In the past, Healthy People has been made available to the public primarily in printed form, although it was also available as a CD-Rom. Healthy People 2010 was released as a three-volume set of publications featuring metrics and tools. Each of these volumes was large—nearly 2 inches thick. At least for some stakeholders, the size of the printed volumes may have been a deterrent to using Healthy People.

A Web-accessible version of Healthy People 2020 would expand the number of people able to use this resource on a regular basis. It would also permit a database approach, facilitating linkages with other tools and data sources.

To accommodate the needs of users who need or prefer the printed version of Healthy People, hard copies should continue to be made available. Concepts and linkages among HP2020 components that are developed for the Web-accessible database can be incorporated into the printed version as appropriate and feasible.

The number of Healthy People objectives has increased with each update. This trend has been due, at least in part, to the increasingly participatory nature of the process for developing them. Some have argued that the long list of objectives in the printed Healthy People volumes was unfocused and unworkable. Yet limiting the number of objectives could negatively impact the visibility of certain critical areas within Healthy People. It could also diminish the ability of stakeholders at various levels to use Healthy People as a basis or mandate for their work.

By making objectives available through a Web-accessible database, Healthy People 2020 can enable improved management and appropriate use of a large number of objectives. This approach would avoid the need to place arbitrary limits on the number of objectives included in Healthy People 2020.

Approaches used to organize Healthy People objectives have evolved over time. The 1990 Health Objectives were almost all focused on risk factors within the broad groupings of health promotion, health protection, and preventive services. Healthy People 2000 used a mix of category types.^xiv Some were risk-factor oriented; others were disease-specific (e.g., Cancer, HIV Infection, Heart Disease and Stroke) or addressed operational issues (e.g., Educational and Community-based Programs, Surveillance and Data Systems). Healthy People 2010 also used assorted category types. It continued to address risk factors, diseases, and operations, and added categories dealing with methods (i.e., Health Communication), resources (i.e., Public Health Infrastructure), and disparity (i.e., Access to Quality Health Services).

Less systematic approaches drove development of objective sets that sometimes overlapped, and did not encourage cross-cutting collaboration to address risk factors and determinants of health and disease. Yet many stakeholder groups endorse Healthy People 2010 specifically because they are able to find their own disease area interests reflected in the initiative.

Employing a dual focus on determinants/risk factors and disease-specific categories would keep existing stakeholders engaged. At the same time, it would help to deepen their awareness of health determinants, thereby encouraging increased collaboration and multi-level interventions. This flexible approach to organizing objectives would allow stakeholders with different priorities and resources to use objectives in a manner that meets their needs.

The HHS publication Tracking Healthy People 2010 provides technical information meant to help partners and the public understand how the data are derived and how statistical issues affect their interpretation. It gives general guidance on how targets were set for objectives. Yet, because the information is not specific to each objective, its value for helping partners decide if they wish to adopt specific objectives and targets has been limited.

Decisions about target-setting methods in Healthy People 2020 should be based on relevant information about the potential for success and the usefulness of existing or potential indices that are available for monitoring progress. Users should be able to easily find and understand information about how objectives and their targets were set. For example, were they straight-lined from past trends? Were they developed based on expert opinion? Healthy People 2020 should explain the basis of targets for each objective (or for sets of objectives where the same basis applies).

In past decades, tracking data have not been available for all Healthy People objectives. When such data have been available, they often showed that objectives made no progress, or minimal progress, toward reaching their targets. Some objectives even moved away from their targets.

It is important to ask why so many objectives have not met their targets. One explanation could be that the targets selected for these objectives were not based on appropriate principles. Another possibility is that the metrics used to assess progress were not appropriate.

By carefully considering appropriate target-setting methods, the objective development process for Healthy People 2020 can avoid the potential for misclassifying or misinterpreting progress levels for various targets. This would help, for example, to diminish the possibility of reporting results that suggest a lack of progress when, in fact, progress has been made but was missed by the metric being used.

When tracking data for a Healthy People objective show that progress on improving a health problem has been slow, or that the problem has worsened, this should be a call to action. It is not enough to monitor the downward trajectory of data trends for objectives over a decade. Downward or slow trends may indicate that activities to achieve an objective's target have been unfocused or ineffective. They may reflect harmful societal changes that have led to an increased rate of occurrence of the risk factor, disease, or condition in the population at a given time, or increased severity of the problem. It is important to understand the problem, examine what interventions if any were put into place and why the interventions applied have not had the intended result, and identify more effective interventions and policies.

All user groups who are working to achieve Healthy People 2020 objectives should be encouraged to adopt a continuous quality improvement (CQI) approach. Plans and actions should be iteratively developed and refined based on the most recent data and evidence-based recommendations from targeted population and sub-groups. Recognizing that "you can't manage what you can't measure," CQI activities for Healthy People 2020 should ensure adequate flows of relevant, accurate, and timely data to support the plan-do-check-act cycles driving quality improvement efforts. This would require ongoing monitoring of trends (i.e., more often than once every five years).

In previous Healthy People iterations, missing data made it difficult to assess progress for some objectives. For example, 26 percent of objectives lacked data in 1990; 10 percent of objectives lacked data in 2000, and for Healthy People 2010, current estimates find that 40 percent of objectives cannot be assessed due to inadequate data. Data are especially limited for identifying trends among population groups that experience health and health care disparities, such as individuals with disabilities and ethnic groups that are at high risk but are not well-represented in federal health surveys.

Restricting objectives to only those areas where systems exist for baseline and ongoing data systems exist is not always an option. Many data gaps relate to populations that experience health and health care disparities. Setting developmental objectives (where no source of baseline or tracking data is available when the objectives are set) may be an important first step to stimulate the creation of data collection systems.

Healthy People objectives should identify data sources for assessing progress toward targets, and should specify how they will be collected when such data do not yet exist. It makes sense to include objectives that have existing baseline and ongoing data systems. When objectives that are related to critical areas for achieving health equity cannot be set due to a lack of data, developing data collection objectives should be the priority.

Federal health surveys should plan for contributing to Healthy People assessment efforts. In particular, surveys should identify and provide tracking data for population subgroups that experience disparities so that progress in eliminating disparities can be measured. The use in Healthy People 2020 of data from federal surveys for other agencies that positively affect the health of individuals and communities (e.g., education, employment, housing, environmental quality, and agriculture) should be considered. Ensuring adequate resources to support federal data collection is critical.

Healthy People 2010 has sometimes been described as a catalogue of the burden of ill-health, disability, and premature death. It sets targets for reducing burden, but does not offer guidance on potential actions for achieving these targets, or the relative effectiveness of such actions.

Healthy People 2020 should offer a more focused approach to evidence-based interventions than has been provided in the past. Seamless linkages are needed to existing resources that periodically evaluate and interpret evidence. Examples of such resources include The Community Guide, Clinical Guide to Preventive Services, and Cochrane Reviews.

Healthy People 2010 does not offer guidance to users who must answer the question, "If I have my last dollar, what should I spend it on?"

Allowing users to prioritize objectives by criteria that are of interest and importance to them would facilitate decision-making and enhance the relevance of Healthy People 2020 for a variety of audiences. Healthy People users differ in the health outcomes they value, and in skills and resources.

The Web-accessible format proposed for Healthy People 2020 would allow users to prioritize potential aims according to their particular values, skills, and resources. When possible, data on cost-effectiveness should be included among the measures in the Healthy People 2020 database to help users answer the question of how to spend limited resources when cost is a concern.

The public's health is not the domain of public health agencies alone. Yet the Healthy People 2010 objectives do not clearly show the role of different entities in accomplishing the objectives. Collaborative efforts between multiple sectors are needed for Healthy People 2020.

The Web-accessible database for Healthy People 2020 would enable a user-driven process of identifying and prioritizing a set of objectives that are relevant to the user's needs. As an element of this process, Healthy People 2020 should encourage public health, private organizations, and other collaborating entities to be accountable for convening multisectoral stakeholders to address a particular health problem.