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Appendix 7. Building on Past Challenges of the
Healthy People Initiative
The Form/ Medium for Presenting Healthy People Objectives
Challenge: |
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 largenearly 2 inches thick.
At least for some stakeholders, the size of the printed volumes may have been a
deterrent to using Healthy People. |
Proposed Approach: |
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. |
Number of Objectives
Challenge: |
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. |
Proposed Approach: |
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. |
Approach to Organization of Objectives
Challenge: |
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.
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Proposed Approach: |
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. |
Transparency about Setting Targets for Objectives
Challenge: |
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. |
Proposed Approach: |
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). |
Achievement of Targets
Challenge: |
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. |
Proposed Approach: |
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. |
Reversing Downward Trends and Accelerating Slow Positive Trends
Challenge: |
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.
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Proposed Approach: |
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). |
Tracking Data to Assess Progress
Challenge: |
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. |
Proposed Approach: |
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. |
Guidance on Strategies for Achieving the Objectives
Challenge: |
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. |
Proposed Approach: |
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. |
Clear Direction on Priorities for the Nation
Challenge: |
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?"
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Proposed Approach: |
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. |
Accountability
Challenge: |
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. |
Proposed Approach: |
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. |
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Continue to Appendix 8. Feedback From Users of
Healthy People Back to Appendix 6. Past
Processes for Developing Healthy People Goals And Objectives
Return to Phase I Report Table of Contents
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