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3. Implementing the Objectives at State and Local Levels The realization of national objectives depends, in large measure, on the extent to which national, regional, state, and local organizations-both public and private-use and adapt them to better understand and act on the health concerns of the groups and communities they serve. The testifiers made clear that translating national objectives into an action plan for the United States must involve the building blocks of the U.S. public health system-each and every state and local health department. It also must involve the efforts of the private sector, including businesses, educational institutions, community groups, and professional or voluntary organizations. Individuals from all sectors must be encouraged to take 'ownership' of the objectives," according to the Association of State and Territorial Health Officials. (#750) Almost 200 witnesses addressed implementation issues. Their comments summed up experience with the objectives at state and local levels, and focused especially on the relationship between the national objectives and the Model Standards for Community Preventive Health Seances, an effort of a coalition of public health professional organizations.t Testifiers also addressed other issues that can be summed up as the need for cooperation with the general public, with communities, and with the private sector, on a state and regional basis, as well as with the federal govern- ment. Strong pleas were made for more federal funding in support of state and local health depart- ment programs aimed at achieving the objectives. STATE AND LOCAL PUBLIC HEALTH INITIATIVES Since the publication of the 1990 Objectives, many states, counties, and cities have developed their own objectives based on the national model, and state and local health officers testified at length about the successes and failures. Successes tend to be related to cooperation across governmental levels, with the private sector and the community, and to use of the objectives to set priorities and manage resources. State and Local Health Department Experience Hawaii was one of the first states to hold a meeting addressing the 1990 Objectives," according to Julian Lipsher of the Hawaii State Department of Health. "The Governor's Conference on Health Promotion and Disease Prevention was designed, not to just establish the objectives as part of a state agenda, but as a community-based process involving organizations, agencies, and sectors of our community who would own the objectives and be, in part, responsible for their attainment. (~340) According to Thomas Halpin and Karen Evans of the Ohio State Department of Health: The 1990 Objectives have given Ohio strong direction in planning strategies for health promotion and disease prevention throughout the state. They have served as the primary guide in the development of the Health Promo- tion and Disease Prevention Component of the Ohio State Health Plan and in the preparation of the annual Preventive Health and Health Services Block Grant Plan. The objectives have strongly influenced the implementation of community-based health promotion projects and have directed attention to issues of statewide significance, such as hypertension. (#129J The Indiana State Board of Health found the 1990 Objectives helpful in providing a framework for several activities, including developing strategic initia- fives, assessing health needs, and formulating a state health plan. (#405) The Mississippi State Depart- ment of Health used the 1990 Objectives in develop- ing an operational plan for the agency as well as a state health plan. (#125J The Texas Department of Health also is an avid supporter of the 1990 Objectives process. It has used the process in setting and influencing state health policy and in organizing traditional and nontraditional community organizations that have the ability to influ lmplementing the Objectives at State and focal Levels 15

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r Furthermore, the objectives are influencing management practice by being integrated with Model Standards language into performance contracts established with local health departments. (~020J According to Dick Welch of the Minnesota Depart- ment of Health, "The 1990 Objectives had an impor- tant influence in Minnesota at both the state and local level. The 1990 goals have helped turn what were broad generalities into pragmatic goals. This pragmatism has made our job easier in developing our own statewide initiatives such as the recent Nutrition Initiative and the earlier Non-Smoking Initiative." (#225) Robert Harmon, Director of the Missouri Depart- ment of Health, says that his agency "has a strong commitment to goal-directed public health manage- ment. The 1990 Objectives and the Model Standards have been acknowledged as important documents to which Missouri public health must respond. The Department of Health chose first to pursue long- range strategic planning for the year 2000, and now is in the process of addressing the 1990 Objectives in the form of a mid-range plan." (~085) The West Virginia Department of Health also used the national objectives to develop health goals for the year 2000. The state health department will develop a list of the major health problems in each county that account for the most potential years of life lost. Each local health department will prioritize its major public health risk hazards and develop health promo- t~on and disease prevention plans. (~098J The national objectives have also been used at the local level. Bud Nicola, Director of the Seattle-King County Department of Public Health, states that his department ence Public health within the state. has made good use of both the Model Standards and the 1990 Objectives in its long-range plan- ning process and in annual program review and budget preparation. Historically, local govern- ment services are not prioritized or based on major causes of morbidity and mortalit~not even on measures such as years of life lost. The use of national objectives helps us at a local level to use morbidity and mortality data to allow policy makers and the public to focus on health status outcome measures, interrelated and developed in a broad context as a basis for policy, rather than individual perceptions. (~320J 16 Healthy People 2000: Citizens Chart the Course "The Allentown Pennsylvania Health Bureau has used the 1990 Objectives as its primary programmatic planning guide" says Gary Gurian, the bureau's director. The Health Bureau has shifted its emphasis from what was generally an acute problem agency to a professional public health organization providing the community it serves with prevention-oriented leader- ship and services. Most of the Health Bureau's award-winning initiatives have their roots in the 1990 Objectives. These initiatives include home and motor vehicle injury prevention services, targeted smoking cessation and awareness activities, and cancer preven- tion and early detection services. Unfortunately," Gurian adds, "this nation's 1990 Objectives remain one of the best kept secrets. They have been a seldom-used tool by this nation's network of private and public sector health organizations and decision makers." (~076) According to Thomas Milne, representing the Washington State Association of Local Public Health Officials, local health departments need more informa- tion and encouragement to join in the objectives. Most have not had the resources, time, or inclination to assimilate the objectives into their work plans. To increase the participation of local health departments, Milne suggests (1) seeking more active involvement of national organizations representing state and local health officers, (2) distributing the revised objectives to all local health departments and encouraging their participation, (3) promoting and providing expanded technical assistance for implementation of the Model Standards, and (4) establishing a national focus in each of the priority areas at different times during the l990s and distributing materials to local health departments to promote their involvement. (~328) Robert Spengler of the Vermont Department of Health is concerned that the 1990 Objectives lacked practical implementation suggestions, such as how to use multiple approaches, coalitions, and limited resources to achieve results at the state level. Resources, motivation, commitment, and account- ability at the state level have been missing from the 1990 experience, along with valid studies about which approaches work and which do not. He has three suggestions: 1. Establish priorities. "List the top 10 achievable objectives that should be considered first as national priorities in health promotion or disease prevention. An alternative might be to identify the top priority for each of the major content areas." 2. Establish motivational efforts. "Detailed plans

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are needed to translate objectives into action at the state and local levels. Motivational efforts are needed and can be fostered by more technical support and guidance from federal agencies, educational institu- tions and the private sector." Financial support for demonstration projects is also needed. 3. Establish evaluation efforts. "A greater em- phasis must be placed on agencies/organizations with principal responsibilities being held accountable for monitoring and evaluation." These agencies should determine "efficacy, effectiveness, efficiency, cost- benefits, and transferability of program activities" and should share data and compare intervention strategies and evaluations across states. (#458J Robert Bernstein, Texas Commissioner of Health, suggests that As we move forward with the develop- ment of Year 2000 Health Objectives, it is essential that the roles of states are fully established in the objective-setting process." He recommends that time be provided for states to react and start a companion process to establish their own objectives while the Year 2000 Health Objectives are being drafted. Once national and state objectives are established, state and local implementation plans must be written to incor- porate the appropriate strategies and actions into operational plans of appropriate organizations. (#020) The Model Standards The 1990 Objectives are not the only federal approach to improving health promotion and disease preven- tion. In particular, many state and local health officers and others make reference in their testimony to the Model Standards for Community Preventive Health Services, a collaborative effort of the Centers for Disease Control, the American Public Health Association (APHA), and a number of public health professional associations to establish local standards through planning. According to the testimony, some communities, when presented with the Model Standards and the 1990 Objectives, have had difficulty in understanding how the two are related. This confusion results from differences between the documents. First, the 1990 Objectives are national in scope, whereas the Model Standards are oriented to local action. Although the goals of the Model Standards and the 1990 Objectives are complementary, they often are seen as two sets of policy directives for already limited resources. The Model Standards, however, can assist states and localities as an implementation tool to make the 1990 Objectives meaningful and applicable at the local level, and as a means of gaining strong partnership and commitment to these objectives. For instance, William Schmidt of the Wisconsin Department of Health and Social Services says, "I perceive the objectives for the nation as a statement of intent, and Model Standards as the linking mecha- nism between those intentions and an achievable public mission. The objectives set the direction, but Model Standards describe the organizational capaci- ties, administrative and program processes, and by inference, the financial resources to get there. Objectives without standards are unfocused public will; standards without objectives are unfocused public resources." (~4 76) Richard Biery, Director of the Kansas City Health Department, adds that Setting national objectives is only an empty and futile gesture without, at the same time, promoting a practical, usable implementation plan for achieving the objec- tives, one that involves every unit of our public health system. (#365) According to Susan Addiss, Director of the Quinnipiack Valley Health District in Connecticut, "The Model Standards provide the quintessential process for successful implementation of the Year 2000 Health Objectives at the state and local levels. Because the outcome objectives are set by the com- munity itself, it is possible to establish incremental steps that are attainable and that give the community a sense of accomplishment on the way to attainment of a national objective that may by itself appear unattainable." (~460) Nelson Frissell, Director of the CiW-County Health Department in Casper, Wyoming, says: The Model Standards process is a primary and inherent ingredient in the development of any objective. It becomes a way of thinking, a way of looking at the ability to come from a com- mon ground to diverse but specific outcomes within the overall umbrella of a national effort rather than trying to get from the diversity of local effort back into some common denomina- tor of maximum effect. By using the Model Standards process, it is easier to see how we integrate one with another even though the ultimate objective may seem different. It's a universal tool, a common skill basis, that can highlight and emphasize the connectedness, that notices and points out the similarities, and focuses where we fit together instead of where we don't. I view the Model Standards process Implementing the Objectives at State and Local Levels 17

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as the building block, as the basis for com- plementing efforts, the process from which the objectives for the nation can flotsam allowance and assistance of local implementation and focus, while augmenting interconnected actions in the local effort to define roles and relation- ships by utilizing a common process to focus on a larger national impact. (#364) The fact that the Year 2000 Health Objectives are objectives for the nation is both their principal strength and their principal weakness, according to Schmidt. The strength is in the recognition that all sections of the U.S. health care system, public and private and at all levels, need to marshal behind these objectives. The weakness is that objectives for all, conceptually, can all too easily become objectives for none in actuality. Model Standards has recognized this by stressing the concept of "A Governmental Presence At the Local Level (AGPALL3." (#476) Carole Samuelson, Director of the Jefferson County Department of Health in Alabama, adds that AGPALL represents the idea that government, either at the local or state level, is ultimately responsible for ensuring that standards are met. Not that government can or should do everything that has to be done to meet all standards, but that government must take the lead in this process (by providing necessary services or at least making sure that the necessary services are being provided). The very best objectives are unlikely to be accom- plished unless a specific person or agency assumes leadership for promoting and achieving them. Likewise, it is extremely important that while one agency is responsible, objectives must be community-oriented and must promote inter- agency and intergovernmental cooperation. (~260) The 1990 Objectives document gives specific rates and figures for objectives, whereas the Model Stan- dards document uses an open-ended, fill-in-the-blank framework for local objectives. Many testifiers note that in instances where the intent of the two documents is the same, incongruent terminology between them sometimes masks their 18 Healthy People 2000: Citizens Chart the Course agreement and complicates their relationship. Samuelson says that One of our frustrations In using the Model Standards has been the confusion that occurs because there are two very similar documents: the Model Standards document and the 1990 Objec- tives document. There have been instances when the wording in the two documents is similar but different enough to cause confusion." (~260) Schmidt says that the "process of using both documents works, but it takes a great deal of effort and requires patching the two together. Often, though the overall intention of the two documents is the same, the terminology differs and the relationships are difficult to ascertain. It doesn't have to be that way. It would be a tremendous service to the people using the two documents to meld them together so that they flow and complement each other." (~476) Many other witnesses? such as Carol Spain of the Health Officers Association of California, suggest that the national objectives and the Model Standards be better integrated. The Year 2000 Health Objectives need to go further by actually integrating the relevant Model Standards in the appropriate sections of the year 2000 document. This integration is critically needed in order to provide the imple- mentation framework for achievement of process and outcome objectives that will assist each local and state health department in meeting the Year 2000 Health Objectives within their own juris- dictions. It is only through the achievement of the Year 2000 Health Objectives at the local level that the objectives will be achieved at the highest level, the nation. (~204) The witnesses suggest that the merged document keep some of the philosophy (e.g., Bexibili~, AGPALL, community involvement) of the Model Standards for use by states and localities. The merged document "should establish national objectives but have a mechanism for local communities to convert these national objectives into attainable local objectives. The document also should stress the government's responsibility to ensure that objectives are met, but emphasize the importance of the entire communing working toward a common goal." (~260) The Model Standards committee and the U.S. Public Health Services (PHS) Office of Disease Prevention and Health Promotion are currently planning to develop such a document. Represen- tatives of the Model Standards committee are working

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with the groups drafting the Year 2000 Health Objectives, and the Model Standards committee will produce a companion document for use by state and local health agencies that employs the Year 2000 Health Objectives as a base and focuses on the steps required to implement them on a community level. Federal Funding Many witnesses called for a federal leadership role in implementing as well as determining the objectives. Their suggestions ranged from providing research results and technical assistance in implementing the objectives to the financing of state and local activities. According to William Blockstein of the University of Wisconsin-Madison, for instance, there should be a separate federal interagency work group for each health problem, and this structure should be dupli- cated at the state level by using a consortium of state and territorial health departments and private sector professional and voluntary organizations. These ef- forts should be coordinated by the PHS. The work groups should develop (1) print, radio, and television public service announcements in a variety of lan- guages, in tune with the educational level and cultural values of the subculture being addressed; (2) help lines that will provide callers with nonthreatening, helpful, and comprehensible information on preventive measures; and (3) resource manuals that detail successful prevention programs in many languages and for various educational or cultural backgrounds. (~518) According to Alfred Berg of the University of Washington: The United States needs a process of ~den- titring essential services and ensuring that they are delivered. The scientific basis underlying health promotion and disease prevention can be expected to change constantly, so that a per- manent body constituted to monitor the state of the art and to advise the government should be appointed. The U.S. Preventive Services Task Force should become a permanent advisory body, and its scope of responsibilities expanded to include access and manpower issues. A mechanism for incorporating recommendations from the Task Force into national health policy should be identified; the recommendations should include a minimum core of essential im munizations, screening tests, and health promo- tion activities. All Americans should have ac- cess to the recommended core of health pro- motion and disease prevention services, regardless of insurance status. (#315) Stephen Goldston of the University of California, Los Angeles suggests that federal health agencies be required to budget specific funds to implement the plans for achieving the Year 2000 Health Objectives, emphasizing primary prevention, rather than secon- da~y or tertiary prevention. (#280J Nor due con- sideration of the major chronic diseases, the National Institutes of Health should be involved," writes Lester Breslow of the UCLA School of Public Health. That involvement did not occur to any great extent in setting the objectives for 1990, thereby perhaps limiting the achievement. You will re- call that in the 1990 Objectives no mention of the major chronic diseases appeared. Now the Public Health Service appears to be embarking, with all of its relevant elements, on a full and appropriate health agenda. That is a highly promising development. It will tend to bring the National Institutes of Health into what many of us always thought should be included in their missions, namely, efforts to prevent the chronic diseases and promote health, especially among the elderly. (#026) Many witnesses testified that state and local health departments lack the resources necessary to imple- ment the national objectives. Their suggestions for addressing this problem include direct federal funding of health promotion/disease prevention activities, demonstration projects at the state or local level, and direct support through already existing funding pro- grams. Many of these issues are discussed in more depth in Chapter 8. The American Public Health Association's Com- munity Health Planning Section reports that since the Midcourse Review came out in 1986,2 there have been substantial decreases in federal funding for some health programs. If new goals are to be attained, or old ones maintained, the objectives are going to have to deal more with supporting infrastructures. With- out federal funding and strong community planning, states lose focus and the ability to implement the objectives. (#756) Implementing the Objectives at State and Local Levels 19

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The Association of State and Territorial Health Officials comes to the following conclusion: Establishing and achieving the national health objectives is a process that will require the commitment of resources from all levels of government-not just the federal government as well as from private sources. Lawmaking bodies, from the Congress to individual city councils, must accept the idea of national health objectives and support the objectives by appro- priating funds. For example, the federal gover- nment should consider funding staff for the objectives-setting process at the state level. In turn, states must work to ensure provision of technical assistance to local governments in building community support for priority health objectives. Even when the burden is shared, resources for achieving the national health objectives will be limited. To be successful, the objectives must be realistic in terms of the expected resources available to achieve them. Existing and poten- tial resources must be tied to the national objectives, and, in turn, the objectives must be realistic to accommodate limited resources. (#750) Rhode Island's Director of Health, Denman Scott, agrees that state health departments are in a strategic position to translate the Year 2000 Health Objectives into action. To help them do this, he suggests that the federal government specifically earmark a pool of money for attainment of the Year 2000 Health Objec- tives at state and local levels. As a prerequisite to receiving such assistance, health departments would be required to produce a health objectives plan. "In order to give this proposed program the momentum it deserves," says Scott, An initial funding base of $1 per person, or about $250 million per year should be allocated to the state health departments based on the size of their state populations and the quality of their national health objectives plan." Scott suggests that the Centers for Disease Control administer the process Because of its excellent track record of work- ing collaboratively and constructively with state health departments." (#461J A number of witnesses testified that some of the 20 Healthy People 2000: Citizens Chart the Course funding problems could be solved by tying currently existing federal funding programs to the national objectives. The preventive health and health services block grant program, funds for community health centers, and Medicare and Medicaid were all dis- cussed. Mark Richards, Secretary of Health for the Commonwealth of Pennsylvania, recommends "that all recipients of block and categorical grant funds should clearly demonstrate how they will help to meet the appropriate Year 2000 Health Objectives." (#387) Based on her experience with the 1990 Objectives in South Dakota, Katherine Kinsman suggests that one way for the federal government to consistently sup- port the objectives is to use them as the focus and criteria for federal grants. (#629J Thomas Halpin and Karen Evans report that the preventive health and health services block grants have been crucial in shaping disease prevention and health promotion plans in Ohio. "Well-prepared plans and strategies that lack resources for implemen- tation are lofty but unobtainable ideals," they write. "The objectives must be supported with a con- centrated, cooperative effort at the federal, state, and local level to continue and to increase the preventive health and health services block grant." (#129) Karen Grieder, Director of Research with the Texas Association of Community Health Centers, writes that centers are federally funded and serge poor or indigent populations. In South Texas, for instance, the community health centers are primarily used by minorities, migrants, uninsured females, and border communities-people who have nowhere else to go for health care. These centers operate on limited budgets and do not have or collect very much data. They must, however, write their health plans around the 1990 Objectives when applying for grant money. This is especially difficult because the cases they are seeing~iabetes, for example-are not specifically targeted in the 1990 Objectives. Grieder asks for better coordination between state and federal agen- cies, improved funding, and a realistic expectation from the government of what community health centers are to monitor and implement. f#747J Many testifiers also suggested that Medicare and Medicaid should more consistently cover preventive health. Richards says that The Medicaid and Medi- care programs should be restructured to encourage and allow for the reimbursement of preventive and early disease detection services." (~387)

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INTERSECTORAL COOPERATION: ROLE OF THE PRIVATE SECTOR Across the board, witnesses testified about the need for various sorts of intersectoral cooperation in implementing the national objectives at a local level. States and local health departments were seen as having the pivotal role in implementing national objectives locally, but testifiers repeatedly stressed the need for cooperation with other sectors. Some called for involving the general public, for community participation, and for developing partnerships with the private sector. Others stressed the need for local, state, and regional efforts, and the need for a federal role in implementation. Harmon suggests that public health institutions at each level of government take the lead in identifying other public or private par- ticipants and inviting them into the Year 2000 Health Objectives process. The objectives, he says, are "natu- ral bridges for cooperative interagency ventures to promote public health." (#085J Professional organizations also have an important role to play in formulating and implementing the national objectives. According to the American Asso- ciation of Public Health Dentistry, success in meeting the objectives "is only possible through coordinated public and professional efforts, individually and collectively. Each professional association must be involved and must identifSr potential roles that its members may play in accomplishing the objectives and make efforts to challenge its members to do soy (#156) Many of these issues are discussed in depth in Chapters 8 and 9 on health promotion and disease prevention in medical and nonmedical settings. Community Participation As Jerrold Michael of the University of Hawaii at Manoa says, The achievement of health is not in the hands of the health professions alone. The resources of health, education, economic development, and hu- man services must become connected to and inter- woven with health objectives." (#149) Many other witnesses supported this point of New, and called for public and community participation in implementing the objectives. Some spoke about mobilizing indivi- duals and ~consumers." Others called for efforts to mobilize entire communities. Some testifiers ad- dressed the potential role of community organizations and professional societies. The APHA calls for strong public participation in the objectives process. There is a need to involve the general public in health promotion and disease prevention, in order to enable individuals to determine for themselves the means to achieve optimal health. Methods should be developed to increase con- sumer participation and expand the roles of health consumers in achieving the objectives for the nation. The objectives should go well beyond health professionals and health agencies and develop consumer roles and outreach pro- grams that are more conducive to achieving the objectives and reaching the population in great- est need. The APHA testimony contains three suggestions for increasing public participation: (1) developing state implementation plans that have public service materi- als supporting an active role for health consumers and health professionals, (2) developing curricula material for public health professionals to promote public educational programs, and (3) building coalitions of health consumers and providers. (~198) Woodrow Myers, Indiana State Health Commis- sioner, says that "we must do more work within our communities to revive their ability to identity and address their own health needs, to look for local solutions to local problems, and where appropriate, to link these problems to statewide solutions that affect other communities' problems and ultimately to national solutions, whether private or public, to address those needs." (#405J Colorado's Governor Roy Romer agrees that communities must get involved in preventive health care. At a hearing on the Year 2000 Health Objec- tives in Denver, he described a successful community- based program in Colorado aimed at preventing alcohol and drug abuse. "We are talking to high school youngsters about what they can do, themselves, within their own peer groups and within their own community to begin to set the stage for mutual reinforcement of coming to terms with their own responsibility as citizens." (~786) Many other community-oriented programs are described In Chapter 9 of this report. Herbert Rader of the Salvation Army uses his organization's efforts as an example of the role that community organizations can play in implementing national objectives. The Salvation Army has activities that address (1) health needs of the poor; (2) sub- stance abuse (including intravenous drug use and Implementing the Objectives at State and Local Levels 21

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AIDS); (3) homelessness; (4) assisting young people to avoid high-risk behaviors; and (5) sexual behavior, unintentional pregnancy, and sexually transmitted diseases. Rader says that psychosocial factors and religious principles play a major role in determining the content of these programs. (~432J "Our nation does not lack the epidemiological or biostatistical evidence for the benefits of disease prevention and health promotion initiatives," writes Bertram Yaffe, President of the Erna Yaffe Founda- tion. Nor do we lack the educational or primary prevention techniques for the deployment of these initiatives. What we do lack is a sustained dialogue between health professionals and the individuals who can create the political will to transform the curative model of health services into a preventive model of a health system. We need a constituency for prevention-a broad- based, advocacy process analogous to the civil rights, feminist, and environmental movements. It must be global in its concerns, but politically very local and indigenous In implementation. It is the leadership in the creation of the move- ment, that is the future and the real challenge of Public Health. Health status is a reflection, not of lifestyle alone, but of social, economic, political, and all other circumstances that impact on individuals. We must recognize that it is not sufficient for health status goals to be articu- lated by health professionals alone; they must also be delivered as messages of political com- mitment. All of us must be agents for the creation of a nonpartisan, but very political, movement to promote the Ecology of Health. (#454) Yaffe calls for more regional consortia on health promotion and disease prevention. The New England Conference for Disease Prevention, Health Protection and Health Promotion (NECON), which Yaffe chairs, is a coalition of six New England public health departments; four schools of public health; federal health agencies in the region; various departments of the schools of medicine and allied health professions; educators; legislators; and representatives from in- dustry, labor, and voluntary organizations. It was set up to assess the progress of the New England states toward the 1990 Objectives and to offer some strate- gies for further improvements in the health status of the region. It is funded by grants from the public 22 Healthy People 2000: Citizens Chart the Course and private sectors. Through a series of conferences and task force activities, NECON has developed a regional network of nearly 300 individuals That has evolved into an effective, nonpartisan constituency to achieve healthy public policies and develop specific programs." The New England Governors' Conference has recognized the importance of NECON's goals and activities, and has established a New England Regional Health Committee to receive and consider NECON's recom- mendations. (#454) The Colorado Trust is another group that believes that grass roots health promotion can lead to lasting improvements in health status. According to its executive director, Bruce Rockwell, the trust is a philanthropic, grant-making foundation devoted to health, medical, and human services in Colorado. One of its major programs is Colorado Action for Healthy People, which is based directly on the 1990 Objectives, funded by the Colorado Trust and the Kaiser Family Foundation, and carried out through the auspices of the Colorado Health Department. The program's strategies include (~) grants to com- munities that already are well organized to seIve as demonstration projects for other communities; (2) technical assistance in community organization such as needs assessment, selection of interventions, and evaluation; and (3) state-level activities, including media campaigns, data collection, dissemination, and regulatory activities. (#709) Corporate Partnerships The business community, too, has a role to play In implementing the Year 2000 Health Objectives. The testimony shows that there is interest in the business world. For instance, a survey of 48 companies about business involvement in health promotion and disease prevention, more specifically the national objectives process, conducted by the Washington Business Group on Health found the following: Many of the objectives are especially relevant to businesses who pay for the health care costs of not only their employees, but also their dependents end retirees. Increasingly,companies are concerned with maintaining and improving health. In addition, it is hoped that businesses will use the new objectives to help set their own health goals. Therefore, it is not only impor tant, but necessary that America's businesses

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play a key role in the process of establishing new national health objectives for the year 2000. The survey showed that over half of the firms that responded (27) had heard of the 1990 Objectives, and almost a quarter (11) had used them in some way. Some companies used them to gain support for health promotion and disease prevention activities in general, to justify adding new programs, and as a means of comparing their company's performance to national standards. Others used them to change or reinforce existing programs, help target new programs, and set goals and objectives for long-range strategic plans. (#355) Paul Entmacher of the Business Roundtable says that "as corporate citizens and as major taxpayers, the countries major companies have a shared interest in the health of the nation. Ceding the primary leader- ship role to the government, however, the Business Roundtable endorses the concept of ongoing, nonpar- tisan, appropriate, public-private collaboration in setting and measuring the nation's health objectives." (~465) The New York Business Group on Health calls the work!site ha uniquely advantageous arena for programs of health education/promotion that will further help to achieve the national objectives." The work setting offers the opportunity to target individuals based on age, sex, education, and ethnic backgrounds; in addition, it offers economies of scale, ease of access, and peer pressure to increase program effectiveness. (~448) Virtually all the objectives can be addressed through a specific workplace program, according to testimony by the American Occupational Medical Association. Health education and promotion pro- grams developed to address problems of reproduc- tion, childrearing, immunization, mental health, substance abuse, hazard exposure, risk taking, and self-destructive habits, can be provided efficiently and effectively at the workplace. (~071) Carl Schramm writes that the Health Insurance Association of America (HIAA) has encouraged coalitions by business and industry to foster a com- munity environment" for health promotion and disease prevention. For example, the HIAA's Center for Corporate Public Involvement "sought to influence the AIDS public debate by increased public/private sector collaboration and through the expansion of industry resources to combat the epidemic." Schramm says that 21 community organizations received funds for AIDS information and education and for support programs from HIAA and the American Council of Life Insurance member companies through a chal- lenge grant program. (#619) SURVEILLANCE AND INFORMATION RESOURCES The need for better data, in general, for specific health problems and special populations arose repeat- edly in testimony on the Year 204)0 Health Objectives. For instance, Harmon says that Data represents the single most critical element to successful planning." As part of the objectives process, the nation must identify data base weaknesses and build information systems to fill the gaps. (~085J Others discussed the need for other kinds of information, such as technical assistance in implementing the objectives and informa- tion about the effectiveness of health promotion and disease prevention interventions. Like a number of testifiers, the American Public Health Association sees a need for an improved system of data collection and analysis in order to monitor the achievement of objectives. "lithe data collection and analysis system is crucially according to the AP HA, in identifying the nature and scale of problems to be faced in achieving the objectives and also in evaluating implementation activities to make sure that the most effective program is in place to achieve the objectives. (#198) Other witnesses re- cognized the importance of establishing baseline data in order to measure progress and evaluate outcomes. State and Local Data Systems Many witnesses spoke about the need for state and local data and surveillance systems to set objectives and to monitor progress toward them. Three criteria came up repeatedly: uniformity, timeliness, and quali- ty. The Association of State and Territorial Health Officials suggests that "data should, when feasible, be collected in standardized forms across the country, allowing for comparison of how different cities, states, and regions are faring. For data that are not col- lected nationally, state and local data should be utilized in lieu of establishing new data systems." (#750) Viewing matters from the state level, Harmon calls for efforts at both national and state levels to arrive at a uniform data base with data that are no more than two years old. (~085) Mary Anne Freedman, representing the Association for Vital Records and Implementing the Objectives at State and Local Levels 23

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Health Statistics, stresses data uniformity and quality. Data derived from systems that have multiple collec- tion points with non-uniform collection methodologies or non-standard sampling techniques must be used with caution." Furthermore, "since the Year 2000 Health Objectives will provide a focus for many agencies working to improve the health of all citizens and are expected to be translated to state and local needs, many state and local agencies will also adopt the objectives." Therefore, says Freedman, "data systems should address the needs of state and local agencies as well as those for the nation. (#527) Tom Jones, speaking for the Northwest Portland Area Indian Health Board, says that healthy com- munities depend on contributions from the individual and family, the health delivery system, and community government. He recommends an objective that would urge all communities to have an information system and appropriate statistical tools that could diagnose the community's health problems, assess risk factors, monitor health status progress, evaluate the effective- ness of health programs, and identify additional requirements necessary to arrive at an acceptable level of health. The Native American tribes of the North- west, Jones reports, are currently developing such a system. (#473) At the local level, "one would ideally have a local office to gather, tabulate, interpret, and disseminate those data needed to track the community's progress, or lack thereof, relative to the various objectives for the nation," according to Joel Nitzkin, Director of the Monroe County Health Department in New York. "Placing this function within the health department will facilitate access to birth and death certificate data and data on reportable communicable disease. In more realistic circumstances, one can still do pretty well with some relatively simple indicators that may indicate the presence or absence of an obvious problem." In addition, Nitzkin says, an "effective means for integrating the surveillance data and epidemiological process into the priority setting and budgeting processes is also necessary. (#523) Nitzkin suggests that The surveillance activity not limit itself to simple totals and averages for the entire jurisdiction. The jurisdiction should be divided geographically, socioeconomically, and racially/ ethnically into subpopulations representing different levels of health risk and geographic areas that might be considered for targeting of programming. By sorting both the numerator and denominator data this way, one can avoid missing small areas of high risk because they had been hidden Within a larger popula 24 Healthy People 2000: Citizens Chart the Course lion at much lower risky (#523) Specific Diseases and Problems Many witnesses call for better data and data systems on particular health issues. For example, testifiers call for the following . An expansion of the current nutritional data system by using registered dietitians as data gatherers. (~5 72) Better data on environmental issues and occupational safety and health. (~104) A "comprehensive and integrated system for periodic determination of the oral health status, dental treatment needs, and utilization of dental services of the U.S. population." (#106J A national registry to measure the incidence of fetal alcohol syndrome and fetal alcohol effects. (~542) Better data on the incidence and prevalence of AIDS and HIV (human immunodeficiency virus) infection, as well as incidence and prevalence of other retroviral illnesses. (~698) Other particular data needs are discussed elsewhere in this report. An existing data source that could be used better In setting objectives, according to Patrick O'Malley and Lloyd Johnston of the University of Michigan, is the National High School Senior Survey, "one of the county's major sources of epidemiological informa- tion on substance abuse among American adolescents and young adults." It serves as a valuable source of trends on drug and alcohol abuse, the potential for accidents, and physical fitness and nutrition, and should be used in setting and tracking objectives and teen behavior. (~419) Special Leeds of Minority Populations Minority groups in the population have special data needs. First, data on minorities as groups are often lacking. Furthermore, as a number of testifiers point- ed out, individual minority populations are themselves heterogeneous, which calls into question even the available data for groups such as Blacks, Hispanics, and Asians. For example, according to Sandral Hullet, Director of West Alabama Health Services, there are no characteristics shared by all minority subgroups. Furthermore, speaking of the Black populations that

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she selves, Hullet says that health research policies and programs fail to differentiate among the special needs of subgroups within racial, ethnic, and social communities, which accounts for the disproportionate burden of illness among minorities. More informa- tion on the determinants of health and illness in each subgroup is necessary to account for the different susceptibilities and resistance of these groups to risk factors. (~671J Similarly, David Hayes-Bautista of the University of California, Los Angeles suggests that basic data about health promotion and disease prevention are lacking for Latino populations. The problems arise from (1) lack of uniformity~ome surveys are coded to names, others to national origin, others to nationality, so it is difficult to find homogenous populations for comparison purposes; (2) lack of uniform definitions and procedures; and (3) lack of data to get a baseline profile of the Latino population. Hayes-Bautista also says that a conceptual model for looking at Latino health is lacking-the Black model simply does not apply. With more than one linguistic group, more than a single cultural or economic group, and not solely an immigrant population, the Latino community has unique characteristics and structural elements that must be understood to develop appropriate interven- tions, he says. (#679J Michael Watanabe, representing the Asian Pacific Planning Council, suggests that the Asian-Pacific community also requires special attention because it is not homogeneous. There are 17 distinct ethnic groups with different norms and problems, including a large refugee component. According to Watanabe, Asians are often represented as a model minority, but when subgroups are examined, problems with poverty, education, crime, and delinquency arise, which are not always represented in official statistics. Major health problems also emerge in subgroups: high stomach cancer rates among the Japanese and lung cancer among the Chinese. f#683) Information Resources A number of testifiers identified the need for more or better information to help implement the Year 2000 Health Objectives. This information included techni- cal assistance about the objectives process for states and local areas, better information about the costs and benefits of disease prevention, and research to support the objectives. Milne called for more technical assistance to help states and local areas implement the objectives. (#328J Similarly, Kinsman suggested an addendum to the publication of the Year 2000 Health Objectives giving methods and tools needed to use objectives. (#699) According to Harmon, one of Missouri's main recommendations for the Year 2000 Health Objectives is to centralize technical resources at national, state, and local levels. This requires establishing a technical resources office at the national level to provide technical assistance and training to states and local areas involved in using the national objectives and the Model Standards. This office could (1) establish a library and clearinghouse for data and technical information, (2) operate an electronic bulletin board to disseminate information and encourage communica- tion between states and local areas, and (3) make a uniform national data set available through the clearinghouse or bulletin board. (~085) Those implementing the objectives at the state or local level also require more information on the effectiveness of prevention interventions. "All too often," says Michael Eriksen of the Society for Public Health Education, "the marketplace drives the availa- bility of effective interventions. If money can be made, programs will be marketed and sold, irrespec- tive of need, quality, and effectiveness. Special efforts need to be made to assure that effective health promotion programs are diffused to the annror~riate target groups." f#309) --r Hi- - - r ~ _ _ ~ . ~ David Lawrence of the Kaiser Foundation Health Plan of Colorado points out that employers and other purchasers of health care, as well as "buncllers~ of care such as health maintenance organizations and other managed care organizations, are increasingly con- cerned with the quality and appropriateness of the health care they purchase. Many, however, are still not sure which preventive programs are suitable at the worksite, which are most effective, and how to evalu- ate success. The national objectives can be a guide for purchasers to determine how well bundlers (those who put together the pieces necessary to deliver care within systems) are doing in the areas of disease prevention and health promotion. For this to work, however, Lawrence says that data commissions or other data collection and analysis entities must be developed to evaluate the bundlers' effectiveness at health promotion and disease prevention. (#3 75J Similarly, the Business Roundtable suggests that a public-private data consortium be organized early in the objectives-setting process to help develop baseline data and assist in the collection, retrieval, and analysis of follow-up data. The absolute and relative expenses Implementing the Objectives at State and Local Levels IS

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associated with each goal should be estimated to facilitate planning and prioritizing. (#465J To use the national objectives well, information about successful programs and the strategies used to implement them must be shared. According to Spengler: To achieve objectives and strive for improving health, it is essential that monitoring and evalu- ation efforts be supported throughout any pro REFERENCES ject. A greater emphasis must be placed on agencies/organizations with principal responsibi- lities being held accountable for monitoring and evaluation. The same agencies/organizations should be held accountable for determining efficacy, effectiveness, efficiency, cost-benefits, and transferability of program activities. There also needs to be more interstate data sharing and comparison of intervention strategies and evaluations. (~458J 1. Model Standards Work Group: Model Standards: A Guide for Community Preventive Health Services (2nd Edition). Washington, D.C.: American Public Health Association, 1985 2. U.S. Department of Health and Human Services: The 1990 Objectives for the Nation: A Midcourse Review. Washington, D.C.: U.S. Government Printing Office, November 1986 TESTIFIERS CITED IN CHAPTER 3 020 Bernstein, Robert; Texas Department of Health 026 Breslow, Lester; University of California, Los Angeles 071 Givens, Austin; American Occupational Medical Association 076 Gurian, Gary; City of Allentown Bureau of Health (Pennsylvania) 085 Harmon, Robert; Missouri Department of Health 098 Heydinger, David; West Virginia Department of Health 104 Hyslop, Thomas; Harris County Health Department (Texas) 106 Isman, Robert; The Association of State and Territorial Dental Directors 125 Larsen, Michael; Mississippi State Department of Health 129 Halpin, Thomas and Evans, Karen; Ohio Department of Health 149 Michael, Jerrold; University of Hawaii School of Public Health 156 Easley, Michael; American Association of Public Health Dentistry 198 Sheps, Cecil; American Public Health Association 204 Spain, Carol; Health Officers Association of California 225 Welch, Dick; Minnesota Department of Health 260 Samuelson, Caroler Jefferson County Department of Health (Alabama) 280 Goldston, Stephen; University of California, Los Angeles 309 Eriksen, Michael; University of Texas Health Science Center at Houston 315 Berg, Alfred; University of Washington 320 Nicola, Bud; Seattle-King County Department of Public Health 328 Milne, Thomas; Southwest Washington Health District 340 Lipsher, Julian; Hawaii State Department of Health 355 Jacobson, Miriam; Washington Business Group on Health 364 Frissell, Nelson; City-County Health Department, Casper, Wyoming 365 Biers, Richard; Kansas City Health Department 375 Lawrence, David; Kaiser Foundation Health Plan of Colorado 387 Richards, N. Mark; Pennsylvania Department of Health 405 Myers, Jr., Woodrow; Indiana State Board of Health 419 O'Malley, Patrick and Johnston, Lloyd; University of Michigan 432 Rader, Herbert; The Salvation Army in the United States 26 Healthy People 2000: Citizens Chart the Course

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448 Warshaw, Leon; New York Business Group on Health 454 Yaffe, Bertram; New England Conference for Disease Prevention, Health Protection and Health Promotion (NECON) 458 Spengler, Robert; Vermont Department of Health 460 Addiss, Susan; Quinnipiack Valley Health District (Connecticut) 461 Scott, H. Denman; Rhode Island Department of Health 465 Entmacher, Paul; Metropolitan Life Insurance Company 473 Jones, Tom; Northwest Portland Area Indian Health Board 476 Schmidt, William; Wisconsin Division of Health 518 Blockstein, William; University of Wisconsin-Madison 523 Nitzkin, Joel; Monroe County Health Department (New York) 527 Freedman, Mary Anne; Association for Vital Records and Health Statistics 542 Weiner, Lyn and Morse, Barbara A; Boston University 572 Williams, Corinne; California Dietetic Association 619 Schramm, Carl; Health Insurance Association of America 629 Kinsman, Katherine; South Dakota Department of Health 671 Hullet, Sandral; West Alabama Health Services 679 Hayes-Bautista, David; University of California, Los Angeles 683 Watanabe, Michael; Asian Pacific Planning Council (Los Angeles) 698 Lafferty, William; Washington State Department of Public Health 709 Rockwell, Bruce; The Colorado Trust 747 Grieder, Karen; Texas Association of Community Health Centers 750 Richland, Jud; Association of State and Territorial Health Officials 756 Reeves, Philip; American Public Health Association 786 Roemer, Milton; University of California, Los Angeles Implementing the Objectives at State and Local Levels 27