Setting objectives for public health in the 1990s: experience and prospects.

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Rev. Public Health. 1990. 11:231-49

SETTING OBJECTIVES FOR PUBLIC Annu. Rev. Public Health 1990.11:231-249. Downloaded from www.annualreviews.org Access provided by University of Queensland on 02/01/15. For personal use only.

HEALTH IN THE 1990s: Experience and Prospects 1 J. Michael McGinnis Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, Washington DC 20201 INTRODUCTION The decade of the 1980s contributed substantially to the changing shape of public health in the United States. It was a decade of unprecedented life expectancy for Americans, historic lows in the rates of infant mortality, continued progress against leading killers like heart disease and stroke, a deeper public awareness of the behavioral roots of the leading chronic disease threats, and the beginnings of practical application of the lessons of research in cellular biology and molecular genetics. It was, however, also a decade of acquired immunodeficiency syndrome, new levels of drug-related violence, homelessness, and a keener understanding of the stark differences in the health profiles of many Americans in minority and disadvantaged groups. Appreciation of the magnitude of these challenges has coincided with the onset of a period of constrained economic resources to answer them. Another public health development of the 1980s has been the advent of an objective-setting process to marshall targeted support in the face of these challenges and resource constraints. In 1979 the US Public Health Service issued Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (6), which contained five broad and measurable health goals to be achieved by 1990 for people at various life stages. The following year the document, Promoting Health/Preventing Disease: ObjecI

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copyright covering this paper.

231

232

McGINNIS

tives for the Nation (7), was issued, specifying 226 quantified objectives for

1990 across 15 priority areas. This chapter reviews the process to develop and track the 1990 objectives, the progress to date, and the implications for the establishment of health objectives for the year 2000. THE NATIONAL HEALTH GOALS AND OBJECTIVES FOR 1990

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Setting the Targets

Based on an analysis of the changing nature of the various factors determining the health status of Americans, the central elements of a national strategy for disease prevention and health promotion were set out in Healthy People. In that report five national goals were set. 1. To continue to improve infant health, and, by 1990, to reduce infant mortality by at least 35%, to fewer than 9 deaths per 1000 live births. 2. To improve child health, foster optimal childhood development, and, by 1990, reduce deaths among children aged 1 to 14 years by at least 20%, to fewer than 34 per 10,000. 3. To improve the health and health habits of adolescents and young adults, and, by 1990, to reduce deaths among people aged 15 to 24 years by at least 20%, to fewer than 93 per 100,000. 4. To improve the health of adults, and, by 1990, to reduce deaths among people aged 15 to 64 years by at least 25%, to fewer than 400 per 100,000. 5. To improve the health and quality of life for older adults and, by 1990, to reduce the average annual number of days of restricted activity due to acute and chronic conditions by 20%, to fewer than 30 days per year for people aged 65 years and older. These goals were based on an assessment of where recent trends were leading, combined with an estimate of the extent to which strategic and sustained intervention might accelerate progress. Special emphasis was given to two problems, expressed as subgoals, for each life stage. For infants, particular attention was given to the problems of low-weight births and birth defects; for children, factors in childhood growth and development as well as childhood accidents and injuries; for adolescents and young adults, fatal motor vehicle accidents and misuse of alcohol and drugs; for adults, heart attacks, strokes, and cancers; and for the elderly, greater functional in dependence and reduced premature death and influenza and pneumonia. The conceptual underpinning for efforts to accomplish these goals is illustrated in Figure 1, which portrays the various factors that go into determining the health status profile of a particular population group (4).


Research

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&

f-f

Development

Intervention

-

Technologies

Service

Risk

!II

Programs

f-1-+

Resources

Attitu des

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- Health Promotion

Status

Factors

- Health Services

Fiscal

Health

- Biological

r---.

r---+

- Behavioral

- Health Protection

- Environmental

- Other Social

- Social

�

�

*

-

Norms

!

Survei IIance

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Programs !II

Figure 1 status.

Focus for Management by Objectives Effort

The conceptual underpinning of the objectives-setting process stems from the associations between the various factors that determine health

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234

McGINNIS

To further characterize the elements of the model important to attaining the established goals, 15 priority action areas were also identified in Healthy People. These priority areas provided the framework for the specification of 226 measurable objectives that supported achievement of the overall health status goals, and they were derived by assessing the risk factors involved in the leading causes of morbidity and mortality for each age group and de termining which issues the field of public health could address most effective ly. The 15 priority areas, listed in Table 1, were grouped into three catego ries-preventive health services, health protection, and health promotion. Although the 1990 health objectives were published in a US government document, subject to the review process required of federal policy, they were not intended to constitute a federal plan. The objectives themselves were national, rather than federal, in scope and served as a challenge to both public and private sectors of American society. Because the objectives were comTable 1

The 1990 national health objectives were divided

into 15 priority areas. The number of objectives in any given area does not necessarily reflect the relative importance of that area, rather it reflects the diversity of the issues addressed within that area

Number of objectives by area Preventive services

9a

High bl ood pressure control Family planning

9 19b ISh II

Pregnancy and infant health Immunization Sexually transmitted diseases Health protection Toxic agent and radiation control Occupati on al safety and health Accident prevention and injury control Fluoridation and dental health Surveillance and control of infectious diseases

20 20 17 12 13b

Health promotion

17 19b 17" II 14

Smoking and health Misuse of alcohol and drugs Nutrition Physical fitness and exe rci se

Control of stress and violent behavior

226' U Duplicates. Duplicate. , Accounting for duplicates. discrete h

objective s

total 222.


NATIONAL HEALTH OBJECTIVES

235

posed through arbitration and consensus, they represented a unique blend of values and perspectives, as well as the state of knowledge at the time they were developed. Hence, some are imperfect statements of the actual potential involved. Within each area, the objectives were grouped into five categories: im proved health status; reduced risk factors; improved public and professional awareness; improved services and protection; and improved surveillance and evaluation. The number of objectives in each priority area varied from nine objectives for high blood pressure control to 20 objectives each for toxic agent control and occupational safety and health, but the number for a given area was not so much a reflection of the extent of the target problem, as its nature. For example, high blood pressure control requires augmentation of public awareness and a few key intervention strategies to reach vulnerable pop ulations with services. In contrast, occupational safety and health involves a broader spectrum of issues, ranging from exposure to toxic substances in the work environment to prevention of back injuries and smoking controL As such, the area required more specific objectives. Establishment of the objectives was based on certain assumptions about the anticipated scope of program activity, the level of financial support, the range or participants, and the state of the science base. It was presumed that if major disjunctures occurred with respect to one or more of the assumptions, certain of the objectives would require amendment. To implement the objectives, the government divided its efforts between the formulation of its own agenda and the stimulation of activity in the non-federal sector. To tailor the federal agenda, each of the 15 priority areas was assigned to one of the US Public Health Service agencies responsible for program activity in the area (Table 2). Each lead agency convened a working panel involving other agencies to identify those objectives of highest priority from the federal perspective, to develop plans for implementation that re flected the available and potential program activity to meet these objectives, and to identify federal participants beyond the Department of Health and Human Services as well as private sector participants whose cooperation in the process might be required (8). To a large extent, however, attaining the 1990 health objectives has depended upon successful implementation at the state and local leveL There fore, in addition to the federal activities-including individual agency work to involve the private and voluntary sectors-a broad effort directed at catalyz ing state and local efforts to tailor the objectives to their needs was sponsored by the US Public Health Service, particularly through the Centers for Disease ControL States and localities were encouraged to take the model provided by the nationwide objectives and apply it to local conditions, based on their own assessment. A manual, entitled Model Standards for Community Preventive

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McGINNIS

Table 2

The US Public Health Service agencies that were responsible for activity in a particular prior

area were assigned to be lead agencies for that area for reaching the 1990 national health objectives Priority area

DHHS agency/office

Preventive services


High blood pressure control

National Institutes of Health

Family planni ng

Office of Population Affairs

Pregnancy and infant health

Health Resources and Services Administration

Immunization

Centers for Disease Control

Sexually transmitted diseases


Health protection Toxic agent control

Senior Advisor for Environmental Health

Occupati on al safety and health


Accident prevention and injury control


Fluoridation and dental health


Surveillance and control of infectious


diseases Health promotion Smoking and health


Misuse of alcohol and drugs

Alcohol, Drug Abuse, and Mental Health Administrati,

Nutrition

Food and Drug Administration

Physical fitness and exercise

President's Council on Physical Fitness and Sports

Control of stress and violent behavior

Alcohol, Drug Abuse, and Mental Health Administrati,

Services, was prepared through a cooperative effort of the federal Govern ment, the American Public Health Association, and the Association of State and Territorial Health Officers ( 1). Model Standards provided a template for use at the community level in efforts to set targets for health improvements and to implement public health programs in communities.

Monitoring the Progress

One of the most important elements of the national health objectives process was the task of monitoring progress, whether national or local. When the objectives were first published, the data sources then available were listed for each of the 15 areas. The magnitude of the monitoring challenge is reflected in the deficiencies noted. Not only must the data necessary to track progress come from a variety of different data sources, but baseline data are not al ways available for the objectives established. For example, of the 190 objec tives outside the surveillance and evaluation category, only 1 12 had extant data sources. The greatest share of those which were measurable were in the health status objectives-nearly 90% were measurable-whereas only



237

about 10% of the objectives related to public and professional awareness were measurable. A wide range of possible systems have been drawn upon to provide these data. They include (a) data systems based on records, such as those in the US Vital Statistics System; (b) population-based surveys, such as those periodi cally undertaken by various health agencies to determine the prevalence of various health habits; (c) surveillance and monitoring systems, such as those established to monitor infectious disease prevalence; and (d) regulatory reporting systems established to monitor compliance with statutes or regula tions (3). The agency that generates the data with broadest applicability to the objectives is the US Public Health Service's National Center for Health Statistics, which sponsors surveys such as the National Health Interview Survey, the National Health and Nutrition Examination Survey, the National Ambulatory Medical Care Survey, the National Hospital Discharge Survey, th e National Natality and Fetal Mortality Surveys, the National Survey of Family Growth, and the National Vital Registration System. In spite of the considerable resources made available by these surveys, the various agencies overseeing implementation of the objectives must draw upon more than 40 agencies as data sources, and more data are still needed to track progress adequately. The problems for monitoring are obvious. Many of the surveys employed are one-time-only surveys, hence will not provide data on a longitudinal basis. Furthermore, the fact that so many different sources are involved in generating the data used for monitoring raises problems of comparability of sampling techniques, thereby limiting the ability to general ize the findings. To provide periodic assessments of available data and progress, monthly reviews have been held under the direction of the Assistant Secretary for Health. These sessions offer the lead agency for a given priority area an opportunity to evaluate critically progress and barriers toward achievement of the objectives in that priority area. After each progress review, a summary of the review is published by the Centers for Disease Control in the Morbidity and Mortality Weekly Report. As of 1990, four full rounds of progress reviews were completed, allowing for several midcourse corrections. The dissemination of information regarding progress toward achieving national health objectives to community and professional groups and state and local agencies has been important for effective pursuit of the national goals. Diverse mechanisms have included presentations at national, regional, and state meetings, conferences, and scientific symposia; and publications con cerning the objectives process, the specific objectives, and the progress toward them. Reciprocally, groups involved in community settings often provided invaluable if informal information about developments for which systematic data are absent or inadequate.

238

McGINNIS


The Midcourse Review

A midcourse review conducted in 1985 revealed that the United States has made substantial progress toward the age-group-specific mortality goals es tablished in Healthy People (9). Based on 1984 population statistics, infant mortality had declined by 24%, childhood mortality by 23%, adolescent and youth mortality by 13%, and mortality among adults by 16%. If current trends continue, the United States should achieve its broad national health goals for 1990, with the one for children already accomplished by 1985. The 1987 population statistics available after the midcourse review support this conten tion, with infant mortality down 29%, childhood mortality down 21% , adolescent mortality down 11%, and mortality among adults down 21% (Figure 2). The midcourse review also revealed substantial progress toward the 226 specific objectives; approximately one half of the objectives had either been achieved at midpoint or were on track to be achieved by the end of the decade. In 1985, 13% of the 1990 objectives had already been accomplished, with another 35% on track to be accomplished by 1990 if current trends continue. Just over 26% are unlikely to be achieved, and there is an absence of data on the remaining 26% of the objectives. Still, available data indicate that the trends are in the wrong direction for less than 4% of the objectives (Table 3). STATE-BASED ACTIVITY IN SETTING OBJECTIVES

Given the importance of state and local initiatives to the success of the national effort, encouraging progress has also been reported on the state-based front. The first summary of state progress toward achieving the national health objectives was included in a 1986 report prepared by the In tergovernmental Health Policy Project (IHPP) for the Public Health Service (to). The report examined how thc Surgeon General's challenge to emphasize disease prevention/health promotion had been received by the 50 states. Specifically, the report documented how states had interpreted that challenge and what strategies they had used to implement their own objectives. The report found that as of October 1985, most states had made a good beginning, but only 33% had set their own health objectives. In December 1987, the Public Health Foundation surveyed health de partments in all 50 states, the District of Columbia, and four US territories: American Samoa, Guam, Puerto Rico, and the Virgin Islands. That survey attempted to determine whether states had established, or planned to es tablish, disease prevention/health promotion objectives. According to the survey, 44 of the 55 jurisdictions had established their own objectives for at lease some of the 15 priority areas of the national objectives; 84% of the states


Healthy Infants

Healthy Children (1-14 years)

14.1

42

1977 baseline

Deaths per 1,000 Live Births

Deaths per 100,000 Population

�

1987 provisional

Healthy Adolescents & Youth (15 - 24 years) 115

III 1990 goal

Healthy Adults (25 - 64 years)

�

533

::t

�

1:::1

g

Deaths per 100,000 Population

Deaths per 100,000 Population dphpB22e

Figure 2

During the period of 1977-1987 significant progress was made toward reaching the national goals for health promotion. The objective for

healthy children was met well before the 1990 target.

� N W \0

McGINNIS

240 Table 3

The number of objective� within each priority area that by 1986 had been achieved,

were on track, were unlikely to be achieved, or were without data could be used as a measure

of quantitative progress Prevention objectives

Priority


High blood pressure Family planning Pregnancy

& infant health

No. of

No.

No. on

No.

No. with

objectives

achieved

track

unlikely

no data

9 IO

2

4

2

2

I

6

1

18

1

4

9

4 3

Immunization

18

5

5

5

Sexually transmitted diseases

11

0

4

4

3

Toxic agenVradiation

20

0

3

2

15 3

& health

20

5

3

9

Injury control

17

2

10

4

I

Dental health

12

5

3

3

Infectious diseases

13

0

8

Smoking

17

5

8

1

19

5

5

4

5

7

3

6

Occupational safety

Alcohol

& drug misuse

Nutrition

17

4 3

Fitness

11

1

1

5

4

Stress

14

2

4

2

6

& exercise & violent behavior

Totals

226

32

72

60

62

Percentage of totals

100%

14.2%

31.9%

26.5%

27.4%

(46 states) had established objectives, and 15% (8 states) had begun the process (Figure 3). Only Arkansas indicated it had done neither (5). The objectives in Promoting Health/Preventing Disease were not intended to be applied, unchanged, in all states. Many states have, however, used the priority areas in the national objectives to formulate their objectives, and only a few have established their own priority areas. Reports from the states on their progress toward meeting the state objectives indicated that the priority areas addressed by states reflect individual state health concerns and the availability of state level data pertaining to the priority areas. States tended to set objectives in areas in which data exist to track progress. As of 1987, 12 (26%) of the 46 states and territories with objectives had established objectives for each of the 15 priority areas: Arizona, Guam, Hawaii, Indiana, Kansas, Maine, Montana, New York, Ohio, Oklahoma, Rhode Island, and Texas. Another 20 states have set objectives for at least two thirds of the priority areas. Some priority areas were addressed by almost all of the 46 states, including pregnancy and infant health, blood pressure, immunization, sexually transmitted diseases, dental health, and nutrition, thus illustrating the prevalence of these health problems. In contrast, some


241

90 80

70 60 C

� if. 40 Annu. Rev. Public Health 1990.11:231-249. Downloaded from www.annualreviews.org Access provided by University of Queensland on 02/01/15. For personal use only.

II)

50

30 20 10 0 *

1988

1985

Number

Figure 3 The proportion of states and territories that set their own health objectives jumped from 33 to 84% in three years, percentages that reflect the States' adoption of the objectives setting process.

priority

areas, e.g. occupational safety and health, were addressed with much less frequency, thus indicating a lack of state initiative in those areas. Sixteen states established objectives not covered by the

15 priority areas;

these objectives often presented a general grouping of child, adolescent and school health, and public health objectives. Other states reported objectives for

specific illnesses

or

health issues, such as cervical cancer, diabetes,

arthritis, osteoporosis, weight control, reproductive health, domestic vio

lence, chronic disease control, and aging. Still other states established objec tives for specific external health hazards, such as food protection, water

programs, sanitation, childhood lead poisoning prevention, and shellfish sanitation.

In most states, objectives were stated in terms of rates, numbers of cases, or the existence or lack of implementation; in other words, the objectives are quantifiable. For example, in 30 of the 43 states that established objectives for the pregnancy and infant health priority area, at least 75% of the objectives were quantifiable. The immunization and sexually transmitted disease priority areas also showed a large number of states with objectives that were generally quantified. States were less likely to have established quantifiable objectives for the occupational safety and toxic agent control priority areas. For the nutrition priority area, many states set objectives but not quantifiable ones. In only 17 of the 46 states were at least 75% of the objectives for all priority areas quantifiable. ,


242

McGINNIS

As of 1987, 21 (26%) of the states with objectives had published reports on their progress toward meeting the state health objectives. In several of the remaining states, reports were planned, or reports on individual health issues, rather than consolidated reports, were published; Of the 15 reports reviewed by the Public Health Foundation, no report addressed all 226 of the national objectives and most reviewed fewer than 100 state objectives. Fifteen (33%) of the states with objectives had held statewide conferences on the objectives. To foster these efforts, 73% of the Foundation's 55 respondents (40 states) had established disease prevention/health promotion units within the state health agency. Most such units had been established within the last decade. A few were initiated in the early 1970s, and Tennessee and Nebraska reported units dating back to the 1940s. Establishing state objectives may have helped educate the public about the importance of disease prevention/health promotion activities. The IHPP re port found, for example, that governors in ten states endorsed disease pre ventionlhealth promotion initiatives in their 1985 "State of the State" mes sages, and during 1985, disease prevention/health promotion legislation was introduced in about two thirds of the states. Furthennore, 18 (39%) of the 46 Foundation respondents with objectives reported that the objectives had affected legislative decisions, including budget justification. UTILITY OF THE OBJECTIVES PROCESS The management-by-objectives approach is intended to be applied in day-to day program management. Though improved program management has re sulted in some cases from the process of setting the national 1990 objectives, the major benefits have come through its utility in other contexts. Several lessons have been learned from the various assessments undertaken to date about the utility of the objectives process for people working at various levels of public health. Reports suggest that the process has been useful in clarifying opportunities; recording successes; fostering accountability for failures; pro viding a common language for communicating about priorities; providing a national validation for local initiatives; and for identifying gaps in data collection efforts. Measurable objectives have proven useful in clarifying the nature of nation al prevention opportunities in concrete tenns that give a sense of both possibilities and priorities. Establishing plans with measurable targets for accomplishment, in tenns of improved health outcomes and reduced risks, facilitates understanding about what is needed and what is possible. For example, it is important to know that if adult smoking rates can be reduced



243

from 35 to 25% of the population, then deaths in this age group will decline by about 100,000 people a year. The existence of these objectives has also helped provide a chronicle of successes. In the public health and disease prevention arena, often spectacular events occur by definition in the absence of any spectacle. For example, the more than 40% decline in heart disease deaths and more than 50% decline in stroke deaths-the first and third leading causes, respectively, of deaths among Americans-that occurred from the early 1970s to the late 1980s, offers the kind of development that society should count among its most dramatic achievements. The benchmarks provided through the objectives process has helped draw attention to such accomplishments. Conversely, the objectives process has helped draw attention to areas in which progress is not as good as it should be, given current knowledge. Assuring that failures are confronted directly is a strong motivation for the effort. If a decade passes when the infant mortality rates for both black and white babies decline on parallel courses, but when the gap between them has not narrowed despite substantial knowledge about correctable risks, failure to meet a national objective on closing the gap can generate attention and pUblicity. It has prompted stronger efforts and sharper focus. The attention given to such shortcomings is a strong justification for the effort. Having agreed-upon objectives has facilitated communication around pro grams and priorities, both among various members of the public health community, and between the public health sector and those who work in other sectors whose activities are of special importance to advances in the health arena. Active participation and collaboration, for example, from the educa tion, environment, recreation, transportation, and business sectors, has been improved through the specification of shared objectives and has been impor tant to focus program activity in related areas. State and local health officials have also reported that the existence of national targets in various areas has been helpful to them in the establishment of targets tailored to their own needs and conditions. The national objectives have in effect served as a partial validation of cases made on behalf of various programs with (and sometimes by) governors, legislatures, city councils, and other decision-making bodies. Of special importance has been the utility of the objectives process in exposing data needs and data discrepancies. Close scrutiny of the information available to assess progress on these key dimensions has pointed out the need to strengthen surveillance and data systems in various areas. Prominent examples include those related to morbidity of chronic disease and injury, special problems of minority and disadvantaged popUlation groups, and refinement in measures of the prevalence of chronic disability.

244

McGINNIS

PROSPECTS: NATIONAL HEALTH OBJECTIVES FOR THE YEAR 2000 During the decade of the 1 980s progress as defined in terms of the goals of the 1 980s has been substantial. Those broad goals were expressed predominantly in terms of reduced mortality for the population as a whole at various age groups, but a great deal has been learned from the science-base and sur veillance efforts in the intervening period about other overarching challenges,


opportunities, and priorities. Though the opening line of Healthy People is still valid-"the health of the American people has never been better"-in many ways it may now be more appropriate to suggest that the health of the American people has never fallen more short of what is possible, given the current knowledge base. For example, given that changes in a handful of behavioral risk factors-like those for smoking, diet, alcohol, drugs, sexual behavior, motor vehicle use, and frrearms-could reduce 40 to 70% of premature mortality in the United States, the nation can do much better than it is, especially for certain high risk groups (2). A social consensus is also emerging that our national goals ought not to be based on mortality reductions alone, but also on principles of reduced disabil ity and improved quality of life, of closing the health status gap that exists between those who are privileged and those who are disadvantaged in our nation, of universal access to basic health services regardless of socioeconom ic status. Addressing these principles directly is central to making progress against the kinds of challenges that will grow in the decade of the 1 990s problems of older people, of babies born unwanted and often with long-term disabilities,

of drug abuse among society's poorest, of acquired im

munodeficiency syndrome. Although new technologies will doubtless be presented as tools for improving the health of Americans during the 1 990s, our national aspirations must be recast to better capture opportunities avail able based on what is now known.

The Year 2000 Process Building on the experience with the 1990 objectives, the national objectives effort has been extended to the year 2000 through a three-year process (11). Emphasis has again been placed on establishing measurable objectives that address issues of greatest priority, that are scientifically sound and attainable, and that represent a balanced mix of outcome and process measures. Thus the general principles underlying the year 2000 national health objectives are similar to those that guided the 1 990 objectives effort (Table 4). Yet benefit ing from the lessons of the 1 980s, the year 2000 health objectives process differs from the previous effort in several substantive ways.

NATIONAL HEALTH OBJECTIVES Table 4

245

General principles underlying the year 2000 national health objectives

Credibility

Objectives should be realistic and should address the issues of greatest

Public comprehension

Objectives should be understandable and relevant to a broad audience,

priority. including those who plan, manage, deliver, use, and pay for health services. Objectives should be a mixture of outcome and process measures,

Balance

recommending methods for achieving changes and setting standards


for evaluating progress. Measurability

Objectives should be quantified.

Continuity

Year 2000 objectives should be linked to the 1990 objectives where

Compatibility

Objectives should be compatible where possible with goals already

Freedom from data restraints

The availability or form of data should not be the principal determinant

possible, but reflect the lessons learned in implementing them. adopted by federal agencies and health organizations. of the nature of the objectives. Alternate and proxy data should be used where necessary. The objectives should reflect the concerns and engage the participation

Responsibility

of professionals, advocates, and consumers, as well

as

state and

local health departments.

First, the process for fonnulating the year 2000 health objectives has placed greater emphasis on public and professional participation. Recognizing that success

in

achieving national health objectives requires a major in

terdisciplinary effort at all levels and within many sectors, the year 2000 project was designed to elicit broader opinions, expertise, and involvement of the many groups that can help further the work toward the objectives. To this end, a consortium of more than 300 national organizations and state health departments was convened to help guide the process; public hearings that heard testimony from almost 800 groups and individuals were conducted prior to drafting the objectives; and multiple opportunities for public and pro fessional review and comment were offered throughout the fonnulation and revision phase.

A second difference between the 1990 and year 2000 national health

objectives can be found in the breadth or comprehensiveness of the priorities targeted for intervention. The experiences of the past decade and input from the public hearings identified additional health promotion priorities beyond the 15 priority areas addressed by the 1990 objectives, such as the early detection of cancer and acquired immunodeficiency syndrome (AIDS). Hence the number of priority areas has been increased from the original 15 (Table 5). In addition, new priority areas have been developed to focus on strengthening the infrastructure for public health programs.

246

McGINNIS Table 5 Priority areas for the draft of year 2000 objectives. Grouping among the 21 categories is not intended to be exclusionary. There is overlap in the approaches embodied in the objectives of the various priority areas Health promotion priorities

I. Nutrition 2. Physical activity and fitness 3. Tobacco


4. Alcohol and other drugs

5. Sexual behavior and fainily planning 6. Violent and abusive behavior Health protection priorities

7. Environmental health 8. Food and drug safety 9. Occupational health

10. Unintentional injuries II. Fluoridation and oral health Preventive services priorities

12. Maternal and infant health 13. Immunization and infectious diseases 14. HIV infection

15 . 16. 17. 18. 19.

Sexually transmitted diseases High blood cholesterol and high blood pressure Cancer Other chronic and disabling conditions Mental and behavioral disorders

System improvement

20. Health education and preventive services 2 1. Surveillance and data systems

A third difference is the attention given in the year 2000 project to the needs and concerns of special populations, particularly those who are dis advantaged. One of the main themes that emerged from the public hearings was a request for special objectives for vulnerable or high risk groups, such as the poor, minorities, and the elderly. Therefore, the year 2000 project has yielded objectives for specific populations that, compared to the general population, experience significantly higher disease rates, higher levels of risk, or lower levels of awareness, services, or protection. Special populations for whom specific objectives have been formulated include children, adolescents, older people, African Americans, Hispanic Americans, Native Americans, Asian Americans, and persons with disabilities. Fourth, the year 2000 health objectives employ increased use of statistical models to assist in establishing meaningful numerical targets for objectives with multiple baseline data points. The National Center for Health Statistics



247

assisted work groups in using statistical extrapolation models to analyze historical trends, predict future levels based on current trends, and generate statistical confidence intervals. Work groups could then consider the expected impact of added intervention and adjust the numerical target accordingly. Work groups were also encouraged to consider the use of more sophisticated extrapolation models that take into account age-period-cohort effects and projected demographic changes or mathematical models that relate health outcomes to interventions. A final but important distinction between the year 2000 objectives process and the 1990 objectives effort was the early attention being given by the year 2000 project to implementation. Part of the rationale for encouraging public and professional participation in the formulation of the year 2000 health objectives was to develop the partnerships and sense of ownership important to successful implementation. Careful planning was also undertaken early in the formulation process to identify strategies for translating the national health objectives into health promotion programs and activities at many levels and within many sectors. A new edition of Model Standards designed for state and local health departments constitutes one such implementation plan. Further facilitation of implementation will be provided by a series of implementation plans for a variety of settings and population groups: clinical settings, work sites, schools/children, adolescents, older people, disabled people, Native Americans, African Americans, Hispanic Americans, and Asian Americans. The Prospects The prospects for achieving the 1990 and the year 2000 national health objectives are as disparate as the individual objectives themselves. In spite of the merit and utility of the management-by-objectives approach, there are certainly constraints. The targets with the best prospects are probably those that depend more on technical interventions and less on behavioral change, those that offer the potential for greater economic returns or at least fewer economic losses to industry or society, and those that appear to be most socially neutral. Accordingly, a few important caveats must be considered. First, the amount of support that can be drawn from the science base for use in the formulation of objectives varies considerably across the categories. For example, among the health status objectives, a specific objective for reduction of caries can feasibly be established based on the anticipated provision of fluoridated water supplies, because the protective nature of fluoride against dental caries is well defined. On the other hand, understanding of the rela tionship between a number of toxic agents and various disease outcomes is still limited, so that qualitative-not to mention quantitative---estimation of the potential for improved health status is difficult. Among the objectives related to reducing risk factors, setting a target on exposure to the

248

McGINNIS

risks of smoking is much easier than formulating one for exposure to atmos phere sulfates, or even one on the adoption of certain exercise levels (levels that people frequently misreport). Action based on the information available is nonetheless required. Second, even when quantified objectives are established, state and local interest in, and capacity for, such evaluative efforts vary substantially. Yet, since the purpose of setting objectives is to encourage program evaluation and adaptation of the objectives at the local level, progress depends on that


interest and those efforts. Third, progress depends upon the continued development of data systems. Yet at this time data collection is especially vulnerable because of financial constraints. Although data-gathering capabilities in the United States surpass those of many other countries, some prominent geographic and substantive deficiencies still exist in these data sets. Possibly, the most limiting is the paucity of data available at the state and local levels. Beyond these geographic constraints are the limits of information relative to certain categories of objectives, especially those related to improving public and professional awareness of the various prevention areas. An apparent lack of interest in assessing such awareness suggests that people are assumed to be passive participants in the protection of their own health-an attitude that presents a compelling program challenge. The gains that will be most difficult to achieve will be in health promotion and behavior enhancement; facilitation of the gains made in those areas will depend upon adequate data to track progress. Fourth, though much of the progress of the future will depend upon how effectively people can be motivated, understanding of both the potential and the constraints of the behavioral and communications sciences remains lim ited. Although considerable numbers of people apparently have been improv ing their life-styles as better information has become available about the links of life-style to ill health, there is still insufficient evidence to offer tested ways of accelerating societal response to this information. Fifth, if this goal-oriented approach is to succeed, a social will must exist to support its various components. Though uniform agreement is not required on the priorities to be assigned to activities, some commitment is needed to the process of establishing targets, measuring progress, and realigning activities. This commitment requires not only consensus, but a considerable amount of will at a variety of levels.

CONCLUSION The establishment of measurable health objectives holds promise for enhanc ing health gains. One of the more significant features of this process is the extent to which the effort reflects progress in the development of consensus



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about new health goals and about some of the means for attaining them. The broad and elaborate review that was undertaken in the course of drafting and revising the health objectives for the US has ensured a thorough discussion of the issues. Consensus, however, does not denote unanimity. Diversity and compromise figure prominently in developing consensus, and the product that emerges is inevitably more conservative than many participants would have urged. Yet the degree of consensus about appropriate directions for preven tion is considerable, given the scope of the objectives and the number of participants in the process. Recasting national goals to embrace more fully the notions of improving quality of life, reducing disparities among population groups, and assuring access to basic services can foster objectives that reflect the challenge more directly. Setting objectives is in effect only a starting point. This process reveals the need also for a commitment, which must be met by realigning activities and resources-tasks that can be onerous, particularly for those at the state and local level. Although difficult, a deliberate review of priorities and the targeting of activities can improve the allocation of resources--4:hores that are even more critical during times of fiscal constraint. If targeting progress in health helps set the sights more specifically, a nation should be better able to register its successes and detect its failures-and perhaps even, in time, correct its course. Literature Cited I. Am. Public Health Assoc. 1985. Model

Standards for Community Preventive Health Services. Washington, DC:

APHA. 2nd ed.

2. Amler, R. W., Dull, H. B., eds. 1987. Closing the Gap: The Burden of Un

necessary Illness. New York: Oxford

Univ. Press

3. Green, L. W., Wilson, R. W., Bauers, K. G. 1983. Data requirements to mea sure progress on the objectives for the nation in health promotion and disease prevention. Am. 1. Public Health 73:1824 4. McGinnis, 1. M. 1985. Setting nation

wide objectives in disease prevention and health promotion: The United States experience. Oxford Textbook of Public Health, 3:385-401. New York: Oxford Univ. Press 5. Public Health Found. 1988. Status Re

ease Prevention. Washington, DC: US GPO 7. US Dept. Health Hum. Servo 1980. Pro

moting Health/Preventing Disease Objectives for the Nation. Washington,

DC: US GPO

8. US Dept. Health Hum. Servo 1983.

Public Health Service implementation plans for attaining the objectives for the nation. Public Health Rep. Sept.!Oct. Supp!. to Vol. 8 9. US Dept. Health Hum. Servo 1986. The

1990 Health Objectives for the Nation: A Midcourse Review. Washington, DC: US GPO

10. US Dept. Health Hum. Servo 1986. A

review of state activities related to the Public Health Service's health promo tion and disease prevention objectives for the nation. Washington, DC: US

GPO

port: State Progress on 1990 Health Objectives for the Nation. Washington,

II. US Dept. Health Hum. Servo 1989. Pro

6. US Dept. Health Hum. Servo 1979.

public review and comment). Washing ton, DC: US GPO

DC: Public Health Found.

Healthy People-The Surgeon General's Report on Health Promotion and Dis-

moting Health/Preventing Disease: Year

2000 Objectives for the Nation (draft for

The future of public health: prospects in the United States for the 1990s.

Child health in the United States: prospects for the 1990s.

Public health policy for the 1990s.

Toxics and public health in the 1990s.

Genetics and public health in the 1990s.

Nutrition: prospects for the 1990s.

Health promotion as a public health strategy for the 1990s.

Prospects for cancer control in the 1990s.

Public health assessment in the 1990s.

An agenda for public health in the 1990s.

Challenges for public health nutrition in the 1990s.

Prospects for ancillary treatment of sinusitis in the 1990s.

Injury prevention and control: prospects for the 1990s.

Setting the national agenda for injury control in the 1990s.

Setting the national agenda for injury control in the 1990s.

Setting goals and objectives for LD children--process and problems.

Arrival of chikungunya virus in the new world: prospects for spread and impact on public health.

Occupational health in the 1990s.

Hospital cost containment in the 1980s. Hard lessons learned and prospects for the 1990s.

Under the influence: 4. Election prospects triumph over public health.

HRSA's role in primary care and public health in the 1990s.

The state and territorial public health laboratory: program activities, organization and prospects for the future.

Prospects for change in public mental institutions.

Health and the environment in the 1990s.