U.S. Department of Health and Human Services
The decade's midpoint is an opportune time to assess progress on the Nation's prevention agenda. In 1995, it is important to celebrate the achievements in health promotion and disease prevention and to examine the challenges that remain. As the year 2000 approaches, increased knowledge about health and the potential to prevent disease, disability, and premature death puts a fuller measure of health and a better quality of life within each individual's and the Nation's grasp.
For 15 years, the U.S. Public Health Service (PHS) has monitored and publicly reported on national health objectives. The first set of national health goals was published in 1979 in Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. In that report, targets were set to be achieved by 1990 for five major stages of life:
Reducing mortality and improving the quality of life by utilizing the available tools for disease prevention were the goals of this plan.
The 1990 objectives set the foundation for an expanded agenda for the decade leading to the year 2000. Over a 3-year period beginning in 1987, the PHS, with the assistance of the Institute of Medicine of the National Academy of Sciences, held regional hearings across the country. Through public testimony collected in these hearings and other sessions conducted in conjunction with national health organizations, a prevention agenda for the Nation was established.
The Healthy People 2000 Consortium was formed with 150 member organizations initially and has grown to 333 organizations, including all State and territorial health departments. National membership organizations, such as the American Cancer Society, the National Medical Association, the American Public Health Association, the Girl Scouts of America, and the American Association of Retired Persons are examples of the organizations that have become actively engaged in the development and support of the Nation's health objectives.
Released in 1990, Healthy People 2000: National Health Promotion and Disease Prevention Objectives set forth three broad goals for the Nation:
The first goal includes targets to reduce death, disease, and disability, and also to reduce the prevalence of risks to health or to increase behaviors known to reduce such risks. The second goal addresses the disparity in health status among disadvantaged populations--low-income, minority, and disabled people--and the rest of the Nation. The third goal challenges the Nation to provide accessible, comprehensive basic primary care services, including clinical preventive services and interventions, for all people.
Healthy People 2000 Midcourse Review and 1995 Revisions provides an assessment of the Nation's progress towards these three goals and the year 2000 targets supporting the goals.
Life expectancy has significantly improve--it was 73.7 years when the first Healthy People was published. When Healthy People 2000 was developed, life expectancy was 75 years. On average, babies born in 1992 will live almost 76 years.
Of this 76-year average life-span, about 64 years will be healthy, according to a measure developed by the National Center for Health Statistics and based on self-reported health status, activity limitation data in the National Health Interview Survey, and standard life tables. On average, about 12 years of life (or 15 percent of life years) will be unhealthy, with limitations of major life activities such as self-care (bathing, grooming, and cooking), recreation, school, and work. Because activity limitations increase with age, the challenge of reaching this goal is to minimize disabilities and increase the independence and health of all people but especially older adults.
The measure of years of healthy life enables the Nation to move from merely tracking mortality rates to examining the quality of life. As shown in Figure 1, there are differences among racial and ethnic minorities in both life expectancy and in the estimates of the percentage of life years considered healthy. The 1992 estimates of years of healthy life reflect more self-reported activity limitations, causing the Nation to lose ground on this important goal.
Figure 1. Years of Health Life and Life Expectancy, by Race and Hispanic Origin, 1990
All Races White Black Hispanic _______________________________________________________ Healthy Years 64.0 65.0 56.0 64.8* Life Expectancy 75.4 76.1 69.1 N/A --------------- Estimated from preliminary data.* Source: Centers for Disease Control and Prevention (CDC)/ National Center for Health Statistics (NCHS)
The second Healthy People 2000 goal is to reduce health disparities among Americans. The focus is on closing the gaps in health status and health outcomes among racial and ethnic minority groups and the total population. Whether measured in life expectancy, by specific causes of death, or by use of various clinical preventive services, differences among whites and minorities persist. (Also see Spotlight in this edition for a discussion of Years of Potential Life Lost.) When a comparison is made between the Healthy People 2000 racial and ethnic minority objectives and all 300 objectives, there is a similar picture of progress. However, for blacks there are proportionately more objectives moving away from the targets. For Asian and Pacific Islander Americans, there is a considerable challenge in getting the data needed to track progress (see Figure 2).
Figure 2. Progress on Racial and Ethnic Minority Objectives, 1995
Right Wrong No No Tracking Direction Direction Change Data* ______________________________________________________________________ Total Population 50% 18% 3% 29% (300 targets) ______________________________________________________________________ Special Populations 53% 27% 3% 17% (116) ______________________________________________________________________ Black (48) 50% 35% 2% 13% ______________________________________________________________________ Hispanic(28) 54% 14% 4% 29% ______________________________________________________________________ Asians/Pacific 56% 11% 0% 33% Islanders (9) ______________________________________________________________________ American Indians/ 56% 31% 3% 10% Alaska Natives (31) --------------- Includes objectives with no baseline (8%), and objectives with no update beyond baseline (22%).* Source: CDC/NCHS
The third goal of Healthy People 2000 is to achieve access to preventive services for all Americans. Setting this goal in 1990 called upon the Nation to achieve universal access to preventive health services. One measure of this goal is the percentage of Americans with health insurance coverage (Figure 3. Health Insurance Coverage for People Age 64 and Younger, Percent Unisured by State, 1992, a map). In 1987, 76.2 percent of people under age 65 had private insurance; by 1993, that percentage had fallen to 70.8. The number of people who were not covered rose from 14.4 in 1987 to 17.2 percent in 1993. Among blacks and Hispanics (data on other races are unavailable), the percentage of uninsured was even greater. Using data from the 1993 Current Population Survey, which includes all people regardless of age, the Census Bureau estimated that 39.7 million Americans, or 15.3 percent of the total population, were without health insurance and that 20.5 percent of blacks and 31.6 percent of Hispanics had no health insurance coverage. The lack of coverage implies that these people do not have a regular source of care.
Figure 4. Progress on Life-Stage Objectives, 1995
Year 1990 Targets* Year 2000 Targets* 1977 1990 1990 1987 2000 1992 Age Group Baseline Target Final Baseline Target Status ___________________________________________________________________________________ Infants 1412 900 908 1008 700 852 (aged less than 1) ___________________________________________________________________________________ Children 42.3 34 30.1 33.7 28 28.8 (aged 1-14 ___________________________________________________________________________________ Young People 114.8 93 104.1 97.8 85 95.6 (aged 15-24) ___________________________________________________________________________________ Adults 532.9 400 400.4 426.9 340 394.7 (aged 25-64) --------------- *Deaths per 100,000 population Source: CDC/NCHS Naitonal Vital Statistics System
In 1995 there is progress to report on only four of the five life-stage targets (see Figure 4). The Nation's infant mortality rates reached record low levels in 1992. The children's mortality rate almost equals the year 2000 target. But the adolescent and young adult target continues to be elusive. There are no data currently available to track older Americans' reduction in disability days.
Figure 5. Healthy People 2000 Priority Areas and Lead Agencies
Surveillance and Data Systems
22. Surveillance and Data Systems Centers for Disease Control and Prevention
Healthy People 2000 comprises three major prevention categories: Health Promotion, Health Protection, Preventive Services (Figure 5). The prevention categories are divided into 21 priority areas. Because of the importance of data in monitoring progress and establishing objectives, there is also a separate priority area for Surveillance and Data Systems. For each of these priority areas, a U.S. Public Health Service agency is designated as a lead agency to coordinate activities directed toward meeting the objectives. By measuring health status and health outcomes over the past 15 years, the public health community, in collaboration with the private and voluntary sectors, has established a framework for action based on realistic opportunities to improve the health of the American people.
Healthy People 2000 outlines a long-term plan with enough breadth and specificity that groups throughout the country have joined in an unprecedented collective effort. Constituencies not traditionally involved in health were engaged in setting the goals and objectives and now work on meeting them. Transportation departments, highway safety groups, and advocates of safe and drug-free driving have joined forces with State and local health departments to achieve tremendous success in reducing fatal motor vehicle crashes, particularly those involving alcohol. In schools and on college campuses across the country, students are educated about risky behaviors in an effort to prevent disease, disability, and premature death. Employers are instituting policies for smoke-free workplaces and offering blood pressure and cholesterol screenings. National organizations of health professionals, agencies that focus on specific diseases, and organizations representing specific population groups are using the Nation's health objectives as a framework for program activities, conferences, publications, and strategic plans. The goals and objectives of Healthy People 2000 have provided a sense of what can be accomplished collectively if Americans apply themselves to health promotion and disease prevention.
Assessing current activities and outcomes and designing actions to enhance performance are integral components of management practices traditionally used to achieve long-term improvement in the private sector. National health objectives use parallel processes for monitoring and reporting on morbidity and mortality.
Many lessons were learned from defining the objectives of Healthy People 2000. Measurement of health progress by setting specific surveillance and evaluation targets has proven to be a valid monitoring method. When specific health risks can be identified, as in the case of child safety in automobiles, and an acceptable and cost-effective intervention is available, such as child safety seat use, a combination of education (promotion), service provision (services), and regulation (protection) has been demonstrated to help save lives.
As a part of the 1995 revisions to Healthy People 2000, the PHS began a review of the Nation's disease prevention and health promotion objectives. First announced at the Healthy People 2000 Consortium meeting in October 1993, the review considered new objectives; target revisions based on technical baseline revisions or the achievement of certain targets; the addition of new special population targets where disparities or differing trends in health status existed; and language modifications to clarify the meaning and intent of objectives or to dovetail objectives with current data sources. By incorporating new science, new information, and new data, the 1995 revisions strengthen the Nation's health promotion and disease prevention agenda, making it even more relevant to today's health issues and to setting the prevention agenda of the 21st century.
To order a copy of Healthy People 2000: Midcourse Review and 1995 Revisions, call the National Health Information Center (NHIC) at (800)336-4797 or write to NHIC, P.O. Box 1133, Washington, DC 20013-113. Include your name and address with a check or money order for $5.00.
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