intended Users of Healthy People 2020

Members of the public health community—especially at federal, state and local health agencies—have traditionally been viewed as the primary audiences for Healthy People. The Advisory Committee proposes that Healthy People 2020 should be developed to be relevant to a wider range of key user groups in both the public and private sectors. This expanded audience base should include: decision and policy makers; state and local elected officials; voluntary, advocacy, community, and faith-based organizations; the general public, businesses; health care providers; and other sectors whose actions have significant health consequences.

In considering the informational needs of Healthy People audiences, the Advisory Committee distinguishes between those who are already aware of Healthy People 2020 and will seek information about it (information seekers) and those who are not aware of the initiative but could potentially help to achieve the objectives (information targets). The Advisory Committee considers information seekers to be the primary audiences for Healthy People 2020. However, information targets are viewed as important secondary audiences whose involvement in Healthy People 2020 is critical to success.

Examples of audiences considered as primary or secondary are shown in Exhibit 6, a matrix that can be expanded into a basic marketing plan to create messages and content about Healthy People 2020 for specific audiences. More detailed information that clarifies the nature of information to be disseminated to user groups will be gathered during Phase II of the Advisory Committee's work.

Helping Users to Create Tailored Data Sets that Meet their Needs

A common use of Healthy People is to facilitate program planning. Users should be able to organize the information they receive from Healthy People 2020 by interventions, determinants, and outcomes of interest to them. They should also be able to follow links to other relevant sources of information, partners, and resources.

Because users make planning decisions within the context of limited capacity and resources, it is important that Healthy People 2020 enable them to sort and prioritize objectives. Examples of criteria that could be used to sort objectives include effects of intervention strategies over time, effects on survival, or effects on quality of life. Where evidence is available, intervention effects on particular population subgroups could also be useful and are recommended.

Users should be able to draw on Healthy People 2020 to assess and prioritize a balanced portfolio of short and long-term targets and interventions. In some situations, results can be achieved only by combining two or more complementary interventions. Where evidence supports a comprehensive approach (e.g., tobacco control, reducing motor vehicle injuries) they would be prompted to choose a mix of strategies that can interact synergistically to yield systems-based solutions.

Exhibit 6. Communicating about Healthy People 2020 with Key Audiences^xi

Users at different levels of the public health system (i.e., national, state/regional, and local) target their actions differently and therefore require different data sources. Non-governmental users (e.g., businesses, foundations) also have needs at different levels. For example, some are national; some are dispersed within two or more states; and many are local. Healthy People 2020 can assist all user groups, both governmental and nongovernmental, to prioritize and to set their own objectives. Users at different levels may draw on Healthy People 2020 for different purposes.

• National-level users may use Healthy People to help drive policy in both legislative and executive branches and to set goals, objectives and performance standards in federal grants and contracts;
• States, foundations, and others that supply funds or drive policy at regional, state or local levels, may use Healthy People to define policy and program priorities and to set performance requirements for grantees;
• Local public health, community and voluntary organizations, as well as businesses whose missions include reducing the avoidable burden of disease may use Healthy People to develop and prioritize strategies to promote health and to reduce health disparities among population subgroups.

Criteria that Can Help Users to Prioritize Objectives

The Advisory Committee recommends that Healthy People 2020 provide the best available information on the following key factors relating to each Healthy People 2020 objective to help organizations and individuals prioritize potential actions in response to the objectives. Different organizations and individuals may differ in their views of which these factors are most important in general, or with respect to a given Healthy People objective. Thus, Healthy People 2020 should assemble the best possible information on these factors for all objectives so that users can prioritize them as they prefer. Detailed explanation of these key factors is provided in Appendix 14. These factors are:

1. The overall burden associated with a particular risk factor, determinant, disease or injury;
2. The degree to which a burden may be preventable or reducible, based on application of interventions of proven effectiveness, (i.e. the projected population health impact of interventions, policies, and programs of proven effectiveness);
3. The cost-effectiveness (e.g., cost per quality-adjusted life years, or QALY) of alternative opportunities to reduce health burden and improve health;
4. The net health benefit, measured in units of population health, of pursuing one particular intervention, policy, or program compared with another one of proven effectiveness;³⁵
5. The synergy of different interventions that target the same disease, risk factor, or health determinants;
6. The likely timeframe to observe the impact of different interventions, alone or in combination;
7. The potential of alternative interventions to improve the health of racial/ ethnic minority populations and reduce health inequities among populations; and
8. The willingness of public health, private organizations, and other collaborating entities to address a particular health problem and to accept accountability for convening multisectoral stakeholders to effect changes in these areas.

Organizing Objectives by Interventions, Determinants, and Outcomes

Past versions of Healthy People were primarily released in a printed, static format that could best be navigated through the use of easily recognizable chapter headings. These headings were called "priority areas" in the 1990 health objectives and Healthy People 2000, and "focus areas" in Healthy People 2010. For Healthy People 2020, the database approach recommended by the Advisory Committee would enable users with different perspectives and responsibilities to readily obtain the information they seek through a Web interface.

This more dynamic and user-friendly approach would not require assigning objectives to specific focus areas. Instead, Healthy People objectives could be organized into three broad categories within the database: 1) interventions, 2) determinants, and 3) outcomes. There would be no need for a hierarchy that places one area above the other within these groupings. Instead, the categories would serve as entry points into the Healthy People 2020 Web-accessible database. Governmental public health and legislative bodies and other users at various levels would be able to use these entry points to begin the process of sorting objectives to meet their specific user needs (see Exhibit 7).

Exhibit 7. Entry Points for Organizing Healthy People 2020 Objectives

Within this matrix, the principles for prioritization that were discussed in the previous section could be used to sort objectives. Prioritization criteria would be entered by the user to yield a list of objectives and interventions that are tailored to the user's needs. For the health objectives to meet the needs of different user groups, pertinent data and other information must be linked to the Web-accessible database. Relevant national, state, and local surveys should also be linked to Healthy People 2020, but need not be included within the database itself.

The justification for specific Healthy People objectives should include the three general categories so that objectives can be searched on these parameters. This organizing structure could encourage interest groups to think about opportunities for collaboration and would avoid creating an impression that issues had been pitted against each other as priorities for the Healthy People initiative overall. For example, broad issues such as "public health infrastructure" should not be seen as competing for resources against specific diseases such as "cancer."

Using this approach, Healthy People 2020 could educate users about different ways of thinking about health outcomes. It would leverage the tremendous weight of stakeholder support for specific disease areas to cultivate deepened understanding of health determinants. Healthy People 2020 should enable communities to organize and take action to promote health equity. A marker of the success of Healthy People 2020 will be its usefulness in engaging stakeholders in creating a better and fairer society.

Interventions. The Healthy People 2020 Action Model illustrates that interventions affect the determinants of health at multiple levels to improve outcomes. Healthy People must address cross-cutting determinants to reduce rates of disease and disability. It must also point to specific, proven actions that can contribute to reducing burdens for specific diseases and injuries or can have broad effects covering a wide range of diseases. It is critical that measures of actual interventions (e.g., policies, programs, evidence-based interventions, be developed and used—not just measures of health outcomes, environmental determinants, and disparities. Unless outcomes for evidence-based interventions are measured, continuous quality improvement and accountability will be limited.

Interventions that have been shown to be of proven effectiveness in systematic reviews of evidence should be included in Healthy People 2020, as these are the actions that can contribute to reaching objectives. Because policies are often the most effective "treatment" for reducing diseases or improving health conditions in populations, information on policy solutions that have proven to be effective (e.g., banning smoking in restaurants and bars) should also be included in this category.

Determinants. Healthy People 2020 should explore the processes whereby susceptibility and determinants lead to health outcomes, and highlight opportunities for intervention. Entry through the "determinants" category would ultimately lead the user to information about specific diseases. For example, the category of "physical environment" could include objectives dealing with access to healthy foods; neighborhood safety; or access to safe paths for biking and walking. These should be cross-linked with objectives for specific health and disease outcomes (e.g., diabetes or hypertension).

Outcomes. Entry through the "outcomes" category would lead the user to a list of objectives for specific health conditions and diseases which would, in turn, link back to risk factors and determinants. For example, a user who clicks on "asthma" could be guided to objectives addressing socioeconomic status, neighborhood characteristics, housing conditions, or access to health care.

Development of Health Objectives

To develop health objectives, a schema should be used to describe both how current information was gathered, the degree to which proven interventions, including mean effect sizes, were used in developing each objective (i.e., reduction in the burden of disease/injury), and the diversity or nature of the contexts in which the interventions were tested. Healthy People 2020 objectives should be presented by type to help users understand their context. For example, some objectives may be about improving health outcomes; others may address processes; and still others may focus on infrastructure.

It is essential for users to understand how objectives and their targets were formulated, and who has formulated them. For example, some targets might be set by extrapolating from recent trends. Others might be formulated using expert opinion of what it might be possible to achieve, given current data about effective interventions. In the absence of reliable, valid, current data, targets can be set by using the best estimate of current burden, and then assuming that existing interventions could be used to reduce that burden by a certain percentage.

Health Information Technology (IT) and Health Communication

The Advisory Committee recommends that health information technology (IT) and health communication be mobilized to support the full implementation of Healthy People 2020. This would include building the public health IT infrastructure together with the national health information infrastructure; extending in time and scope the IT Strategic Plan developed by the HHS Office of the National Coordinator; integrating IT to meet the direct needs of Healthy People 2020 around measures and interventions; and building on current work on health literacy and health communication.

For this latter purpose, the Advisory Committee proposes a nation-wide health improvement platform, the Healthy People Community, which would be available and accessible to all. The Healthy People Community would be grounded in health literacy principles and would provide an electronic communication infrastructure to promote shared learning to achieve long, healthy lives for all. The Healthy People Community can play a direct role in addressing health determinants (see Appendix 15). The Advisory Committee will continue to explore these issues during its Phase II efforts.

To avoid deepening existing disparities in access to health and medical information, Healthy People 2020 must take steps to ensure that the information it provides is available to and accommodates all—including those who lack access to computers and the Internet. The term "digital divide" refers to the gap between individuals, households, businesses and geographic areas at different socio-economic levels and with different accommodation needs, in terms of both their opportunities to access information and communication technologies and their use of the Internet for a wide variety of activities. There continues to be a digital divide in access to computers and the Internet generally, as well as in access to high-speed, broadband connectivity.

Though generally viewed as an element of other social divides in the United States, the digital divide may be narrowing more quickly than others. Even so, one in five American adults in a 2005 survey reported that they had never used the Internet or email, and did not live in an Internet-connected household. This digital divide exists across age, race/ethnicity, and SES groups. The Advisory Committee recommends that Healthy People 2020 products be made available through multiple media for those who cannot or prefer not to access IT. Appropriate accommodations should be made for persons with disabilities.

Another key issue is that the public is confused about the most trustworthy sources of health information—especially on the Internet. Many existing sources are paid for or influenced by those with commercial interests. It is a responsibility of government to provide the most objective information available on how to improve personal and family health and well-being, as well as on how individuals can contribute to improving community health.

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Last revised: December 11, 2008